Teaching students behavior change skills: description and assessment of a new Motivational interviewing curriculum

Abstract

Background: One of the US government health goals outlined in the Healthy People 2010 document (2000) is to increase the number of physicians who counsel their patients regarding unhealthy behaviors. Studies have shown a low rate of physicians provide smoking cessation counseling. We introduced a motivational interviewing curriculum into our medical school for first and third year students and then evaluated the effect of this curriculum on third year students counseling skills.

Methods: The motivational interviewing curriculum was comprised of a lecture series and small group teaching with practice in role plays. The effectiveness of the curriculum was evaluated by student performance in a videotaped interview with a standardized patient who portrayed a smoker. The interview was rated using the Motivational Interviewing Treatment Integrity scoring tool (MITI). The MITI assesses 6 criteria: empathy, MI spirit (autonomy, evocation and collaboration), MI adherence (asking permission, affirmation, emphasis of control and support), MI non adherence (advise, confront and direct), the types of questions (open or closed) and the number of reflections. Secondary outcomes included a knowledge exam related to motivational interviewing and students’ evaluations of the effectiveness of the motivational interviewing curriculum.

Results: Analysis of the MITI scores showed that students reached a proficiency level on the rate of reflections, were just below proficiency in assessment of empathy and motivational interviewing spirit and substantially below proficiency in the percent of open ended questions. These proficiency scores were for professional counselors but nevertheless provided us with information on the effectiveness of the new curriculum and where the focus of our teaching should be. On the optional evaluation of the first-year MI curriculum by 112 students, 83% felt that the MI curriculum had helped them be more comfortable in discussing behavior change with patients and 98% felt it was an important skill for physicians to have.

Introduction

Smoking contributes to an estimated 440,000 deaths per year, obesity to 300,000 and alcohol to another 100,000 (National Center for Chronic Disease Prevention and Health Promotion 2002, Center for disease control and prevention 1990 and 2000). This sobering reality is a call to action for physicians emphasized in Healthy People 2010 (US Department of health and Human Services 2000) which outlines goals for improving national health by increasing the proportion of primary care providers who are assessing and counseling their patients regarding physical activity, nutrition, and smoking. Thorndike et al. (1998) surveyed 3254 physicians and found that physicians inquired about tobacco use in 61% of patient visits but counseled known smokers on smoking cessation at only 21% of visits. These rates are regrettably low since a systematic review of the data from 188 randomized controlled trials done by Law & Tang (1995) showed that brief physician advice on smoking cessation given during a single consultation resulted in a 2% quit rate, confirming that even brief physician interventions are effective. Two studies by Yeager et al. (1996) and Kushner (1995) found that physicians who were asked why they did not counsel their patients to change their diet identified several barriers, including lack of time, reimbursement, and training and low confidence in their ability to be successful. To address this lack of training and confidence some medical schools and residency programs have implemented motivational interviewing (MI) curricula as described by Humair & Cornuz (2003) and Brown et al. (2004). Motivational interviewing is a patient-centered yet directive style of behavior change counseling first described by Miller (1983). The focus of this method is on eliciting “change talk” from the patient instead of advising the patient on what to do. The role of the physician is to help patients explore and resolve their own natural ambivalence regarding the target behavior. Rollnick et al. (1999) have adapted motivational interviewing into a briefer form for use by physicians. This brief type of motivational interviewing has been shown by Butler et al. (1999) to be more effective in moving smokers to quitting than brief advice. Poirier et al. (2004) and Brown & Oriel (1998) demonstrated the positive effects of teaching MI to medical students, including improved student confidence, increased knowledge of counseling techniques, and stronger belief in the importance of behavior change counseling.

Table

Practice points
•Medical students believe motivational interviewing skills are important to acquire.
•Training in motivational interviewing can improve students confidence in talking to patients about behavior change.
•A motivational interviewing curriculum for medical students can improve their ability to use motivational interviewing techniques although some of the more subtle motivational interviewing skills are harder to obtain.

Currently, the University of Virginia School of Medicine curriculum includes required training in motivational interviewing for both first and third year students, with a specific focus on smoking interventions. The goal of this study is to assess the efficacy of this new motivational interviewing curriculum on students’ attitudes, knowledge and competence.

Methodolgy

Setting

The University of Virginia is a four-year public allopathic medical school with a traditional curriculum.

