Original Publication
Open Access

A 1-Hour Session to Refresh Motivational Interviewing Skills for Internal Medicine Residents Using Peer Interviews

Published: February 12, 2018 | 10.15766/mep_2374-8265.10679

Appendices

  • Slide Presentation.pptx
  • Whiteboard.pdf
  • Peer Observation Checklist.pdf
  • Facilitator Guide.docx

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

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.


Abstract

Introduction: Motivational interviewing (MI) is an interviewing style with extensive evidence to support its use in clinical encounters. Physicians and other health professionals require dedicated education to learn MI techniques. Methods: We developed a replicable, 1-hour session to refresh MI skills for internal medicine residents. The session focused on utilizing MI to address health behavior change during ambulatory visits. Using mixed presentation methods, the session offered a review of the conceptual background of MI followed by the introduction of a brief interview structure adapted from the SBIRT (Screening, Brief Intervention, and Referral to Treatment) technique. Learners then conducted peer interviews to discuss a health-promoting behavior and were observed by a peer and the instructor. Results: Based on immediate pre- and postfeedback, resident learners expressed enjoyment of the sessions and reported a perception of improved skills and confidence in MI, suggesting the session met its objectives. The session was refined over 2 years to fit standard 1-hour learning sessions in an internal medicine residency curriculum. Though the adaptations are not presented here, the slides and supporting materials were used in multiple settings with other levels and disciplines of learners. Discussion: We offered a 1-hour session to refresh skills in MI. The session accommodated the learning needs of resident physicians working in primary care but could be adapted to other groups of learners. This refresher session is not intended for nor likely to be successful with learners who have not had prior training in MI.


Educational Objectives

At the end of the session, learners will be able to:

  1. Recall the principles of motivational interviewing (MI).
  2. Describe a brief MI framework appropriate for a primary care visit.
  3. Conduct a brief motivational interview regarding a health behavior.

Introduction

Motivational interviewing (MI) is an extensively researched interview style for facilitating behavior change.1-3 In recent years, dozens of clinical trials have demonstrated its replicability, efficacy, and patient-centeredness. It represents a preferred interviewing method for clinicians.4

Most MI curricula rely on faculty who are committed to the topic and comfortable with its principles. Limited data exist regarding the prevalence of such MI curricula in internal medicine residencies, and based on anecdotal reports, MI teaching is inconsistently provided, suggesting gaps may be widespread.

We set out to create a straightforward refresher session to strengthen internal medicine residents’ MI knowledge and skills. As with many internal medicine programs, the standard curriculum at our program occurred in 1-hour blocks. We attempted to adapt the material into a session that fit this time constraint. The key aspects of MI in this session included reviewing the principles of MI, strengthening interview skills, and focusing on applicability to clinical encounters. Because psychiatrists and primary care physicians are among the groups that most often utilize MI and are most familiar with the context of MI, we arranged for representatives of both fields to design and teach the sessions. Because this resource describes a session designed for internal medicine residents, the term resident appears interchangeably with learner. However, these tools were also adapted to other learner groups, and readers may consider such adaptations at their discretion.

This resource offers succinct MI content in a 1-hour format allowing portability to different settings. There exist other peer-reviewed resources that may meet similar pedagogical needs, although they do require substantially more time to complete or are not geared towards residents. Such resources include “Advanced Patient-Centered Communication for Health Behavior Change: Motivational Interviewing Workshops for Medical Learners,”5 a 12-hour curriculum designed for first-year medical students that may serve as a starting point for new learners; “Helping Your Patient Change: A Patient-Centered Behavioral Counseling Presentation for Second-Year Medical Students,”6 a brief curriculum designed for second-year medical students and focused on the stages of change; and “A Skills-Based Curriculum for Teaching Motivational Interviewing-Enhanced Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Medical Residents,”7 a 16-hour comprehensive curriculum in substance use disorder counseling and MI for residents.

It should be noted that content outside the core principles of MI was not the target of this session, though instructors may choose to allude to such content during Q&A periods and interview feedback. That type of content includes complementary conceptual frameworks, counseling principles related to recovery from substance use disorders, and evidence of MI’s efficacy in various settings. All are helpful adjuncts to MI and are often taught in combination with it. However, we believe that the benefits of focusing learners on MI and fitting the session into 60 minutes outweigh the inclusion of noncore content. This other material may be useful to make allusion to during the Q&A components of the session.

Methods

The presented materials were taught to postgraduate first-year residents typically in the first third of the year. Given that such learners were entering the clinic for the first time, this was thought to be an optimal period for instruction regarding how to integrate patient counseling for health behavior change into clinical encounters. The session lasted 1 hour.

Personnel and materials required for these sessions included one or two instructors, with the second instructor primarily assisting with observing peer interviews; a projector for the slide-based portion; a whiteboard for the corresponding portion (can be projected if needed; Appendix B); enough space for learners to comfortably split into groups of three and conduct peer interviews; and the printing of enough checklists so that each learner could be distributed a copy. Detailed instructions for how to deliver this section are included in Appendix D.

