Motivation in medical education and patient communication. The EGPRN meeting in Zurich, Switzerland, October 2010

Abstract

The European General Practice Research Network held an international research meeting on ‘Motivation in medical education and patient communication’ in Zürich, Switzerland, in October 2010. The two authors were keynote speakers, who introduced the theme from different angles and summarized and reflected on individual papers presented at the conference. The theme of the conference underlined the importance of communication in general practice and of motivation in medical education in particular. There were a variety of papers each addressing in its own way the topic of this meeting. We conclude that it is still uncommon to use psychological theories on motivation in research on motivation and patient communication in general practice/family medicine. Motivation and readiness to change are essential concepts in experimental health services research. Research designs increasingly follow the Framework for the Evaluation of Complex Interventions in Health Care as suggested by the British Medical Research Council. However, there are also difficulties related to classical experimental designs that have to be critically discussed.

Key words::

• Medical education
• motivation
• research methods
• general practice
• family medicine
• standardized patients

Background: The EGPRN Conference in Zürich in 2010 (Autumn)

The European General Practice Research Network (EGPRN) is a research network within Wonca Europe, with the primary aim to initiate and support development of research projects and capacity in general practice/family medicine. EGPRN does this in several ways, one of which is by organizing ‘two-day’ meetings targeting a specific theme. In these meetings, usually in May and October, invited experts give their view on the theme and invite for discussion. Furthermore, the programme includes presentations of theme papers, poster sessions and freestanding papers by authors from all over Europe. The two authors of this article were the keynote speakers who introduced the theme from different angles and at the end of each day summarized and reflected on the theme papers.

Motivation in medical education and patient communication

At first glance it may sound unusual to hold a meeting of a research network on the topic of medical education and patient communication. However, at second glance it is only a natural thing to do. First of all, medical education represents a large research area, in which theories about how we as health care professionals learn are developed, hypotheses are made and subsequently are investigated. For example, problem-based learning initially started as an enjoyable way of teaching and learning. It is now mainstream in medical education with a robust literature (1) and used in many postgraduate courses for general practitioners/family physicians. Research in patient communication has shown that knowing how to communicate with patients is as important as knowing what to communicate (2). Indeed, in vocational training in general practice/family medicine communication with patients has a prominent place.

Use of simulated and standardized patients (SPs) to motivate learning

In this keynote the message was conveyed that the methodology of SPs is a sound scientific method, which also brings fun, and fun is a key element of motivation (3). Without doubt real patients are the best motivators for learning. However, with more students entering medical schools, who all need to be assessed in an equal way, shorter in-hospital stays of real patients, the evidence that feedback is a core element of learning and that repetitive practice is essential, there definitively is a need for alternative methods in medical education. Simulation is one of these methods, with simulated and standardized patients as the oldest and ‘human’ part in these (4,5).

There is a difference between simulated and standardized patients. A simulated patient is a layperson who has been trained to portray a patient with a specific condition in a realistic way. There is an emphasis on the authentic-realistic case portrayal. A standardized patient is a simulated patient with the emphasis on standardization. Therefore, standardized patients are predominantly used for high-stakes assessment purposes, where all candidates must meet the same standardized stimulus, and for research for the same reasons. However, simulated patients are more used for teaching situations, where differences between simulated patients sometimes are even sought for just as real patients with a similar complaint or disease may differ. Standardized patients are also widely used for research purposes in real practice as for example the use of ‘incognito’ or unannounced patients has shown (6).

For simulated as well as standardized patient methodology validity, reliability and feasibility have been shown to be high, whereas acceptability is very high for those who have worked with SPs: students and staff love it. In teaching communication skills simulated patient methodology has shown to be one of the most effective methods since it enables experiential learning and facilitates receiving/asking for feedback and repetitive practice, for example breaking bad news (7).

