EVALUATION OF A WORKSHOP TO IMPROVE RESIDENTS’ PATIENT-CENTERED OBESITY COUNSELING SKILLS

Abstract

Background

Primary care physicians are being asked to counsel their patients on obesity and weight management. Few physicians conduct weight loss counseling citing barriers, among them a lack of training and confidence. Our objective was to pilot test the effectiveness of a three-hour interactive obesity-counseling workshop for resident physicians based on motivational interviewing (MI) techniques.

Design

This study used a pre/posttest cross-sectional design. A convenience sample of resident physicians was invited to participate. Participating resident physicians completed a pre- and post-intervention questionnaire to assess their knowledge, beliefs, and confidence in obesity counseling. MI techniques taught in the intervention were evaluated by audio-recording interviews with a standardized patient (SP) pre- and post-intervention. Audio-recordings were transcribed and coded by two independent coders using a validated assessment tool. Paired T-tests were used to assess pre and post intervention differences.

Results

Eight-six residents attended the workshop. At baseline, the majority (71%) felt that there is not enough time to counsel patients about obesity and only 24% felt that residency trained them to counsel. After the intervention, knowledge and confidence in counseling increased (p<0.001). Among the 55 residents with complete pre-post SP interview data, MI adherent statements increased from a mean of 2.88 to 5.42 while the MI non-adherent statements decreased from 6.73 to 2.33 (p<0.001).

Conclusion

After a brief workshop to train physicians to counsel on obesity-related behaviors, residents improved their counseling skills and felt more confident on counseling patients. Future studies are needed to assess whether these gains are sustained over time.

Introduction

As obesity becomes more prevalent in our society, physicians are being charged with addressing lifestyle and behavioral change issues [1]. The Centers for Medicaid and Medicare Services now provides physicians reimbursement for obesity screening and counseling in an effort to combat the epidemic of obesity and its long term health consequences [2]. Patients who receive behavior and lifestyle counseling from their physicians report higher motivation to lose weight and a better understanding of the risks of obesity [3]. In fact, behavioral and counseling interventions can affect modest (4-8%) weight loss in patients, prompting the US Preventive Services Task Forces to recommend physician screening for obesity risk using Body Mass Index (BMI) [4]. These guidelines, in conjunction with evidence that modest weight loss can positively affect risk factors associated with obesity highlight the potential impact that primary care physicians could have when implementing weight loss counseling in their practice [5]. Despite these findings and recommendations, a recent study found that weight loss counseling was only initiated by primary care physicians in 17% of their overweight or obese patients [6]. Physicians are often not comfortable addressing behavior change with their patients, citing a lack of training and knowledge in obesity counseling, low confidence in their own skills, time constraints and patient non-compliance [7]. In a study among primary care physicians, only 30% of physicians reported being trained well in obesity management [8]. Those who reported previous training were more likely to discuss diet and exercise with their obese patients [8]. In a separate study, physicians who practiced more patient-centered techniques such as motivational interviewing (MI) had success in achieving higher degree of weight loss in their patients [9]. A recent review of MI interventions indicated that MI techniques can be integrated into residency education programs [10].

Motivational Interviewing (MI) is a counseling technique designed to enhance patient centeredness and is now being applied to various types of behavior change counseling, including obesity-related behaviors [11]. By emphasizing a patient’s own motivation, MI more effectively elicits behavior change than traditional counseling techniques [12]. Training resident physicians in principles of MI provides them with counseling skills that are often lacking in resident training, while addressing the Accreditation Council of Graduate Medical Education (ACGME) core competencies of “patient care” and “interpersonal and communication skills” (acgme.org).

Taking into account the impact of counseling on patient care combined with the cited lack of physician training in patient-centered counseling, we developed an obesity counseling workshop that was based on the core principles of Motivational Interviewing (MI) and the 5A’s. The US Preventive Services Task Force has endorsed using the 5 A’s (ask, advise, assess, assist and arrange) as a counseling framework that can guide practitioners when addressing behavior change [13]. We developed a 3-hour obesity counseling workshop for both Internal Medicine and Pediatric Residents that provided instruction in patient centered counseling as well as developed tools to measure the newly acquired skills. The goal of our pilot study was to implement and evaluate the effects of an obesity counseling workshop on resident physicians’ knowledge, skills and self-efficacy in patient-centered obesity counseling.