The agenda for the session was as follows:

  • 0-20 minutes: An introduction was given, and slides were presented by the instructor, followed by Q&A.
  • 20-28 minutes: The interview format was presented on the whiteboard, followed by Q&A.
  • 28-58 minutes: Peer interviews were conducted in groups of three (10 minutes per interview).
  • 58-60 minutes: The session concluded with feedback and questions.

Preparation for the session included queuing the slides (Appendix A), prewriting on the whiteboard (Appendix B), and printing peer observation checklists (Appendix C). At the session’s start, the instructor facilitated introductions and outlined the structure of the session. A sample script for this and other oral portions of the presentation is included in Appendix D. Next, slides covering the fundamentals of MI were presented, followed by a brief break for questions (notes for the slide presentation are included in the notes section of the Appendix A PowerPoint slides). The instructor then delivered the whiteboard content, which consisted of a framework for a brief interview. After a second break for questions, the instructor divided students into groups of three to conduct peer motivational interviews. As described in greater detail in Appendix D, during the peer interviews the learners discussed simple, nonstigmatized health behaviors such as exercise habits or avoiding unhealthy food during residency shifts. In each group of three, one learner served as the interviewer, one as the interviewee, and one as a peer observer using the checklist (Appendix C). The instructor circulated during the peer interviews, observing interviewing styles and offering feedback between interviews. Finally, after each student had participated in each role, the instructor ended the session with a final opportunity for questions and feedback. Frequently asked questions with suggested responses are included in Appendix D.

Session Flexibility
Regarding session size, although we had successful sessions with up to 12 learners and a single instructor, six to nine leaners per instructor is felt to be more ideal. Physical space for simultaneous peer interviews was another constraining factor, as each group of three learners needed a certain amount of room to perform the peer interviews without having to speak over other groups.

Regarding learner makeup, this session needs little adaptation to be taught to health professions trainees who are not resident physicians but have previously received instruction in MI. We defer to instructors on specific changes. Past sessions have been taught to dental students, psychiatry residents, and nurse practitioner students with few changes and similar results.

For first-time instructors, the session may run long. If the whiteboard portion finished more than 30 minutes into the session, we found it helpful to set the expectation that only two out of the three peer interviews were likely to be completed. As the session was intended to serve as a refresher, it was designed to last 1 hour if presented succinctly. Other published curricula are available to help first-time learners achieve competence with MI. Such sessions are typically several hours in length.

Results

To date, a total of 12 sessions have been taught to an estimated 150 leaners. Although data regarding the sessions are limited, feedback elicited through the residency program’s standard online feedback system was generally positive, though the sample size and response rate were withheld by the residency. The last three sessions were rated 4.8 on a 5-point Likert scale (1 = poor, 5 = excellent). They were also rated by residents as one of the sessions most likely to change their practice patterns. In prior years, formal feedback was not collected, but the sessions often ran long, and based on learner feedback, various items were streamlined or cut and the overall session further refined. Anonymous comments were positive, primarily stating that MI training was perceived as valuable and undertaught.

Three sessions of learners were asked to respond to brief, anonymous, two-question surveys immediately before and after the session. In the notes sections, no residents left constructive or negative comments, but many left laudatory comments. A few learners had to leave midsession due to clinical responsibilities; thus, the numbers of pre- and postsurveys were not equal. Response rate for the presurveys was 100%. Pre-/postsurvey results were compared with unpaired two-tailed Student t tests. Results of these analyses are included below.

  • “How comfortable do you feel using motivational interviewing?” (1-10, 10 = most comfortable; presurvey M = 5.6, SD = 1.7, N = 35; postsurvey M = 7.8, SD = 1.1, N = 30; p < .001.)
  • “How likely are you to use motivational interviewing in a patient encounter?” (1-10, 10 = most likely; presurvey M = 7.0, SD = 2.1, N = 35; postsurvey M = 8.5, SD = 1.0, N = 30; p < .001.)

These results suggest a short-term benefit in terms of interest in and comfort with MI. The first question roughly represents our first learning objective: the ability to recall the principles of MI. The second question roughly represents the second and third learning objectives: the ability to describe an MI framework for use in a primary care visit and the ability to conduct such an interview, respectively. These results should not be overinterpreted. They come from only three sessions and do not support the idea that the sessions created durable practice changes or achieved other ambitious/comprehensive learner outcomes.

Discussion

Training the next generation of primary care providers to have skills to promote health behavior change may help address growing health disparities related to health behaviors. MI’s effects have been extensively validated in diverse realms, including substance use disorders, dietary habits, exercise habits, and medication adherence. We developed a 1-hour session for internal medicine residents to refresh MI skills that may prove valuable in their future practice. Objectives included refreshing the principles of MI, conveying a format for a brief motivational interview, and practicing delivering such an interview. Learners enjoyed these brief sessions.

