teaching medical students in early interventions in “new chances for early interventions in the...
TRANSCRIPT
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?
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 populationsKaner EF, Dickinson HO, Beyer FR, Campbell F, Schlesinger C, Heather N,
Saunders JB, Burnand B, Pienaar EDCochrane review, 2009
After Fleming study, two projects were conducted in Lausanne
Training primary care residentsto 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 residentsto brief alcohol
intervention
1) Effect of Training on Primary Care Residents’ Performance in BriefAlcohol Intervention: A Randomized Controlled Trial. Chossis I et al, J Gen Intern Med 22: 1144-11479, 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 interventio
n
Control with assessment
p
N 367 429
% low risk drinkers at follow-up
36 34 0.7
2) Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controoled trialDaeppen JB et al, Addiction 113: 1124-33, 2007
BUT association between alcohol use outcome and:
1. Patient characteristic: motivation
2. Interaction characteristic: Provider behavior ↔ patient change talk → alcohol use
3. And…
No influence of brief intervention on alcohol use in our ER study
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
-15
-10
-50
510
Diff
ére
nce
ent
re b
ase
line
et f
ollo
w-u
pen
ve
rres
pa
r se
mai
ne(v
aleu
rs a
just
ées
)
-4 -2 0 2 4Discours changement
(moyenne sur l'entretien de la force de la capacité à changersur une échelle de -5 à +5)
Soignant 1 Soignant 2Soignant 3 Soignant 4Soignant 5
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 trialDaeppen 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. 2012 87:313-8
Training medical students to conduct motivational interviewing: a randomized controlled trial. Daeppen JB et al, Patient Educ Couns. 2012 87:313-8
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-upN=179 (83.3%)
3-month Follow-upN=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 behaviorshad 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 trialGaume 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