Motivational interviewing is missing In action

Abstract

Introduction Chronic disease (CD), such as diabetes, hypertension, and cardio-vascular conditions, remains the leading causes of morbidity and mortality in the USA. Many of these conditions are preventable, with primary risk factors including physical inactivity, poor nutrition , tobacco use, and excessive alcohol consumption [1]. The cost of CD to the American medical system is enormous, exceeding $1 trillion annually [1]. Beyond financial implications, chronic conditions are also strongly associated with reduced quality of life. Management of CD requires not only evidence-based medical interventions but also effective engagement with patients, whose daily behaviors (i.e. diet, medication adherence, and physical activity) directly inf luence their health outcomes. While physicians are increasingly attentive to social determinants of health (SDOH), many lack a structured approach for increasing patient motivation. Motivational interviewing (MI), an evidence-based technique originally developed in addiction medicine, provides a framework for addressing ambivalence and supporting patient-driven change [2, 3]. Yet, despite its documented efficacy, MI remains underutilized in practice. The current shortcomings in CD management stem not from the lack of effective treatments, but in part, from insufficient strategies to engage patients in a meaningful way. Chronic disease management and the role of engagement Effective CD management depends heavily on patient behavior and self-management. A systematic review of CD interventions in primary care demonstrated that self-management support, such as encouraging patients' day-today health decisions, was consistently associated with improved outcomes, particularly for diabetes and hypertension [4]. Furthermore, patient behavior is a major factor in health outcomes when compared with clinical care (Fig. 1) [5]. This highlights that physicians alone cannot ensure long-term disease control: patients' active participation is essential. The physician-patient relationship forms the foundation of CD management. Beyond prescribing medications, physicians inf luence patients' lifestyle choices, behaviors, and treatment adherence through the way they communicate. Historically, medicine has relied on a paternalistic model in which physicians directed patients to act. While expedient, this approach often fails to address ambivalence or build patient trust. Modern care increasingly emphasizes shared decision-making, aligning treatment with what patients' value most in their quality of life. Motivational interviewing offers a structured communication style that fosters this collaborative approach to patient care. Developed from Carl Rogers' client-centered model and expanded in the 1980s, MI emphasizes ref lective listening, respect for autonomy , and guiding patients toward identifying their own reasons for change [2, 3]. Research across multiple disciplines has shown that MI strengthens motivation for behavioral change and improves adherence. For example, in patients with diabetes, interventions that combined MI techniques with traditional education significantly reduced diabetes distress and improved Hemoglobin A1c levels [6]. Why motivational interviewing remains missing in action Broader influences on chronic disease management While behavior change is critical, patients' ability to manage CD is shaped by broader structural and social factors. Social determinants of health, such as poverty, housing instability, and food insecurity, profoundly affect outcomes [1]. Systemic barriers, including limited insurance coverage, restricted access to specialists , and affordability of medications, also hinder adherence. In addition, psychological health, cultural norms, and health literacy further complicate care. Even within these constraints, physicians play a pivotal role in patient engagement. Their communication style can either alienate patients or help them navigate challenges. Directive approaches risk reinforcing power imbalances, while MI supports patients in finding personally meaningful reasons to prioritize their health despite barriers. Barriers to motivational interviewing adoption The persistence of traditional directive styles ref lects entrenched cultural and structural forces within medicine. Although MI has been incorporated into undergraduate medical curricula, literature shows limited uptake in real-world clinical encounters [7]. Medical education continues to prioritize biomedical expertise, often sidelining communication skills. While MI training exists in medical school, it is inconsistently standardized, and exposure may be too brief to foster mastery. The hidden curriculum during Figure 1 Determinants of health outcomes. The figure depicts how each health factor determines health outcomes. Physical environment 10%, health behaviors 30%, clinical care 20%, and Social & Economic Factors 40%. This model was modified from Remington et al. [5]. Data included in the figure were obtained from an outside source that was distributed under the terms of the creative commons attribution license (https://creativecommons. org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited graduate medical education exacerbates the problem. Role mod-eling, mentorship, and informal feedback strongly inf luence how residents approach patient communication [8]. When clinical pre-ceptors neglect MI, learners tend to adopt directive habits instead, leading to skill attrition and reduced confidence in applying and utilizing the MI approach [8]. Attrition is not just limited to students. Clinicians with several years of practice often require additional training to reacquire MI proficiency, suggesting erosion of skills when not regularly reinforced [7]. Thus, the medical training environment perpetuates a cycle in which MI is "missing in action," and a less effective directive communication persists as the default. MI is often perceived as time-consuming by busy clinicians. However, research demonstrates that MI can be integrated efficiently into encounters, particularly when brief interventions are applied with skill [3]. The barrier is less about feasibility and more about culture. MI is not yet seen as the "default" mode of patient interaction. Clinician well-being and burnout Underutilizing MI has consequences not only for patients but also for clinicians. Physicians face high rates of burnout, often exacerbated by frustrating encounters with patients who do not engage in their own healthcare [9]. MI offers a more humanistic approach that reframes these interactions, fostering collaboration rather than conf lict. Evidence suggests that MI may buffer against burnout by creating more meaningful patient encounters and reinforcing professional satisfaction [9, 10]. Thus, prioritizing MI aligns with the "quadruple aim" of enhancing population health, improving patient experience, and reducing cost, all while supporting provider well-being. Skeptics argue that MI training adds to an already crowded medical curriculum or that real-world clinical demands leave no room for lengthy counseling. Yet the evidence indicates otherwise , MI training is teachable, sustainable with reinforcement, and adaptable to brief encounters [7]. Moreover, the cost of neglecting behavior change is far greater, as the USA continues to spend disproportionately on healthcare while achieving poor outcomes [1]. Implications and next steps The underutilization of MI represents a lost opportunity for both patients and physicians. To improve CD outcomes, MI must be fully integrated into the daily practice of medicine. Academic physicians play an important role in this process, as their behaviors in clinical settings serve as models from which students and residents learn. When role models consistently demonstrate MI in practice, trainees are more likely to internalize the approach and implement it within their future careers. Without such reinforcement , classroom instruction quickly erodes, and directive communication styles persist. Medical education must therefore embrace MI within both the formal and hidden curriculum. This requires a cultural shift in how communication is valued within training programs, along with transparency and accountability for the behaviors modeled in clinical settings [8]. In addition, community preceptors who teach students in ambulatory sites should have access to MI training , ensuring that learners receive consistent exposure across the