Methods

Study Design

The obesity counseling workshop was evaluated using a pre-post design. Counseling skills were measured via audio-recorded clinical encounters with Standardized Patients (SPs) prior to and immediately following the workshop. Residents also completed a 33-item questionnaire to assess knowledge, attitudes and self-efficacy before and after the workshop. All study protocols were approved by the university’s Institutional Review Board.

Participants

During their outpatient/ambulatory month, Internal Medicine and Pediatric resident physicians (residents) received email invitations describing the study and inviting them to participate in a three-hour obesity counseling workshop. The workshop was also included on residents’ outpatient/ambulatory schedules for the month. Two workshops were developed and administered, one tailored for Pediatric residents and another for Internal Medicine. The residents were invited to attend the workshop pertaining to their respective specialty. Upon arrival to the workshop, the study was explained again and residents were asked to sign written informed consent. Residents were given the option to participate in the workshop whether or not they chose to participate in the study. The workshops were scheduled in the afternoon and most residents were able to attend with the exception of those who had their continuity clinic or were on vacation. Workshops were held from July 2009 to June 2010, administered once a month separately to each group of residents (Pediatric and Internal Medicine) by AMB and facilitated by two of the authors (ALC and AAA).

Program Description

The obesity counseling workshop was made up of 4 sections developed with specific attention to adult learning theory [14]. Details regarding the development of the workshop have been published previously [15]. Section 1 began with an interactive lecture aimed at increasing the residents’ knowledge regarding the national and regional obesity epidemic and its contributing factors. Current obesity guidelines, as outlined by the U.S. Preventive Services Task Force and the American Academy of Pediatrics, as well as practical ways to implement these into practice were reviewed and tailored for the group of residents [13,16]. Section 2 introduced the spirit of Motivational Interviewing (MI) along with communication techniques to help promote an MI adherent interaction. This section emphasized the use of Open Ended Questions, Affirmations, Reflections and Summaries (OARS) during a clinical encounter. These principles were reinforced and modeled through video examples and interactive exercises aimed at increasing self-efficacy and interpersonal skills. After residents were taught how to incorporate these techniques of MI into a clinical encounter, they received handouts that provided information on community resources and weight loss counseling tools that could be implemented in their clinical practice. Section 3 focused on recognition of the newly learned techniques. Residents listened to audiotaped examples of MI non-adherent and MI adherent clinical encounters. As the encounters played, they were asked to identify the key principles of MI as described above. Lastly in section 4, the residents proceeded to role-play with their peers and practice their newly acquired skills while the instructors (AMB and ALC) gave positive and constructive feedback. The audiotaped encounters and role-play scenarios were carefully selected to target resident physician self-efficacy and interpersonal counseling skills.