Strengths include that the sessions drew their design from well-established methods (i.e., the SBIRT technique). The content/material presented was selected for its simplicity from a broad set of available MI materials. The included materials were also among the aspects of MI most frequently utilized in higher-complexity interviewing and counseling formats. The material was curated by a multidisciplinary team of authors with experience and/or certification in primary care–based health coaching, relapse prevention counseling, self-management and recovery training,8 and other MI-linked forms of counseling.

Additional strengths of the sessions include brevity, practicality, applicability to different levels of learner, and reliance on well-validated interview techniques. The sessions were taught to approximately 150 learners, and although feedback on early sessions was not routinely collected, the available feedback has been positive. While several published curricula exist to teach MI to new learners, this is the first session to our knowledge that is designed for a trainee with past experience to succinctly refresh skills and apply MI to clinical encounters. It should be noted that this session is not suited for initial training in MI. Resident learners typically receive training in MI during predoctoral courses, and any residency program interested in teaching this session is encouraged to ensure that learners have the requisite background in order for the session to serve its purpose as a refresher.

A few limitations are noted. When this session is taught elsewhere, the instructors may be more inexperienced. Teaching this session helps the instructor gain more context in MI pedagogy and more skill in how to effectively communicate interviewing techniques to others. For the first several sessions, we suspect instructors may be less effective. Also, we did not track whether this session leads to long-term changes in trainee attitudes and use of MI, the identification of such trends being beyond the scope of this simple pedagogical intervention. We are certain that more study regarding optimal teaching of MI would be valuable, including whether further best practices may be integrated into this session. We encourage others who adopt or adapt these materials to share their thoughts and experiences with us. Furthermore, the ultimate goal of a pedagogy similar to this is to create a primary care workforce with sophisticated interviewing skills for health behavior change. This small intervention is unlikely to achieve that goal. As such, the ideal quantity and frequency of MI training during residency training for primary care physicians are unknown, and further work will be needed to define these parameters.

As may be inferred from the appearance of other topics in this report, MI techniques may be most valuable when included in a curriculum that also features related topics. These may include, for instance, the transtheoretical stages of change, the evidence base for MI, principles of recovery, and the principles of other interview/counseling modalities (e.g., mutual-help groups, health coaching, etc.). In this session, we do not offer a full curriculum to cover these varied and important topics. At our institution, such topics are generally taught to later-year resident physicians or integrated into sessions focused on other materials (e.g., grief responses, substance use disorders, etc.). We encourage instructors to consider their own institution’s curricular approach to teaching such topics when adapting this session.


Author Information

  • Matthew Tobey, MD: Attending Physician, Division of General Internal Medicine, Massachusetts General Hospital; Instructor, Harvard Medical School
  • David Marcovitz, MD: Psychiatry Attending, Harvard Medical School; Staff Psychiatrist, Department of Psychiatry, Massachusetts General Hospital
  • Gowri Aragam, MD: Resident Physician, Department of Psychiatry, Massachusetts General Hospital; Clinical Fellow, Harvard Medical School

Disclosures
None to report.

Funding/Support
None to report.

Ethical Approval
Reported as not applicable.


References

  1. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009;65(11):1232-1245. https://doi.org/10.1002/jclp.20638
  2. Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013;93(2):157-168. https://doi.org/10.1016/j.pec.2013.07.012
  3. VanBuskirk KA, Wetherell JL. Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med. 2014;37(4):768-780. https://doi.org/10.1007/s10865-013-9527-4
  4. SBIRT: Screening, Brief Intervention, and Referral to Treatment. SAMHSA-HRSA Center for Integrated Health Solutions website. http://www.integration.samhsa.gov/clinical-practice/SBIRT. Accessed November 5, 2016.
  5. Brogan Hartlieb K, Engle B, Obeso V, Pedoussaut MA, Merlo LJ, Brown DR. Advanced patient-centered communication for health behavior change: motivational interviewing workshops for medical learners. MedEdPORTAL. 2016;12:10455. https://doi.org/10.15766/mep_2374-8265.10455
  6. Kolasa K, Craven K, Byrd J, Merricks P. Helping your patient change: a patient-centered behavioral counseling presentation for second-year medical students. MedEdPORTAL. 2015;11:10166. http://doi.org/10.15766/mep_2374-8265.10166
  7. Azari S, Ratanawongsa N, Hettema J, et al. A skills-based curriculum for teaching motivational interviewing-enhanced Screening, Brief Intervention, and Referral to Treatment (SBIRT) to medical residents. MedEdPORTAL. 2015;11:10080. http://doi.org/10.15766/mep_2374-8265.10080
  8. Frequently asked questions. SMART Recovery website. https://www.smartrecovery.org/resources/faq.htm. Updated 2018.


Citation

Tobey M, Marcovitz D, Aragam G. A 1-hour session to refresh motivational interviewing skills for internal medicine residents using peer interviews. MedEdPORTAL Publications. 2018;14:10679. https://doi.org/10.15766/mep_2374-8265.10679

Received: September 9, 2017

Accepted: January 2, 2018