Advanced Patient-Centered Communication for Health Behavior Change: Motivational Interviewing Workshops for Medical Learners

Abstract

Introduction

Medical settings are critical access points for behavior change counseling, and lifestyle behavior change is considered a key component of chronic disease management. The Association of American Medical Colleges recommends that future physicians be competent in shared decision making and patient-centered behavioral guidance to prevent illness and improve patient self-management of chronic disease. Motivational interviewing (MI) is a patient-centered, directive method of communication to enhance behavior change. Specific teachable strategies underlie the collaborative MI communication style that aims to reduce discord and build motivation for change.

Methods

We present our three-session 12-hour MI curriculum as an advanced form of patient-centered communication. Each session includes presession assignment, large-group interactive lecture, and small-group activities for practice. An interdisciplinary team consisting of medical educators and health behavior change research-educators who are also members of the Motivational Interviewing Network of Trainers created the submission. The purpose of this resource is to provide medical educators with a short curriculum that incorporates materials and learning activities to promote skill in MI.

Results

In addition to positive feedback from student evaluations including the areas of relevance to training and self-rated skills improvement, preliminary pre- and posttraining scores from the medical students show significant improvement in expression of empathy and the ratio of reflections to questions.

Discussion

Implementation of the curriculum allows learners the opportunity to practice evidence-based communication that promotes intrinsic motivation for health behavior change in patients, a key treatment focus in chronic disease management.

Educational Objectives

Upon completion of this curriculum, learners will be able to:

• 1.Demonstrate the spirit of motivational interviewing (MI): partnership, acceptance, compassion, and evocation.
• 2.Demonstrate MI skills with an emphasis on reflective listening.
• 3.Identify, elicit, and strengthen change talk and commitment language.
• 4.Explore a range of target health behaviors.
• 5.Develop a patient-centered action plan.

Introduction

Medical settings are critical access points for behavior change counseling,¹ and lifestyle behavior change is considered a key component of chronic disease management.² However, the opportunity to capitalize on behavior change counseling is often missed by physicians due to a lack of training and low confidence in behavior change counseling.^3,4 The Association of American Medical Colleges recommends that future physicians be competent in shared decision making and patient-centered behavioral guidance to prevent illness and improve patient self-management of chronic disease.⁵ Self-management support has been shown to improve health care and health outcomes for people with chronic disease as well as clinician and patient satisfaction⁶ and is a hallmark of the Patient-Centered Medical Home.

Motivational interviewing (MI) is a patient-centered, directive method to enhance behavior change.⁷ Emphasis is on accepting the patient's perspective while increasing motivation, self-efficacy, and commitment for change by selectively focusing on patient statements that promote behavior change. Specific teachable strategies underlie the collaborative MI communication style that aims to reduce patient resistance and build motivation for change.

We present our MI curriculum as an advanced form of patient-centered communication. It is helpful for learners to have an understanding of patient-centered communication concepts (e.g., empathy, active listening, nonverbal communication skills) prior to training in MI. In addition, exposure to content regarding physiological and psychological substance dependence, screening methods (e.g., SBIRT: screening, brief intervention, and referral to treatment and the Five A's model), treatment for tobacco, alcohol, and other drugs (e.g., discussion of 12-step programs and specialized treatment programs), the chronic care model of disease management, and discussion of factors associated with adherence to a prescribed medical regimen is useful in setting the stage for how MI may be applicable in different contexts.

The submission was created by an interdisciplinary team consisting of medical educators (family medicine and internal medicine) and health behavior change research-educators with backgrounds in dietetics/nutrition, social work, and psychology who are also members of the Motivational Interviewing Network of Trainers (MINT). This collaboration provided a beneficial melding of the knowledge and skills needed to build, revise, and implement the curriculum in ways that would best meet the needs of the learners.

