Through the lens of motivational work, we zoom in on the social interactions, the measures and preventive actions that occur in the preventive health dialogues. First, we show how motivational work was practiced during the preventive health dialogues. Second, we illustrate how patients perceived the preventive focus on health behavior in general practice. Third, we focus on how both GPs and patients had certain expectations regarding the role of the GP, which affected the motivational work carried out in the health dialogues.
Practicing motivational work
We introduce the results with an ethnographic observation that shows a significant empirical example of how motivational work was practiced in a preventive health dialogue in general practice. As we shall argue, motivational work occurred as one-way communication, in which the GP controlled, instead of facilitated, interplay and dialogue with the patient.
The doctor looks at the screen and confirms that the diet is red (in the risk zone). He asks Kenn whether the health survey has got him thinking about anything. Kenn answers that, yeah, he knows. “Know what?” asks the doctor? Kenn explains that he knows he is overweight and eats too much. He eagerly explains how he’s currently experimenting with leaving candy out all the time to wean himself off eating the whole thing in one go. He talks about an experiment he saw on TV in which a kindergarten kept candy out all the time and only brought out carrots every so often, with the result that the children didn’t want to eat candy but instead rushed over to the carrots. The doctor listens. Kenn continues explaining how he had previously almost been underweight, but after he had stopped smoking, he had gained a bit more weight, a bit more, a bit more. The doctor does not comment on this but glances quickly around Kenn’s health profile and comments instead on his responses regarding smoking and alcohol. He returns to diet shortly thereafter. He asks whether Kenn is familiar with BMI – Body Mass Index – and says: “It should ideally be a maximum of 25 – yours is at 27. What about exercise?” Kenn says that it could be better and explains that he does gymnastics once a week and goes hunting during the season. The doctor asks whether it’s sort of classic men’s gymnastics, “The kind of thing where you don’t sweat?” he asks with a laugh in his voice. Kenn smiles and assures him that they really work hard. The doctor smiles, “Joking aside.” He looks at Kenn: ”It’s important to get your heartrate up and break a sweat. Do you have a bike?” he asks. “No, I just hate biking!” Kenn answers. The doctor does not respond but turns around in his chair and looks at the computer screen. “Then I need to ask you. In terms of increasing your efforts in terms of physical activity, would you maybe be interested in a service from the municipality?” Kenn looks a bit skeptical. “What is it?” he asks. The doctor explains that the municipality has a lifestyle service for overweight adults and a place where you can learn about health. Kenn still looks skeptical. “Hmm… Let’s assume that I’m interested. I mean, that I’m looking for somewhere I can learn about obesity. As a smoker, I didn’t need it.” The doctor looks at the description of the municipality’s service and reads it aloud. A moment later, Kenn acquiesces: “Alright, let’s accept it … Then we’ll have done something at least. It’s not necessarily certain that it would happen here, internally.” The doctor fills out some boxes in the health profile. He points at the screen, where an image shows a scale of 1 to 10. “How motivated are you in terms of the municipality’s lifestyle team?” he asks. Kenn thinks. “It’s probably a 4 or a 5…” “OK,” answers the doctor, types in the number and clicks around on the screen. He prints out a description of the municipality’s service. While the printer is going, he asks, “So, how’s the strategy with the bowl of candy going?” Kenn smiles. “Surprisingly well!” he answers. “The total amount at least has gone down – also when it comes to heavy food.” The doctor responds, “Great!” and hands the information on the municipality’s service over to Kenn in printed form. “If you’re really hardcore, there’s also a nutritionist. It isn’t free, but then you’re setting the agenda.” Kenn does not seem particularly interested as the doctor writes the nutritionist’s contact details down for him. The doctor clicks further in the health profile and asks Kenn a couple of quick questions about medicine use, etc. Afterwards, the doctor talks about cholesterol totals, and he calculates Kenn’s 10-year risk and a current risk with the help of a special computer program. “Hey, it looks really good – 1% risk.” Kenn smiles. “OK, then, it really can’t be much better.” The doctor responds, “It looks really good overall – ideally, you should lose a few kilos! … I also think you need to work on getting motivated to give it a shot – I believe in you! … But should we say that’s that, then? Then you’ll continue the program with the municipality.” (GP 2, Patient 9)
In this example, the GP performed motivational work in different ways. The health dialogue started out with the doctor asking an open-ended question that caused the patient account for his candy experiment. The patient thereby presented the GP with an opening regarding his motivation to change eating behaviors. The GP did not follow up on this information, however, but instead applied an action perspective: recommending that the patient to start biking and try consulting a nutritionist, which resulted in a drop in the patient’s motivation. Overall, our empirical material shows how GPs often carried out motivational work as biomedically based guidance, which included information, suggestions, and advice on risk factors, such as: “It’s important to get your heart rate up and break a sweat. Do you have a bike?”, “You should lose weight to lower your cholesterol level,” or “Try to get 30 minutes of exercise every day, get the heart rate up… go for a daily walk.” As such, the dialogues seldom included the patients’ experiences with behavioral changes, general life situation, or social circumstances that could influence their motivation, ambivalence, and actions regarding health behavior. Although other studies have found that GPs generally do not use information about patients’ perspectives on health behavior in preventive consultations [28], the performance of motivational work in this study could be explained by the structure of the digital framework, which could have facilitated the GPs using the digital health profile as a checklist. In interviews with the patients, we found that when GPs did not follow the digital health profile as a checklist, patients felt that their stories and individual experiences were seen and heard. In the above excerpt, the digital health profile functions as a checklist, which may explain why this GP did not use the patient’s perspectives and experiences to explore and facilitate dialogue about the patient’s ambivalence and motivation to change health behavior.
