Education Columns

By Maryse Pedoussaut, MD, Herbert Wertheim College of Medicine, Florida International University

The Florida International University Herbert Wertheim College of Medicine (FIU HWCOM) teaches motivational interviewing (MI)^1-3 in a longitudinally integrated fashion across all 4 years of its curriculum. Motivational interviewing is first introduced during an advanced communication skills module at the end of the first-year clinical skills course where we dedicate 3-4 hours per week over 3 weeks to teach and practice MI skills.^2,4 We emphasize reflective listening during the first week. The second week is dedicated to teaching ways to elicit and strengthen change talk (which favors desire change) vs sustain talk (which favors status quo). Finally we provide feedback to students during the third week, viewing videos they created role-playing MI skills. The students themselves decide which health behavior they want to work on (tobacco or alcohol cessation, diet, exercises, avoiding procrastination, etc).^2,4

Training in MI continues in the second, third, and fourth year during FIU HWCOM’s Neighborhood Health Education Learning Program (NeigbhorhoodHELP). Through this program, students are assigned to provide longitudinal, interprofessional care to a household in an underserved neighborhood of Miami Dade County through a series of 10 household visits spanning 3 years. On these household visits, medical students practice real-life MI and receive feedback about their skills from supervising faculty members. We created an MI Entrustable Professional Activity (EPA) and workplace-based assessment to set expectations, prompt feedback, and monitor the students’ progress.
Attainment of MI competencies is also assessed using observed standardized clinical examinations (OSCE) on smoking cessation at the end of their second and third year; students who do not pass the OSCE must remediate the skills with the course director to ensure competency.

Courses and clerkships can easily incorporate didactic and clinical instruction regarding motivational interviewing into their curricula. Didactic sessions on various chronic conditions can integrate teaching on promoting and emphasizing patient-promoted behavior change. Furthermore, we have multiple opportunities to demonstrate and teach MI every day either in clinic or during household visits. It just takes a few minutes.

It is our goal here to share a true story about motivational interviewing, which will hopefully increase awareness of the importance and the feasibility of teaching MI. MedEdPortal has multiple publications of existing curricula which can assist courses and medical schools in integrating and implementing education about MI.

This true story occurred during a household visit in Miami on a Monday in 2015 around 4 pm with a medical student (MS).

MS: How are you doing? (Open question)
Household member (HH): Bad! I failed my driving test again.
MS: You feel frustrated to have failed. (Reflection with feeling)
HH: Yes! I do. This is the third time that I failed. I am so sad!
MS: You are sad. (Simple reflection)
HH: Yes especially because each time I missed it by only one point.
MS: How important on a scale of one to ten is it for you to get your driving license? One being not important at all and ten being very important. (Importance scale).
HH: It is a six.
MS: A six is very good! It is better than a four. Why are you a six and not a four?
HH: I need my driver‘s license to bring my children to school and their different activities. I cannot keep depending on others.
MS: You are a wonderful mother! You care a lot about your children and you want to offer them the best! (Affirmation).
HH: Yes! My family is the most important to me!
MS: How can we help you become an eight?
HH (crying): I am so scared to have a car accident! I was in a car accident two years ago and ever since, I am afraid of getting in another car accident.
MS: On one hand your fear of getting into a car accident is preventing you from getting your driver’s license, but on the other hand you need your driver’s license for your children. (Double side reflection).
HH: Yes, I need it. How can I get rid of these fears?
MS: May I suggest something? (Asking permission).
HH: Yes! Please!
MS: Would you consider therapy?
HH: Oh yes! Thank you so much!

In this scenario, we can observe how in a few minutes the student was able to discover the household member’s true hidden reason for failing the driving test. Nobody could have thought this issue would stem from a posttraumatic disorder after a motor vehicle accident. By encouraging the patient to reflect on her fear, as well as on her need for a driver’s license to help her family, the student was able to help the patient to recognize the origins of her ambivalence. The patient felt heard regarding her fears and empowered by the affirmation of being a “good mom.”

Clearly, the medical student kept asking himself, “what does the patient think?” and, “how does the patient feel?” and was able to appropriately link the patient’s thoughts to her feelings, and especially to her fears. In doing this, he exhibited great listening skills, empathy, and an ability to work with and for his patients.

In sum, training in motivational interviewing provides students with the needed tools to empower and enable their patients to change behaviors toward healthier lifestyles. Furthermore, in its collaborative nature, MI promotes the patient-centered communication skills of active listening and displaying empathy for our patients. There are many existing resources to assist medical schools in incorporating MI in their didactic and clinical teaching.

References

1. Miller WR, Rollnick S. Motivational Interviewing. 3rd ed. New York, London: The Guilford Press; 2013.
2. Brogan Hartlieb K, Engle B, Obeso V, et al. Advanced patient-centered communication for health behavior change: motivational interviewing workshops for medical learners. MedEdPORTAL Publications. 2016;12:10455. https://doi.org/10.15766/mep_2374-8265.10455
3. Elwyn G, Dehlendorf C, Epstein RM, Marrin K, White J, Frosch DL. Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. Ann Fam Med. 2014;12(3):270-275. https://doi.org/10.1370/afm.1615
4. Resnicow K, McMaster F, Rollnick S. Action reflections: a client-centered technique to bridge the WHY-HOW transition in Motivational Interviewing. Behav Cogn Psychother. 2012;40(4):474-480. https://doi.org/10.1017/S1352465812000124