Motivational Interviewing Curriculum

All first year students (Medicine1) receive basic instruction in motivational interviewing in a required clinical skills course, the Practice of Medicine 1 (POM1). There is a three hour lecture series on motivating behavior change which addresses the basic skills for MI, the stages of change model, and brief interventions for smoking cessation. In small group sessions, six students and two Mentors review key points covered in the lecture and role-play motivational interviewing with each other. In preparation for this session, Mentors attend a faculty development session and are given detailed instructions and specific comments for each role-play case.

During the required third-year family medicine clerkship, the MI curriculum continues with a lecture-discussion reviewing MI techniques. The lecturer emphasizes the use of specific questions to help establish the patient's level of readiness to change and to draw out the patient's feelings about the pros and cons of quitting (Figure 1). Students then divide into groups of three, and two at a time participate in role play as the physician and smoker while the third student acts as an observer, using a structured evaluation form to generate feedback. The students are required to practice behavioral change counseling with at least one actual patient during their clerkship and have this activity verified on a checklist. At the end of the four-week rotation, the students are videotaped using motivational interviewing skills with a standardized patient who portrays a smoker in the pre-contemplation stage of change.

Figure 1. Questions adapted from Rollnick S, Mason P, Butler C. Health Behavior Change.

Curriculum evaluation

We videotaped interviews of 46 students who rotated through the 2003–2004 Family Medicine clerkship. The primary outcome of our MI curriculum was student performance in these videotaped standardized patient interviews, which was rated using the Motivational Interviewing Treatment Integrity scoring tool (MITI) developed by Moyers (2005) (Figure 2). When used by trained coders, the MITI has been shown to be a reliable observation tool that is effective in evaluating basic motivational interviewing skills. The MITI consists of two main parts: Global scores and behavior counts. The outcome of the MITI provides two global ratings, two percentages, a total number, and a rate labeled as follows: (1) global empathy score, (2) global spirit score, (3) percentage of motivational interviewing adherent statements, (4) percentage of open questions, (5) number of total reflections and (6) rate of reflections per ten minutes.

Figure 2. Motivational interviewing treatment integrity (MITI) coding sheet.

Two coders were trained in the MITI coding system until they were able to achieve excellent intra-class correlation coefficients (ICC of 0.75–1) on a series of nine independently coded video-tapes of motivational interviews performed by students working with standardized patients according to the system proposed by Cicchetti (1994).

When inter-coder reliability had thus been established, the primary coder analyzed the 46 study tapes. Each student's use of the specific questions shown in Figure 2 was also recorded.

Secondary outcomes included student evaluations of the motivational interviewing curriculum at the end of year one and three, and performance on a pre-post knowledge exam. First-year students complete an optional on-line evaluation of the MI curriculum, and an optional pre-post knowledge exam. The evaluation for first year students contained items rated on a Likert scale that asked about the quality and effectiveness of the MI curriculum and perceived importance of motivational interviewing skills. The knowledge exam addressed the prevalence of health-related behaviors and their consequences, stages of change and motivational interviewing. M3's completed a required evaluation using an adjectival item rating the overall quality of the motivational interviewing workshop, and had the option of making written comments.

The Institutional Review Board at the University of Virginia gave approval for the study.

Results

The mean MITI scores for the 46 third year students in the study group are given in Table 1. The global scores for empathy and MI spirit are measured on a 7-point likert scale. The students’ use of the four questions evaluating and exploring importance (Figure 1) and confidence is shown in Table 2. Over 80% of students used the questions that evaluated importance and confidence and 70% explored importance and 39% explored confidence. On the optional evaluation of the first-year MI curriculum by 112 students, 83% felt that the MI curriculum had helped them be more comfortable in discussing behavior change with patients and 98% felt it was an important skill for physicians to have. Ninety percent thought the small group session was successful but only 68% found the MI lecture helpful. Scores on the pre-post knowledge exam showed a statistically significant improvement indicating that student's knowledge of MI increased immediately following the curriculum. The required post-course evaluation for the family medicine clerkship showed that 79.4% of the students felt that the quality of the workshop was good or excellent, while only 5.9% felt that it was poor. Comments made by the students further elucidate their impressions of this segment of their training. The most frequent content of these responses, after general comments such as ‘good’ or ‘helpful’, was regarding a student's frequent use of the skill during his clerkship and the importance of learning motivational interviewing skills.