Another component illustrated in the example is how the GP reduced MI tools, such as scaling questions and goal setting, to a means of gaining numerical information instead of serving as a dialogue tool. The GP asked the patient to assess the scale of his motivation for joining a health behavior course in the municipality. After a brief reflection, the patient gave him a number, and the GP entered the number as data into the digital health profile. The numeric standards and measurements thus constituted preventive work on which the GP never followed up. That is, the GP neither asked questions about the reason for the assessment nor questions about the patient’s specific motivations for changing behavior. As such, perspectives and experiences that the GP could have utilized to activate the patient’s motivation for change remained empty information, and information about behavior was quantified and given in generic terms by the GP, isolated from any sociocultural influences [22, 29].
We argue that the approach to motivational work presented in the example resembles a treatment-oriented practice rooted in the biomedical perspective and characterized by an numeric objectification of bodily functions and symptoms based on classification systems for diagnosing somatic and mental diseases, one that rarely included patients’ experiences, values, or everyday lives [30, 31]. Existing research shows that GPs’ focus on diagnoses and treatment affects whether prevention is introduced in the clinical encounter [8, 32]. These findings correlate well with the findings in this article.
Experiencing motivational work
In this section, we illustrate how patients experienced and perceived the preventive focus on health behavior in general practice and how this influenced the motivational work carried out in the health dialogues. We argue that the patients generally perceived health behavior as a private matter that they did not discuss with the GP. Their understanding of the clinical encounter and of health behavior thus reinforced the performance of motivational work as one-way information provided by the GP with a focus on objectified biomedical classifications of bodily functions and symptoms.
Generally, the patients stated that they had not previously considered seeking advice or guidance from their GP about health behavior issues. Several patients did not regard risk factors, such as obesity, as a definite disease and, as a result, they did not present it as a health problem to the GP. As such, advice about prevention and health behavior issues were new to them, and many patients saw changing health behavior as a private matter. The ways in which patients separated health behavior issues from disease are reflected in the following interview extract:
“When I contact the doctor, it’s because I notice something particular. If there’s something unusual, or there’s something that’s changed, and I notice it, then I get in touch with the doctor. But not my lifestyle, no … Because I feel I’ve got that covered” (Patient 7).
In our study, patients’ understandings of health behavior as a private matter resulted in a lack of interest or in a feeling that the GP interfered too much:
“If it’s about how I have to alter my lifestyle, then it’s really more on the home front where that kind of thing happens. I mean, if we’re sitting around the table and agree, well, ‘we’d better eat a bit more salad and more beet burgers,’ then that’s where it’s decided. Not with the doctor. It’s nice of her to try, but no” (Patient 6).
As illustrated in this quote, patients regarded health behavior issues as things they themselves were responsible for changing and as things that took place at home and not in the GP’s consultation room. Patients’ awareness of their health behavior was in this way often connected to a biomedical understanding of health behavior as an individual affair, as opposed to other clinical health issues. According to a study by BP Mjølstad, AL Kirkengen, L Getz and I Hetlevik [33], the contents of conversations between GPs and patients are framed by an awareness of what is appropriate to share with the GP. These authors argue that this is socially and culturally embedded in the Western society, where patients are taught to regard the body in a physical and biomolecular manner. This framework lessens the degree to which patients introduce experiences from their everyday lives in the assessment of symptoms in the encounter [33]. Instead of agreeing to the preventive premise of the health dialogue, patients often brought other health problems into the conversation, for example eczema, tennis elbow, and birthmarks. Patients thereby shifted the focus and reproduced a treatment-oriented focus in the preventive health dialogues. In a study examining shame and honor in the clinical encounter, shifting focus in preventive consultations has been identified as a means by which patients preserve or regain face when confronted with behavior that is deemed insufficient [25]. Though based on the patients’ understandings of the clinical encounter and health behavior as presented above, we found that by shifting focus, the patients contributed to the health dialogue as one-way information provided by the GP, with a focus on objectified biomedical classifications of bodily functions and symptoms.
Expectations of GPs’ role in prevention
In this section, we demonstrate how both GPs’ and patients’ expectations of the GPs’ role affected the motivational work carried out in the health dialogues.
