Teaching medical students in early interventions in “New chances for early interventions in the general practice” Jean-Bernard Daeppen, Lausanne, Switzerland

Should we train medical students to brief alcohol intervention?

  Brief alcohol intervention trials indicate efficacy in primary care   Systematic reviews suggest a reduction of about 4 drinks per week   Several studies with null findings. Issues about mechanisms of change   How these efficacy translate into effectiveness? Effectiveness of brief interventions in primary care populations Kaner EF, Dickinson HO, Beyer FR, Campbell F, Schlesinger C, Heather N, Saunders JB, Burnand B, Pienaar ED Cochrane review, 2009

After Fleming study, two projects were conducted in Lausanne Training primary care residents to brief alcohol intervention Testing efficacy of brief intervention in hazardous drinkers in emergency room

After Fleming study, two projects were conducted in Lausanne Training primary care residents to brief alcohol intervention

1) Effect of Training on Primary Care Residents’ Performance in Brief Alcohol Intervention: A Randomized Controlled Trial. Chossis I et al, J Gen Intern Med 22: , 2007

Should we train medical students to brief alcohol intervention?   Current considerations about implementing brief alcohol intervention in primary care   efficacy trials cannot be transposed to real world practice   screening is a major issue   universal computer screening and brief intervention, and   computer screening and individualized face-to- face brief intervention in primary care

After Fleming study, two projects were conducted in Lausanne Testing efficacy of brief intervention in hazardous drinkers in emergency room

Brief alcohol intervention in emergency department Difference between intake and 12 months Brief intervention Control with assessment p N % low risk drinkers at follow-up ) Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controoled trial Daeppen JB et al, Addiction 113: , 2007

  BUT association between alcohol use outcome and: 1. 1.Patient characteristic: motivation 2. 2.Interaction characteristic: Provider behavior ↔ patient change talk → alcohol use 3. 3.And… No influence of brief intervention on alcohol use in our ER study

3. Provider characteristics: 3. Provider characteristics: Relationship between change talk and evolution of alcohol use, per health care provider Decrease in alcohol use at follow-up Increase in alcohol use at follow-up

  Exploration of a null study   Importance of patients’ change talk   Importance of MI content (style and technique) within brief intervention   « New » MI focused brief motivational intervention: New (positive) study indicate brief motivation intervention reduce alcohol use in 20 year old men in the community Efficacy of brief motivational intervention in reducing binge drinking on young men: a randomized controlled trial Daeppen JB et al, Drug and Alcohol Dependence 113: 69-75, 2011

Should we train medical students to brief alcohol intervention?   Training should include motivational interviewing (MI) skills   MI is not specific to alcohol   MI potentially addresses multiple hazardous behaviors and dependence, as well as treatment adherence   MI changes the patient-provider communication style   MI is not easy to learn Training medical students to conduct motivational interviewing: a randomized controlled trial. Daeppen JB et al, Patient Educ Couns :313-8

 131 medical students (year 5) randomized to MI training or no training (delayed training)  Encounter with a simulated patient  MITI coding indicate improved scores on  empathy,  motivation interviewing spirit,  proportion of open questions, complex reflections and MI consistent behaviors An example of training medical students to motivational interviewing

Is an 8 hour motivational interviewing training for medical students enough to make a difference in patients behavior? Study explores 20 minutes brief motivational intervention across 18 interventionists with various levels of MI experience and backgrounds in a sample of 20 years old men in the community

C1 N=12... C18 N=12 attributed to 18 counselors 3-month Follow-up N=179 (83.3%) 3-month Follow-up N=182 (81.3%) Randomized to participate N=1023 Assessment only N=224 Assessment + BMI N=217 Screened negative N=196 (30.8%) Eligible N=831 (81.2%) Priority army assessment N=192 (18.8%) Refused -to be followed-up N=185 (22.3%) -audio-taped BMI N=9 (1.1%) Screened N=637 (76.7%) randomization Significant decrease in alcohol use in BMI vs. control (p=0.02, effect size d=0.22)

Counselors that were  more experienced (clinical experience / MI experience)  more favorable BMI attitudes and expectancies  higher MI skills (acceptance, empathy, MI spirit, higher % complex reflections, no MI-inconsistent behaviors)  surprisingly less MI-consistent behaviors had significantly better outcomes than the control group while their counterparts did not. Is an 8 hour motivational interviewing training for medical students enough to make a difference in patients behavior? Probably not, but… Influence of counselor characteristics and behaviors on the efficacy of a brief motivational intervention for heavy drinking young men;: a randomized controlled trial Gaume J et al, Alc Clin Exp Res July 2014

Should we train medical students to brief alcohol intervention? Na-ja!   Training medical students to brief intervention should include motivational interviewing skills   Training with a broader spectrum (not only alcohol)   And not only hazardous behaviors, but also dependence   8 hour- MI training of medical students makes some difference in medical students behavior and appears to be a significant experience