A 59-year-old man comes to the office for follow-up. The patient had an acute myocardial infarction 1 month ago, and a drug-eluting stent was placed successfully. He has no cardiovascular symptoms, but he does have hypertension and hyperlipidemia and a 40-pack-year smoking history. Blood pressure is 132/86 mm Hg and pulse is 68/min. BMI is 30.8 kg/m². Physical examination is unremarkable. The patient says, "I can't wait to get back to work, but at the same time, I'm concerned about having another heart attack. I have a high-pressure job, but I need to find time to exercise. Plus, I know I should stop smoking and lose at least 20 pounds." Which of the following is the most appropriate response by the physician at this time?

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11ec160b_3667_662d_9249_8ddf001a33eb_MD0001_00 This patient recently experienced a myocardial infarction and expresses concern about having another one. He identifies a number of issues he feels he should address to reduce his risk (eg, stop smoking, lose weight, start exercising). Like many patients, he faces multiple health challenges and has specific life circumstances that influence his priorities (eg, high-pressure job). Rather than developing an exhaustive list of changes, helping the patient focus on 1 or 2 specific behaviors he feels most ready to change is more productive. In motivational interviewing, this is referred to as the process of focusing. A patient-centered, collaborative approach is important; the physician should elicit the patient's thoughts and feelings about what to focus on. Rather than giving advice without permission, unilaterally setting the agenda, or overwhelming the patient with a long list of changes, the physician can help the patient focus on realistic changes he is more likely to pursue. (Choice A) This statement prematurely assumes the patient is internally motivated to change. It describes the patient as committed to these goals when he said only that he "should" do all those things. This response also may overwhelm the patient because it fails to help him focus on realistic goals. (Choice B) This is an example of noncollaborative agenda-setting. It is less likely to be effective than eliciting the patient's perspective. (Choice C) Encouraging the patient to make a long list of changes is rarely helpful. It is likely to overwhelm him and may actually decrease his motivation. (Choice D) This question fails to consider the patient's perspective about his job (ie, "I can't wait to get back to work") and reflects a premature suggestion. Exploring the patient's thoughts and feelings about his work is a better approach, eliciting his suggestions about how to best integrate his health goals into his schedule. Educational objective: When counseling a patient who has multiple unhealthy behaviors, the best approach is to focus on 1 or 2 specific behaviors the patient feels most ready to change. This improves the likelihood of change by focusing on realistic goals the patient is more likely to pursue.

A 59-Year-Old Man Comes to the Office for Follow-Up