Measures

Residents’ knowledge in obesity prevalence and weight management was assessed using three questions. Five items addressed residents’ attitudes and perceived barriers to obesity counseling. These questions were scored on a Likert Scale from 1=strongly disagree to 5=strongly agree ( Table 2 & 3). Residents’ self-efficacy for patient-centered obesity counseling was assessed using the Perceived Competence for Obesity Counseling (PCOC) scale [17]. Developed for this study, the PCOC scale consists of 18 items constructed around the 5A’s framework as well as motivational interviewing [17]. The items are scored on a 5 point Likert scale with scores ranging from 5 (extremely confident) to 1 (not at all confident). Factor analysis revealed 3 subscales labled 1) Assist and Agree, 2) Assess and Advise and 3) Arrange with a Cronbach alpha of 0.95. Residents’ patient-centered counseling skills were assessed using their audiotaped clinical encounters with standardized patients (SPs). SPs employed in the present study had been previously trained by the university’s school of medicine for medical student objective structured clinical exams (OSCEs). The SPs participated in an additional hour-long training session to review and practice clinical scenarios specifically developed for residents participating in this study. The residents interviewed a distinct SP both before the workshop and then again at the end of the workshop. They were given 10 minutes for each encounter and all encounters were audiotaped. All audio recordings were then coded using the Motivational Interview Treatment Integrity 3.1 scales (MITI 3.1), a coding system developed and used to assess practitioners’ competence in Motivational Interviewing [18, 19]. Reliability, validity, and sensitivity indices have been published for early versions of the MITI [20-22]. A psychology graduate student (lead coder for this study) and 2 faculty members were trained to use the MITI coding system by one of its developers during a two day training workshop at UAB. Following the initial training workshop, the coding team coded practice interview tapes until they achieved reliability estimates similar to those for global ratings and behavior counts published by Moyers et al., 2005, using intraclass correlation coefficients (ICCs) [23]. One of the trained faculty members cross-coded 10% of the tapes coded by the lead coder in order to address potential drift over time. Global scores for Evocation, Collaboration, Autonomy/Support, Direction and Empathy, were all scored on a 1-5 scale. An average Global Spirit Rating was calculated from Evocation, Collaboration, and Autonomy/Support ratings. The MITI 3.1 also captures counts of specific behaviors related to patient-centered counseling, including Open Questions, Closed Questions, Total Reflections and MI Adherent statements (asking, permission, affirm, emphasize control, support) and MI non adherent statements (advise, confront, direct). Patient-centered counseling emphasizes using open ended questions to help facilitate discussion, moving away from a directive, paternalistic style of counseling that is reflected in closed questions. Additionally, reflective listening statements are statements that clinicians use to convey what the client has said during a patient-centered counseling session.

Table 2.

Baseline attitudes and barriers to counseling among Internal Medicine and Pediatric residents

Question	Percent who Agree or Strongly Agree
	All	Internal Medicine	Pediatrics	P Value
Most obese patients cannot lose enough weight to impact their health.	7%	9.1%	3.2%	0.30
I feel obese patients are lazy.	7%	10.9%	0%	0.05
I feel uncomfortable discussing weight with my patients.	17.4%	10.9%	29%	0.03
There is not enough time to counsel on obesity.	70.9%	74.5%	64.5%	0.32
Residency trains me to counsel.	24%	20%	32.3%	0.20

Table 3.

Selected knowledge questions and proportion of residents answering correctly before and after the workshop

Selected Question	All (n=86)			Internal Medicine (n=55)			Pediatric (n=31)
	Pretest	Posttest	P value	Pretest	Posttest	P value	Pretest	Posttest	P value
What percentage of Alabama is overweight or obese? Correct Answer: 33%	64%	88%	<0.001	71%	95%	<0.001	52%	77%	0.02
What should be your minimal daily caloric deficit in order to lose 1lb per week? Correct Answer: 500kcal	55%	94%	<0.001	53%	93%	<0.001	58%	97%	<0.001
Which of the following are contributing factors to the increase of obesity: a. Increased portion sizes b. Decreased physical activity Correct Answer: A and B only	69%	83%	0.01	71%	82%	0.10	65%	84%	0.03

Analysis

The objective of this pilot was to assess the effects of brief training in Patient-Centered Obesity Counseling on residents’ knowledge, self-efficacy and competence in counseling. Univariate analyses were conducted to describe the sample characteristics, attitudes and perceived barriers to obesity counseling. Paired T-tests were used to assess mean differences (pre vs post) in knowledge (% correct), self-efficacy (Perceived Competency for Obesity Counseling scale and subscales), and counseling (MITI scores and behavior counts). Analyses were conducted first for the total sample and then stratified by program (Internal Medicine & Pediatrics). All analyses were conducted using SAS statistical software version 9.2 [24].

Results

A total of 86 residents attended the workshop (52 Internal Medicine, 31 Pediatric, and 3 Med/Peds) (Table 1). Residents were evenly distributed across training levels (Post Graduate Year (PGY) 1 36%, PGY2 33.7%, and PGY3 27.9% ). Of the residents, 52% were female and 48% male. The majority of the residents plan to enter a Subspecialty (53%), while only 19% identified Primary Care as their career choice. Nearly 60% of residents report regularly counseling their obese patients to lose weight.

Table 1.