Motivation or manipulation

Health promotion is an area where communication skills of GPs are regarded as particularly important. The use of psychological theory and motivational or behavioural techniques has improved GPs’ effectiveness in this area. While previously, doctors’ authority and simple didactic means prevailed, it is now sophisticated strategies that work on patients’ motivation in a collaborative way. Among the approaches developed the ‘stages of change’ or ‘transtheoretical model’ and related approaches are the most popular with GPs worldwide (8). The advent of shared decision-making (SDM), however, has also shown certain limits to motivational techniques (9).

Behavioural techniques still imply that the health professional ‘knows what is best’ for the patient. This is questioned within the SDM-paradigm. It also the experience of every GP that behaviours that look irrational at first glance often follow a certain logic and can even fulfil a supporting function in an individual life. Motivational or behavioural techniques should thus be reserved for goals that patient and physician have agreed upon (10). The discourse leading to this kind of agreement should be an exchange between equals: the GP as the expert of disease and evidence-based management options, the patient as the expert of his illness and his or her life that—in the case of chronic illness—has evolved around the former.

Different perspectives on motivation in medical education and patient communication

During this EGPRN meeting several papers were presented that covered several aspects of motivation in medical education and patient communication. Kremer et al., from Germany touched the issue if and how undergraduate medical student should learn to deal with pharmaceutical advertisements. Bombeke et al., (Belgium) asked how we can motivate students to become more patient-centred doctors since she showed that students, doing their clerkships, experienced a gap between the ideal communicating model and the way doctors in real life talk to their patients. Raginel et al., (France) concluded from their survey, that teenagers in France are not motivated to consult their general practitioner on sexual issues. These papers show the wide range of possible perspectives on the issue of motivation. In this article we will concentrate on two aspects, one relates to the content and another to research design. The content perspective can again be divided into two subjects: the construct of motivation and the area/domain to which the motivation is applied.

The construct of motivation

In their review on the psychological construct of motivation Ryan and Deci (11) distinguish between intrinsic and extrinsic motivation, each of which is defined as a single construct. While being motivated means to be moved to do something, they state that people may vary in their level of motivation as in their orientation of their motivation. Intrinsic motivation is defined performing an activity for its inherent satisfactions rather than for separable consequence: the mere feeling of joy of doing something. Extrinsic motivation, on the other hand, pertains whenever an action is undertaken to obtain some separable outcome. Extrinsic motivation can be divided in several phases, which reflect more or less externally motivations. It is possible that an activity originally perceived by an individual as external, later is perceived as intrinsic by that same individual. For example, memorizing and practicing communication skills to pass an exam (an external motivation) may later turn into a joyful activity (internal motivation), as it is a key element of practicing as a GP.

A dynamic view

In both areas addressed by the conference theme, there is an emphasis on change. Academic teachers do not contain themselves to noticing whether there is motivation in their students or not. They rather want to foster motivation according to the objectives of the programme or school. The same applies to practice where clinicians want to know what their patients’ motivation is to give up smoking, to take tablets for their high blood pressure or to return for regular visits to monitor their INR or Hb_A1C.

These dimensions coincide nicely in the paper by Lapprand et al., (France). Here the motivation of GPs to acquire a new skill is the primary topic. However, the content area is motivational interviewing to help obese patients lose weight. GPs turned out not to be willing to invest sufficient time and money, again showing that engrained behaviours and attitudes are extremely stable, and therefore, difficult to change.

Motivation for change: Research issues

The preceding paragraphs show how pervasive the concept of motivation is not only in general practice but also in the whole healthcare area. It is not surprising that it is an underlying theme in many studies that aim at improving processes and outcome of health care. However, researchers studying interventions to change professional attitudes and behaviours face a double difficulty: achieving measurable behaviour change and managing complexity.