Methods

The purpose of this resource is to provide medical educators with a short curriculum that incorporates materials and learning activities to promote skill in MI. The curriculum can be used in any health care–related professional school. We find it necessary for the faculty facilitator for the large-group lectures (LGLs) to have expertise in MI, along with experience teaching and supervising, and ideal if he or she is a member of MINT.

It is also highly beneficial if the faculty facilitators for the small-group activities (SGAs) are at least proficient in MI; however, the activities have been designed to support faculty who may be in the process of learning MI while acting as a facilitator. When using less-experienced faculty, it is helpful to pair them in small groups with more-experienced faculty initially. Additionally, it is recommended that faculty attend a preview of the MI sessions provided by the LGL facilitator and complete the SGAs as learners prior to facilitating the small group. The prework for each session is extremely important as it activates students; thus, the small-group practical sessions are more impactful.

Each session is designed for completion in 4 hours, including a 90-minute to 2-hour LGL with a 10-minute break and a 90-minute SGA with time for to students to transfer to breakout rooms. Both the LGL and SGA require presentation, audio, and video capabilities in the room. The SGAs benefit from individual rooms for each group of eight to 10 students plus facilitator(s).

The sessions break down as follows. For more details, please consult the instructor files for each session (Appendices F–H).

Session 1

Presession

• •
  Reading material:

  • ○
    Instructions for Role-Plays (Appendix A).
  • ○
    MI Skills Coding for Learners (Appendix B).
  • ○
    Optional: Resnicow and McMaster, “Motivational Interviewing: Moving From Why to How With Autonomy Support.”⁸
• •Record Practice Video 1.

LGL (90 minutes-2 hours)

• •File: Session 1 LGL Slides (Appendix C).
• •
  Videos:

  • ○
    MI Introductory Demo (Appendix I).
  • ○
    Reflective Listening Sample (Appendix J).
  • ○
    Summary Content Sample (Appendix K).

SGA (90 minutes)

• •File: Session 1 SGA for Instructors with Materials (Appendix F).
• •
  Activities:

  • ○
    Soul Train.
  • ○
    Effective/Ineffective Physician Videos (Appendices Q & R).
  • ○
    Group Role-Play.

Homework

• •Optional reading assignment: Resnicow, McMaster, and Rollnick, “Action Reflections: A Client-Centered Technique to Bridge the WHY–HOW Transition in Motivational Interviewing.”⁹

Session 2

Presession

• •Completion of homework from Session 1.

LGL (90 minutes-2 hours)

• •File: Session 2 LGL Slides (Appendix D).
• •
  Videos:

  • ○
    Change Talk Importance Demo with Captions (Appendix L).
  • ○
    Change Talk Confidence Demo with Captions (Appendix M).

SGA (90 minutes)

• •File: Session 2 SGA for Instructors with Materials (Appendix G).
• •
  Videos:

  • ○
    Change Talk Audio (Appendix O).
  • ○
    Change Talk Video (Appendix P).
• •
  Activities:

  • ○
    Reading Between the Lines for Change Talk.
  • ○
    Eliciting/Strengthening Patient Importance and Confidence.

Homework

• •Record Practice Video 2.
• •Optional reading assignment: Miller and Moyers, “Eight Stages in Learning Motivational Interviewing.”¹⁰

Session 3

Presession

• •Completion of homework from Session 2.

LGL (30 minutes)

• •File: Session 3 LGL Slides (Appendix E).

SGA (2 hours)

• •
  Files:

  • ○
    Session 3 SGA for Instructors with Materials (Appendix H).
  • ○
    MI Skills Coding for Learners (Appendix B).
• •Activities: video review, coding, and group feedback.

LGL (45 minutes-1 hour)

• •Selected student practice videos.

Homework

• •MI Practice Change Plan Worksheet (Appendix N).