Generally, the GPs expressed concern about becoming overbearing and scaring patients away when confronting them with advice about health behavioral change. Some GPs expressed skepticism about setting goals in the health dialogues and about patients’ willingness to change health behavior. One GP described an awareness of not “pursuing” the patients:
“[In terms of setting goals,] well… they talk it up a bit while they’re sitting here, and when they get home, then they forget about it? I mean, if they say: ‘Yeah, but it’s a 7.’ Then I don’t know whether they’re going to follow up on it. But I mean, I don’t want to force them into it either. I don’t want to pursue them. I don’t want to punish them. Nah. I have one with these really bad feet, and she can’t have surgery unless she quits smoking. […] So, I say, ‘But, well, can’t you quit smoking?’ She basically can’t do that – what’s she supposed to do? She can’t walk, she can’t smoke. So, I mean… (laughs) it’s hard. […] But you can say to them: ‘Well, I mean, that’s just how it is.’ – and then, well, we don’t need to talk about it anymore (GP 1).
Focusing the health dialogue on biomedical facts and treatment has in other studies been found to stem from GPs’ practical inability at motivational interviewing as well as lack of time and concerns about harming trust in the doctor-patient relationship [6, 10, 13, 34]. GPs have been found to balance authority and respect for patients’ autonomy by compromising on or sidestepping certain health issues to avoid harming their relationships with patients, which has consequences for prevention in the clinical encounter [6, 35]. This means that GPs’ professional commitment to treatment, professional authority, and respect for patients’ autonomy may dominate the motivational work and dialogue with patients in the health dialogues.
Additionally, the excerpt above illustrates that after conveying normative biomedical facts to patients, such as the risks of smoking, motivational work was understood to be completed: “and then, well, we don’t need to talk about it anymore.” This implies a hidden assumption that what the GP says is in itself a motivational factor. The term “the doctor-drug” [36] is widely known and describes how the GP’s presence influences patients’ responses to illness and treatment. As such, GPs’ perception of their professional authority affects the social practices of motivation for health behavioral change that emerges from and is reinforced within the context of the clinical encounter [22]. This correlates well with the findings in this study, as the GPs’ comprehension of their professional position and focus on individual-oriented treatment seemed to influence the ways in which GPs understood and performed their role in the preventive health dialogues.
It is worth noting that the patients in this study expected GPs to focus on medical treatment and not on health behavior and prevention.
“No one said anything about this being a lifestyle change project – because then I don’t actually think I’d have agreed to take part, because that’s not something I need. I thought it was supposed to be about my health” (Patient 6).
Patients perceived the GP as someone who treated illness and as someone who could attend to health problems that they could not handle on their own. We found that patients perceived issues related to health behavior, such as obesity and smoking, as self-inflicted, self-controlled, and not (yet) disease related. According to the majority of the patients, problems related to health behavior were private and ‘inappropriate’ health issues to discuss in the clinical encounter. As a result, the contexts – the patients’ private lives versus the biomedical context framing the clinical encounter – affected whether the patients perceived and recognized health behavior as an appropriate health problem. Patients’ attention to not burden or waste GPs’ time [33, 37] may explain why patients anticipated and assessed health behavior as an individual affair. At the same time though, several patients in our study articulated that the GP should not interfere with their health behavior and lifestyle because such changes should come from within. In the following example, the patient expresses how she saw motivation for changing health behavior an individual affair, outside the GP’s control.
“I know that I shouldn’t smoke, and I know that it’s not healthy, and I know all that. But I’m just not ready for it, right? I’ve tried quitting many times – and it just hasn’t worked yet. And I just think, ‘Well, but, as long as I keep it to under 10 cigarettes a day and am conscious of not increasing it, then I’ll probably decide on my own whether to quit smoking in a year, in three months, or whenever I do. … But the doctor, well, he wants me to set a date. And there, I just thought to myself, ‘I’ll be damned if he’s deciding that’” (Patient 1).
As the excerpt illustrates, changing behavior is a process that may stretch out over several months or years. Quantifying and estimating the length of this process by pushing the patient to set a date for smoking cessation disregarded the patient’s previous experiences with attempting this, which resulted in a decline in motivation. The example illustrates the temporal divergence between the processual motivation to change health behavior on the one hand and the biomedical rational treatment focus on the other hand [22]. Overall, our empirical material, such as the excerpt at the start of this section, shows that numeric standards and quantification of motivation lessens the dialogue and interaction between GP and patient and eliminates the orientation toward the future as well as the focus on the patient’s general life situation.
To summarize, we found that GPs’ and patients’ expectations regarding the structure and content of the health dialogue influenced the character of the motivational work. Our findings show that both GPs and patients in an interplay— influenced and reduced MI in the health dialogues to one-way information due to a treatment-oriented focus and expectations related to perceptions of prevention as an individual and private task. This results in a discrepancy between the biomedical action perspective and the temporality of prevention.