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"The Facts Concerning the Recent Carnival of Smoking in Connecticut" and Elsewhere

Geoffrey C. Williams, MD; Timothy E. Quill, MD; Edward L. Deci, PhD; and Richard M. Ryan, PhD
[+] Article, Author, and Disclosure Information

Grant Support: In part by a grant from the National Institute of Child Health and Human Development (HD19914) to the Human Motivation Program in the Department of Psychology at the University of Rochester.

Requests for Reprints: Geoffrey C. Williams, MD, Department of Psychology, University of Rochester, Rochester, NY 14627.

Current Author Addresses: Drs. Williams, Deci, and Ryan: Department of Psychology, University of Rochester, Rochester, NY 14627.

Dr. Quill: Department of Medicine, North Wing 5, The Genesee Hospital, 220 Alexander Street, Rochester, NY 14607.

© 1991 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1991;115(1):59-63. doi:10.7326/0003-4819-115-1-59
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▪ The behavior of health care practitioners toward their patients can greatly affect the patients' motivation for change. Mark Twain's story, "The Facts Concerning the Recent Carnival of Crime in Connecticut," is used to illustrate how traditional strategies for motivating patients to change can have the paradoxic effect of inhibiting change and growth. We use a theory of human motivation, referred to as self-determination theory, to explain this effect and suggest alternative strategies for facilitating patient motivation. Empirical tests of the theory have shown that people will accept more responsibility for behavior change when motivated internally rather than externally. In the doctor-patient relationship, this internal motivation for change can be faciliated when doctors allow choice, provide relevant information, and acknowledge the patient's perspective. We propose a simple, three-question model, consistent with self-determination theory, for physicians to use with patients who smoke and are not yet ready to try quitting.







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