Can Primary Care Physicians Learn and Adopt Brief Motivational Interviewing Techniques in their Practice? Alan Adelman, MD, MS David Richard, MD Robert Gabbay, MD, PhD Deborah Van Horn, PhD Marie Graybill, RN Allen Kunselman, MA

Supported through a grant from NIDDK Penn State Hershey NIDDK

Context Brief motivational interviewing (BMI) is a patient-centered approach to behavior change counseling Adapted from MI because of time constraints of medical encounter Proposed as a behavioral change counseling method that utilizes specific techniques germane to a primary care practice Mixed results in the literature

Research Aims Can practicing primary care clinicians learn BMI? Will practicing primary care clinicians adopt this counseling technique into their practice? Can a practicing primary care clinician who uses this counseling technique have an impact on diabetes outcomes?

Methods Recruited 24 clinicians from the Penn State Ambulatory Research Network Randomized by office to intervention/control 12 Month training program

Methods Pre-evaluation Post-evaluation Audio-taped baseline encounters with participant-selected established patient with DM2 Post-evaluation Control – audiotaped encounters with participant-selected established patient with DM2 Intervention – 2 unannounced visits by standardized patients – scenario new patient with DM2 Tapes rated using BECCI and MITI scales

Measures of MI Fidelity Motivational Interviewing Treatment Integrity (MITI) Behaviour Change Counselling Index (BECCI)

Training 3 hour workshops at baseline and 3 months 1 hour sessions at 1, 2, 4, 5, 6, 9 and 12 months Submission of 2 audiotaped encounters with particpant-selected patients before each training session – rated using BECCI and MITI with personalized feedback Motivational Interviewing in Health Care – Helping Patients Change Behavior by Rollnick, Miller & Butler

Skills Open-ended questions, affirmative/reflective/summary statements (OARS) Assessing Importance/Confidence Decision Balance Elicit-Provide-Elicit Action Planning

Results

Population 21 physicians completed – 11 intervention, 10 control Specialty – 2 internists, 19 family physicians Experience - several years to > 20 years post residency

BECCI Change in Measure Intervention Control P-value BECCI 0.82 0.10 0.019 BECCI-Speak 0.38 -0.04 0.306

MITI Change in Measure Intervention Control P-value Global Spirit 1.17 0.31 0.037 % Complex Reflections 14.18 -1.74 0.086 % Open Questions -5.22 0.82 0.180 Reflection to Question Ratio 0.09 0.00 0.502

MITI Change in Measure Intervention Control P-value % MI Adherent 19.20 9.41 0.425 MITI Direction 0.61 -0.20 0.014 MITI Empathy 1.28 0.14 MITI Information Giving 9.39 6.86 0.600

Conclusions Can primary care physicians learn BMI – yes, but…. The skill of Reflection may take longer to master Will primary care physicians adopt into their practice – yes in the short term Can a practicing primary care clinician who uses BMI have an impact on diabetes outcomes? – Remains an unanswered question

Limitations Small numbers – this was a pilot study Measuring MI fidelity Not well suited for a clinical encounter No clear standards for primary care No clear threshold

Questions?