Table 1.  MITI scores of Third Year Students in Final SP Interview

Coded item	Mean (standard deviation)
Empathy	4.02 (0.95)
Motivational Interviewing Spirit	4.07 (0.95)
% MI Adherent	66.20% (25.5)
% Open Questions	29.4% (9.8)
Number of Total Reflections	6.9 (3.6)
Rate of Reflections per 10 minutes	10.4 (5.2)

Table 2.  Number of Third Year Medical Students who Evaluated and Explored Importance and Confidence in their Final SP Interviews

Question	Number of students	95% CI
Importance evaluation	41 (89.1%)	76.4–96.4
Importance exploration	32 (69.6%)	54.3–82.3
Confidence evaluation	37 (80.4%)	66.1–90.6
Confidence exploration	18 (39.1%)	25.1–54.6

Discussion

This analysis of our motivational interviewing curriculum shows that students believe that this is an important and relevant topic and they valued the instruction. Their knowledge increased, but objective data on performance shows only limited competency. First-year medical students indicated that the training had improved their confidence in their ability to talk with patients about behavior change and that they felt this was an important skill. Additionally, responses of the students in the third year Family Medicine clerkship indicate that students were using motivational interviewing with patients. Together, these findings suggest that the MI curriculum has the potential to meet one key goal of training — increasing the frequency with which physicians address behavior with patients.

When compared to the suggested proficiency behavior count and summary score thresholds given by the designers of the MITI (Table 3) our students’ scores reached proficiency level on the rate of reflections only. Nevertheless, their scores do show that on average, our students tend more toward behaviors that are consistent with the principles of motivational interviewing. It should also be noted that these proficiency thresholds are for professional counselors engaged in strict motivational interviewing. The students performed well on the use of the specific questions in Figure 1. Training students to ask specific questions that can be used effectively in the context of motivational interviewing, may be a more achievable short term goal than teaching students the more subtle skills of motivational interviewing. During standardized patient interviews, over 80% of the M3s in the study used the ranking questions on the importance of smoking cessation and patient confidence in their quitting potential. However, the students were less consistent in capitalizing on the patient's response to those ranking questions and using them to explore the patient's reasoning behind their ranking.

Table 3.  Comparison of M3 performance on the MITI with proficiency thresholds established by the creators of the MITI

Behavior count or summary score thresholds	Competent level	Beginning proficiency	Third-year UVA student average
Global ratings  (Empathy and Spirit)	6	5	4
Percent Open Questions	70%	50%	29%
Rate of Reflections  per 10 minutes	15	10	10
Percent MI-Adherent	90%	80%	66%

The overall impact of the motivational interviewing curriculum appears to be positive: The majority of the students see it as a useful skill and many have begun to put it into practice during their clinical clerkships. While an objective evaluation of the M3s’ performance in motivational interviewing shows room for continued improvement, it also shows that the students are using some techniques consistent with good motivational interviewing, such as asking permission before giving advice and using reflections. Nevertheless, this evaluation of our program has indicated several areas in which our students could improve: Showing empathy, evoking the patient's own reasons for wanting to change and supporting the patient's autonomy (aspects rated in the global spirit category), and asking more open questions.

The assessment of our motivational interviewing curriculum has been limited by several factors. First, we lacked baseline data regarding student performance and attitudes before the training. Second, there is no current plan for evaluating the long-term effects of our curriculum; without this, we cannot know to what extent this training will be translated into increased and effective behavior change counseling in future medical practice. Third, first-year student evaluations of the MI curriculum were optional and could be affected by respondent bias. Fourth, we did not track students exposure to smoking patients or any behavior change teaching they received during their clinical experiences. Finally, the MITI is a fairly new tool and not directly intended for use among medical professionals; but it is the best instrument we are aware of to evaluate our students’ proficiency in motivational interviewing.

This evaluation provides valuable insight for the design and development of the motivational interviewing curriculum and will enable our instructors to emphasize the aspects of motivational interviewing with which previous students have struggled. Using an assessment tool such as the MITI may also be an effective way to provide the students with specific feedback on their areas of strength and weakness. Putting more emphasis on self or peer-evaluation of practice performance using the MITI may be beneficial to others developing MI curricula for students and residents.