Sample Characteristics of Residents (n = 86)

Characteristic	Response	n (%)
Gender	Female	45 (52.3)
	Male	41 (47.6)
Track	Internal Medicine	52 (60.5)
	Pediatrics	31 (36.1)
	Med/Peds	3 (3.5)
Training Year	PGY* 1	31 (36.0)
	PGY 2	29 (33.7)
	PGY 3	24 (27.9)
	PGY 4	2 (2.3)
Career plans	Primary Care	16 (18.6)
	Hospitalist	6 (6.9)
	Subspecialty	46 (53.4)
	Undecided	18 (20.9)

^*PGY: Post Graduate Year

The majority of residents (71%) felt that there is typically not enough time to counsel patients about obesity; only 24% felt that residency trained them to counsel these patients (Table 2). Regarding attitudes towards obese patients, 7% of all residents felt that obese patients were “lazy”. However this was driven by Internal Medicine residents, 10% of whom agreed or strongly agreed with this sentiment compared to 0% of Pediatric residents (p=0.05). Overall, 17% of residents felt uncomfortable discussing weight with their patients, with significant differences between Internal Medicine residents and Pediatric residents (10.9% vs 29%, p=0.03)

Knowledge improved among all residents for all questions and improvements were statistically significant. Specifically when asked the minimal caloric deficit in order to lose 1lb per week only 55% of the residents answered correctly on the pre-test while 94% answered correctly on the post test (p<0.001). The knowledge questions and the pre and post workshop numbers for all the residents both Internal Medicine and Pediatrics are seen on Table 3.

Using the PCOC scale, residents’ self-efficacy had a significant increase (p<0.001) as evidenced by increase of the mean total scale from 57 pre-test to 70 post-test. There were also significant increases in all 3 subscales (1) Assist and Agree, 2) Assess and Advise and 3) Arrange) across both Internal Medicine and Pediatrics residents (Table 4).

Table 4.

Change in Perceived Competence for Obesity Counseling from Pretest to Posttest

	All Residents (n=55)		P value	Internal Medicine (n=32)		P value	Pediatrics(n=23)		P value
	Pretest	Posttest		Pretest	Posttest		Pretest	Posttest
PCOC	57.02	70.36	<0.001	60.41	72.94	<0.001	52.30	66.78	<0.001
Subscales:
Assist and Agree	33.36	42.53	<0.001	34.88	44.16	<0.001	31.26	40.26	<0.001
Assess and Advise	14.33	16.60	<0.001	15.66	17.06	<0.001	12.48	15.96	<0.001
Arrange	9.32	11.25	<0.001	9.85	11.73	<0.001	8.57	10.57	<0.001

Matched audiotaped SP interviews were coded with MITI for competence in counseling skills. Fifty-two residents had matched pre- and post audiotaped SP interviews for comparison (Table 5). For the Global Score, the mean pre workshop score for all the residents was 15.29 and which increased to 19.73 (p<0.001) at post workshop. These increases in Global Scores were statistically significant for both Internal Medicine and Pediatric residents (Table 5). The ratios of Open to Closed Ended questions increased from 0.56 to 0.83 (p<0.05) for the total group of residents. The number of Reflections also improved from a mean of 4.04 before the training to 4.90 after the workshop (p<0.001). Lastly, the MI adherent statements increased from a mean of 2.88 to 5.42 among both Internal Medicine and Pediatric residents while the MI non-adherent statements decreased from 6.73 to 2.33 (p<0.001).

Table 5.

MITI Scores for Longitudinal Sample (n = 52) and for Internal Medicine residents (n=31) and Pediatric residents (n=21)

MITI Element	All pre Mean(STD)	All post Mean(STD)	P Value	Internal Medicine Pre Mean(STD)	Internal Medicine Post Mean(STD)	P Value	Pediatrics Pre Mean(STD)	Pediatrics Post Mean(STD)	P Value
Global Scores	15.29 (3.88)	19.73 (3.58)	<0.001	15.10 (3.67)	19.74(3.92)	<0.001	15.57(4.25)	19.71(3.12)	<0.001
No. Open Questions/No. Closed Questions (ratio)	0.56 (0.34)	0.83 (0.97)	0.03	0.48 (0.38)	0.82(1.20)	0.09	0.68(0.23)	0.84(0.47)	0.06
No. Reflections	4.04 (2.80)	4.90 (2.81)	0.05	4.77(2.96)	5.42(3.09)	0.31	2.95(2.20)	4.14(2.19)	0.05
No. MI Adherent statements	2.88	5.42	<0.001	2.52	5.10	<0.001	3.43	5.90	<0.001
No. MI non-Adherent statements	6.73	2.33	<0.001	7.19	2.13	<0.001	6.05	2.62	<0.001

