A 34-year-old man is admitted to the hospital due to recurrent pancreatitis following a 2-week period of heavy alcohol consumption. He has a long history of alcohol abuse and has been through inpatient alcohol treatment programs on multiple occasions. The patient realizes he needs to stop, but says he drinks when he is home alone and feels stressed. Medical history is notable for hypertension and type 2 diabetes mellitus, treated with lisinopril and metformin. Blood pressure is 146/85 mm Hg and pulse is 72/min. BMI is 46 kg/m². On examination, the patient appears comfortable. Fasting glucose is 183 mg/dL and hemoglobin A1c is 8.2%. The patient says he is not willing to return to an inpatient alcohol treatment program after hospital discharge but might consider outpatient counseling. Which of the following is the most appropriate response to this patient?

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11ec25c8_d532_b612_bc81_97b090350c5b_MD0003_00 The psychotherapeutic technique of motivational interviewing is used to encourage patients to change maladaptive behaviors. Interventions are geared to the patient's stage of readiness to change. Elements include a nonjudgmental stance focusing on the patient's intrinsic motivation to change, acknowledging ambivalence and resistance to change, and supporting the patient's autonomy and efforts to take responsibility. This patient has recurrent alcoholic pancreatitis and has failed previous attempts at inpatient alcohol rehabilitation, but he is willing to consider outpatient therapy (contemplation stage). Appropriate steps at this point would be to explain how referral for outpatient treatment might work, discuss the pros and cons of outpatient treatment compared to inpatient treatment, and assess the patient's conviction (understanding of the importance of change) and confidence (self-perceived ability to change). The physician should allow the patient time to consider all options and should also arrange follow-up for planning the next steps in treatment. (Choices A and C) A basic discussion of disease processes and complications can provide motivation for change and is most appropriate for a patient in the precontemplation stage. However, this patient acknowledges that change is needed and is willing to consider at least some treatment options. Continued emphasis on consequences from lack of change is likely only to promote anxiety and frustration. (Choices B and D) These statements do not acknowledge patient autonomy. Even if the physician is certain that inpatient treatment would benefit the patient, a better understanding of the patient's perspective is needed before pushing him to do what he does not want. Making arrangements to schedule an appointment with a treatment program before the patient is agreeable may diminish his commitment to treatment. Such actions are more appropriate for a patient in a preparation stage who can collaborate with the physician and take some responsibility for treatment. (Choice F) It is important to convey to all patients, in all stages of change, that their physician is committed to their benefit and is willing to help. However, this patient's willingness to consider treatment options shows that he takes his condition seriously, and this statement would likely be seen as condescending. Educational objective: Contemplation is a stage of behavior change in which a patient is willing to consider changes to maladaptive behaviors but has not yet decided to pursue specific action. Patients considering behavioral change should be assessed for conviction (understanding importance of change) and confidence (self-perceived ability to change). References: Diabetes self-management: facilitating lifestyle change. (http://www.ncbi.nlm.nih.gov/pubmed/28925635)

A 34-Year-Old Man Is Admitted to the Hospital Due to Recurrent