The Question That Changed Everything About How I Practice She sat across from me with blood pressure readings I could not stop thinking about. Numbers consistently in the 150s and 160s over 80s and 90s, a family history of heart attacks, a prescription she was clearly not filling. When I asked her how important it was for her to take her medication, she said three. Three out of ten. My first instinct, trained into me over years of nursing, was to explain the risk more clearly. To make the fear louder. To add more education to a pile that was clearly not working. I had been doing that my whole career. It almost never moved the needle. The Training Gap in Healthcare Here is the thing about how most of us were trained in healthcare. We learned the disease process. We learned what goes wrong and how to fix it. We became experts at emergencies, at diagnosis, at the surface-level solution. What we were not trained in what most clinical programs still do not teach is health behavior change. Seventy-five percent of the chronic disease we are facing in our healthcare system is preventable. It is driven by what people do, think, and say. To actually address it, we need to be skilled at something none of us signed up to learn: being genuinely interested in what the person across from us cares about, more than we are interested in being right about what they should do. The Importance Ruler, a tool from motivational interviewing developed by Rollnick, Miller, and Butler, is where I started learning that skill. What the Importance Ruler Actually Is It is a question. On a scale of zero to ten, how important is it for you to make this change? That is it. That is the beginning. What happens next is where the real work lives. After they give you a number, you ask: why did you pick that number and not a lower one? That single question invites them to say, in their own words, why it matters at all. Not your reasons. Theirs. If the number is low, you do not panic. You ask: what would have to happen for this to become more important to you? That question reveals education gaps, competing priorities, and sometimes a completely different path toward the same goal that you never would have discovered by telling them what to do. The third question is the one I return to more than any other. What matters most to you? If you do not know the answer to that question, you are practicing medicine on a diagnosis and ignoring the person inside it. When you can connect a health behavior change to what someone is actually living for a granddaughter they want to chase around the yard, a retirement they want to be well enough to enjoy, a body they want to trust again the importance number moves. Not because you pushed it. Because they found it. Start with Yourself Here is what makes this framework different from a clinical checklist: it is a dual-process tool. You are supposed to practice it on yourself first. Before I could use it effectively in a patient conversation, I had to know what it felt like to sit with the question. I had to feel the difference between changing because something was important to me versus changing because someone else told me to. When I asked myself how important it was to lift weights, I gave myself a one. Which was honest. I had been setting that goal and abandoning it for two years. That honest one led me somewhere useful: I found out I needed a DEXA scan before I could actually care, I discovered that what I love is Tai Chi and yoga and bodyweight movement, and I gave myself permission to pursue bone density in a way that actually fit my life. The skill worked on me before I could work it on anyone else. If you are a clinician, a nurse, or a healthcare leader reading this, I invite you to try it right now. Think of one health behavior change you are working on. Rate its importance zero to ten. Then ask yourself the follow-up questions. Write down what you notice. That experience will do more for your clinical effectiveness than any training hour you have ever logged. Four Moments to Use This in Your Next Visit The Importance Ruler is flexible. You can open a visit with it to build trust: “Before we get started, what matters most to you about your health today?” You can use it mid-visit to connect a goal to a value: “You mentioned your family is everything to you. How does managing your blood pressure help you be there for them the way you want to be?” You can reach for it when resistance shows up, when a patient has missed appointments or stopped filling prescriptions, because resistance almost always means the importance has dropped and nobody has asked why. You can use it when the same goal has appeared on three consecutive visit notes without moving. Each time, the goal is the same: shift the focus from what you think is important to what they know is important. They are the experts of themselves. Their motivation is what changes behavior. Your job is to help them hear it clearly. One Small Action for This Week Before your next conversation with a patient or a staff member where change feels stuck, ask the importance question. Just one conversation. Notice what you learn that you would not have learned any other way. Then come back and tell me what happened. Take it on a test drive. If you are serious about improving your communication skills consider becoming a paid member of Communication station. In the paid community you will access videos and worksheets that accompany each skill. I am rooting for your success! Karla This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit communicationstation.substack.com/subscribe