Discussion

Multiple studies including ours have shown that physicians do not feel prepared to discuss issues about obesity with their patients, citing a lack of training [7 25]. Our study addressed this lack of training as well as low physician confidence through the implementation of a 3-hour workshop to improve patient-centered obesity counseling skills among Internal Medicine and Pediatric resident physicians. After attending the workshop, residents had a significant increase in knowledge, self-efficacy and counseling skills.

Physicians who are better trained and more confident in their counseling skills are more likely to discuss weight loss with their patients [25]. Post workshop residents’ perceived competence for obesity counseling improved. Adult learning theory would suggest that the workshop’s success lies in the interactive design, including multiple opportunities for the residents to practice the newly taught skills of patient-centered counseling [14]. To emphasize key principals of Motivational Interviewing (MI), residents watched brief clips and listened to examples of MI adherent and MI non-adherent interactions within clinical encounters. They had the opportunity to practice with their peers while receiving real-time feedback from MI trained instructors and also interviewed SPs pre and post workshop.

Training residents in the principles of MI not only holds potential for increasing confidence and competence in behavior change counseling, it simultaneously focuses on Patient Care and Communication skills, both of which can be difficult to teach and evaluate. Our workshop is proof of skill acquisition that can be used to enhance patient care. Our workshop provides a practical example of how residency programs can incorporate the ACGME Milestones into an educational experience. This workshop allows the resident to demonstrate specific behaviors that can be observed and measured. For example, two of the Internal Medicine Milestones for Interpersonal and Communication Skills are “use patient-centered education strategies” and “engage patients/advocates in shared decision making for uncomplicated diagnostic and therapeutic scenarios.” By incorporating principles of MI, this workshop addresses both ACGME competencies of Patient Care and Interpersonal and Communication Skills and further demonstrates specific Milestones that correspond to those Competencies.

Teaching trainees to use MI can address one of the barriers often cited by practicing physicians for addressing behavioral change – lack of training [7]. The spirit of MI emphasizes the patient’s control and explores their ambivalence about change, and unlike traditional patient education it does not rely on the physician to provide what is often untailored advice to their patients [26]. In a recent study by Pollak et al, patients of physicians who specifically used MI consistent techniques lost weight 3 months after the encounter, while those whose physicians used MI inconsistent techniques either gained or maintained weight [9].

This study is limited by a small sample size confined to one geographic location and thus the results may not be generalizable to other programs in other settings. Also, the outcomes in this study were assessed immediately after the workshop and thus we cannot determine whether or not the skills will persist long term. In the future, it may be beneficial to have spaced reminders or brief refresher sessions for the resident physicians to maintain their newly obtained skills. Although several portions of this workshop are easily implemented, having instructors trained in MI facilitating the workshop and providing feedback could be a limitation to disseminating a program of this style. Fortunately, there are an increasing number of opportunities to gain exposure to Motivational Interviewing through online resources and consultative services. Finally, this study did not assess patient outcomes and thus we cannot assess the influence of increases in residents’ confidence and competence in patient-centered counseling on outcomes such as BMI or patient adherence.

In conclusion, we developed a 3-hour workshop designed to improve residents’ patient-centered obesity counseling skills. After the workshop, residents not only felt more confident in themselves but their skills improved. Importantly, the skills acquired in this workshop could be carried over into other areas of health behavior change such as smoking cessation and medication compliance. Other residency programs could implement this workshop to simultaneously teach Patient Centered Care, an ACGME Core Competency, while equipping residents to counsel in health behavior change (acgme.org).

Main Message

A brief workshop is feasible and effective method to teach resident physicians MI techniques to counsel on obesity-related behaviors.

Current Research Questions

How often and when should refresher courses and/or spaced reminders on MI counseling techniques be offered?