To analyse meaningful data, researchers studying the topic must motivate GPs to behave differently from usual. In the paper of Badertscher et al., (Switzerland) GPs were expected to improve the detection of skin cancer. In the CARAT-Study (Frei et al., Switzerland), a specially trained nurse within the practice team took care of type-2 diabetic patients. In the control group of this cluster-randomized trial practices provided usual care. Both studies were still ongoing at the time of the conference. These reports and others highlight the need to employ effective means to motivate participating practices to test a novel approach to a particular clinical problem. If there was no change of providers’ behaviour, collecting outcome data at the patient level would have been a waste of resources. However, unusual effort and sophistication of principal investigators may threaten the external validity of a study. Intense motivational work aimed at participating GPs to implement innovative care will not reflect what will happen after the end of study in every day routine. This is a dilemma any researcher of health care interventions does face. Policy makers and clinicians acting upon the results of such studies must keep this in mind.

A framework to evaluate complex interventions

Not unlike drugs interventions for the improvement of health care have to be evaluated in carefully designed research process. The framework developed within the British Medical Research Council has become the widely accepted paradigm to develop, test, optimize and evaluate complex interventions to improve health care (12).

Among the studies presented at the conference, the work by Laporte et al., (France) on an intervention to reduce cannabis consumption most clearly refers to this framework. The basic ideas of the framework are (1) a profound understanding of the setting and the people that the intervention is aimed at; and (2) a gradual process of testing and improving the intervention. Qualitative studies are essential to explore these areas. Only after these stages have been completed with still a good chance for the intervention to make a difference, a phase-III-evaluative study should be embarked upon. This is usually a cluster-randomized trial involving several dozens of practices and between 500 and 2000 patients. Researchers and clinicians working their way through this sequence must be (self-) critical enough to give up their idea if preliminary studies show that the intervention is unlikely to have an impact.

Difficulties

That change is difficult to achieve is an almost universal experience in health services research. We have reasons to assume that this is even harder in primary care than in other parts of our health care systems. One reason might be that general practice teams are part of wider communities, which adds complexity to the process of care and related change. Another difference to the hospital setting is that GPs think in longer time frames (‘longue durée’). GPs work with their patients on a long-term basis. Diagnosis and therapy are negotiated over weeks or even months, treatments can be tried in sequence with patient evaluation of effects. This reality clashes with the usual time frame of externally funded intervention trials. Here the time span between an intervention to change provider behaviour and the assessment of patient outcomes rarely exceeds 6 months. Substantial change might still happen but not be captured within this short timeframe.

Realistic evaluation

Against the background of these experiences the question arises whether altogether different approaches are needed to evaluate interventions aimed to improve the quality of care. One of these has been suggested by Pawson and Tilley who face similar difficulties in the areas of social work and crime prevention (13).

They suggest that the classical experimental paradigm has reached its limits. Meta-analyses of educational or social interventions inevitably reach the conclusion, that there were improvements in some units (schools, prisons, communities, etc.) but not in others. In some places, circumstances lead to enthusiastic uptake and resulting improvement, whereas in others nothing happens at all. A general statement whether an intervention ‘works’ or does not, therefore, does not make sense. We rather have to understand the local circumstances of success and failure. From this we can learn our lessons, which are like the one shown in Figure 1. These include the interplay of an intervention, the mechanism by which it impacts on the regular working of a unit, such as a practice or team, and the wider context in which this is happening. This blend of ‘local’ and ‘general’ knowledge limits the external validity of research findings, but still some conclusions can be drawn that will inform future interventions to be implemented in other units (practices, networks, health care systems). This is an iterative process from which transferable knowledge results. However, this will not be of the kind that an intervention will be ‘declared effective’, rather of the structure depicted in Figure 1. Insights from previous projects will only be useful if they are used with critical awareness for the complexity of the specified field in question.

Figure 1. Understanding Interventions to improve the quality of health care. Modified after Pawson & Tilley (12).

In this way the cycle—observation, asking critical questions, theory, hypothesis, piloting, real experiment, analysis and conclusions—seems to be a common currency in assessing individual and aggregate motivation, the chances for change as well as evaluating innovations in health care. For individual researchers, however, this means that their choice of research designs is not simple. They need a broad range of methods and designs to get an answer for their questions. There can be no doubt that this still is a tremendous challenge for every scientist in general practice/family medicine.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper