Optimism Is Not The Opposite Of Realism

“I’ve been smoking for 40 years. Nothing will make me quit, ever. I’m not a quitter. You can’t make me quit!”

The majority of our patients who smoke say they have no interest in quitting. We love them, but they drive us nuts. We know what they need but they won’t do it. Well, they can’t, or believe they can’t, is more like it. But from our perspective, especially those of us who have never smoked ourselves, we see it as a choice they are making. And sometimes it feels like they are doing it just to spite us.

They’re right, though, we can’t make them quit, no matter how much we want to. We want to take away all simple carbs from our diabetics, all sodium from our hypertensives, and the cigarettes from our asthmatics, too, but we can’t. Nor should we want to, that’s not what we’re good for.

All we can do is recommend and hope that telling them will make a difference. We can provide alternatives, help with making changes, and support in self-confidence.

But know what you ARE good for

Research shows that patients listen to us when we’re talking, even if it’s just a throwaway one-liner like “are you ready to quit? No? Okay then, moving on…” Mentioning quitting at the visit is shown to increase quit rates remarkably. So ask if they’re ready to quit at every single visit, but don’t belabor the point. Don’t ram it down their throat; that’s not going to help anything.

It gets tiring asking over and over again, though, doesn’t it? Especially when they get upset at you every time. Sometimes you wish you could just leave it alone, and consider it a lifestyle choice, and let them suffer the consequences. But you can’t, can you? Because you do care, and want the best for them and their health, however paternalistic it may be.

With my most obstinate patients, I make it into a joke. I tell them “okay, you’re going to laugh, but you know I have to ask this every time, like I told you I would… you ready? Okay … Are you ready to quit smoking?” That way, they’re usually laughing with me rather than getting huffy at me for asking yet again.

Then one day, one of your most cantankerous I-will-die-with-a-cigarette-on-my-lips-so-stop-asking patients comes in and says: “hey, I quit smoking!” When you ask why, they say something like “I knew I should,” “you kept asking about it, so I knew it was important,” “I wanted to be healthier,” “I knew it was the right thing to do,” or “I just felt like it.” We don’t care what the reason is anyway, do we? We just wanted them to quit, and when they do we are indeed happy for them and excited for their health.

These moments teach us to be optimistic

Always believe they can change, even when your brain and heart tell you that it’s impossible. Sharing your optimism helps patients be optimistic as well, and optimism breeds self-confidence, which provides fertile ground for change. They can tell when you’re pessimistic, and worse, when you become cynical and jaded and stop caring and stop asking.

Yes, you need to be realistic, too, but optimism and realism are not opposites. You are paid and respected to be realistic, and help them deal with their medical reality. But humanity demands that you do it in ways that have meaning to them.

Realism means not only following their pack-year history and talking to them about risks of heart disease and lung cancer, but also recognizing that change is hard and scary. If you’ve never smoked, you are at a great disadvantage in supporting patients to quit smoking, because you’ll simply never understand. Sure, you can empathize, and you may think you understand, especially if you have worked through other addictions, but even if you’re right, the patient will never believe you.

When I was in school and we were practicing motivational interviewing techniques on each other, about ten minutes into the exercise one of my classmates silenced the entire class by shouting at her partner:

“BUT YOU HAVE TO FLOSS!!! HOW CAN YOU NOT UNDERSTAND THAT?!? WHAT ARE YOU, STUPID?!?”

Clearly she was missing the point, but I see many providers using that same argument style simply because they feel so frustrated, like their recommendations never get anywhere with the patients.

Motivational interviewing is not about browbeating them until they change, it’s about meeting them where they are, assessing their motivation and willingness and ability to change, and then supporting that to the best of your ability. It’s about realistically instilling optimism along with the confidence and skills to change.

I make great use of the smoking helpline in Arizona where I work, because many of the counselors are former smokers, and know what it’s like. I don’t, and I admit that to my patients up front. But I also share that I do know the health benefits of quitting and I want what’s best for them, and I’ll support them in any choice, and do my best to take care of them.

It’s what I’m good for.

Do you have a story about the clash between realism and optimism and how you handled it, or about patients who decided to quit? Share it in the comments below!