Results

The curriculum has been under development at the Florida International University Herbert Wertheim College of Medicine (FIU HWCOM) during the spring semester of the first year of medical school since 2010. During the initial implementation, we found it beneficial to recruit facilitators with experience in MI to assist existing faculty. For example, MI-trained social work graduate students cofacilitate the small groups while faculty are in the process of improving their MI skills. FIU collaborated with Barry University School of Social Work graduates. Over the years, we have developed, implemented, and refined versions of the curriculum. FIU HWCOM implemented the submitted curriculum during the 2015 spring semester. To date, 120 students have completed the submitted curriculum. Four hundred students completed prior iterations of the curriculum. Feedback from the 120 student evaluations rated on a 5-point scale found high agreement between course objectives and course content (3.97 ± 0.85), self-rated improvement in communication skills (3.87 ± 1.02), and relevance to including MI in student medical education (3.88 ± 1.03). This indicates that the majority of students found the curriculum increased their confidence and the importance around using MI for health behavior change conversations. Of note, students also appreciated the feedback and guidance they received during the small-group practice sessions (4.16 ± 0.89). Preliminary pre- and posttraining scores from the medical students using the MI coding tool called the MITI 3.1 show significant improvement in expression of empathy and the ratio of reflections to questions.¹¹

Discussion

It is extremely important that the students be exposed to the rationale for why they are learning MI skills. Showing them the evidence helps to prime them, and interaction with practicing faculty can further reinforce the importance. Also, students need to understand the situations (smoking, drinking, adherence, diet, exercise, any other behavior change discussion) when they should consider using the skills. Also, first-year students need to understand that it is not intended they use MI in every interaction. Rather, they should understand MI as one of the tools they can pull out in the appropriate setting and understand it as an approach to engaging with patients around behavior change topics.

Students need to understand that MI is an approach that does not necessarily require lengthy sessions, that they can use the individual skills (i.e., reflections, goal setting while supporting autonomy) in the appropriate setting without necessarily planning a formal MI session.

MI is a skill. Knowledge is not sufficient. The SGAs are the most important part of this curriculum, giving students the opportunity to practice.

Students can learn a lot of the theory on their own through reading. Providing them some initial reading materials and the initial video assignment prior to the first class session has resulted in significant activation of the students for learning.

Additional practice with feedback beyond the initial sessions is necessary to build and maintain proficiency.

Finally, we acknowledge limitations of the resources. The world of MI is ever evolving. For example, the framework of the four processes—engaging, evoking, focusing, and planning—in the 2012 edition of Miller and Rollnick¹² and the emphasis on question types in MI coding systems, such as in the 2014 Motivational Interviewing Treatment Integrity Coding Manual,¹³ have both changed since the inception of this learning activity. As a result, just as the authors of MI primary resource materials reevaluate their content each year, we encourage users of this curriculum to do the same. In addition, it has been documented that learners require additional opportunities for observation, practice, and feedback in order to reach competency in the MI spirit and communication skills. If there is too much time between the initial curriculum and opportunities for additional practice and feedback, a booster session may be required.

Appendices

A. Instructions for Role-Plays.doc

B. MI Skills Coding for Learners.doc

C. Session 1 LGL Slides.pptx

D. Session 2 LGL Slides.pptx

E. Session 3 LGL Slides.pptx

F. Session 1 SGA for Instructors with Materials.docx

G. Session 2 SGA for Instructors with Materials.docx

H. Session 3 SGA for Instructors with Materials.doc

I. MI Introductory Demo with Labels.mp4

J. Reflective Listening Sample Captioned.mp4

K. Summary Content Sample Captioned.mp4

L. Change Talk Importance Demo with Captions.mp4

M. Change Talk Confidence Demo with Captions.mp4

N. MI Practice Change Plan Worksheet.docx

O. Session 2 Activity 1 Change Talk Audio.MP3

P. Session 2 Activity 1 Change Talk Video.mov

Q. Effective Physician.mp4

R. Ineffective Physician.mp4

All appendices are peer reviewed as integral parts of the Original Publication.