Assessing Medical Students' Tobacco Dependence Treatment Skills Using a Detailed Behavioral Checklist

Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial

BACKGROUND

Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts.

OBJECTIVE

To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change.

DESIGN

A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE).

SETTING/PARTICIPANTS

Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys.

INTERVENTIONS

The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness.

MEASUREMENTS

The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As.

RESULTS

Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills.

LIMITATIONS

Variability in medical schools requiring participation in the WMC curriculum.

CONCLUSIONS

This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management.

NIH TRIAL REGISTRY NUMBER

R01-194787.

Weight management counseling experiences of first year medical students before starting medical school and their self-perceived impact on treating patients with obesity

Physicians can play a vital role in counseling patients on overweight and obesity. This secondary analysis examined whether experiences in patient care specific to weight management before starting medical school were associated with students' intentions and confidence to provide weight management counseling (WMC) to patients who have overweight or obesity, and perceived impact as future physicians on patients' motivation to manage weight. First-year medical students (n = 1305) in the entering class of 2020 at eight medical schools nationwide completed questions relating to their prior experiences in patient care and WMC using the 5As. Also assessed were their intentions to treat patients with overweight or obesity, and confidence in counseling patients to help manage their weight. Over half the students (58.3%) who completed the survey had prior experience in patient care and nearly half (47.4%) began medical school with prior WMC experiences. Prior experiences correlated positively with higher confidence in performing WMC and students' intentions to treat patients with overweight or obesity. Given the relatively high rates of exposure to some type of weight management or lifestyle counseling among students before enrolling in medical school, the curriculum could build on established student interest and experience by offering treatment strategies including counseling for patients with overweight and obesity. By making prior experiences advantageous for admission, medical schools could gravitate towards admitting students who have brief but valuable insights about weight management in health care, thus increasing the possibility of filling important gaps.

Design and Validation of an Instrument to Evaluate the Learning Acquired by Nursing Students from a Brief Tobacco Intervention (BTI-St©)

The aim of this study was to design and validate an instrument, based on the WHO 5As+5Rs model, to test the acquisition by nursing students of a brief tobacco intervention (BTI) learning. A validation design of an instrument following the criterion referenced tests model using videos of simulated BTIs in the primary care setting was carried out. The study included 11 experts in smoking prevention/care and 260 second-year nursing students. The study was in two stages: (1) selection and recording of clinical simulations (settings), and (2) test construction. Content was validated by applying the Delphi consensus technique and calculating the Content Validity Ratio (CVR) and Content Validity Index (CVI). A pilot test was conducted for item analysis. Reliability was evaluated as internal consistency (Kuder-Richardson [KR-20]) and test-retest temporal stability (intraclass correlation coefficient [ICC]). Three simulation settings were recorded. An instrument (BTI-St^®) was developed with 23 items for dichotomous (yes/no) response. CVR was >70% for all items, KR-20 of 0.81-0.88, and ICC between 0.68 and0.73 (p < 0.0001). The BTI-St^® is a robust and reliable instrument that is easily and rapidly applied. It follows the WHO 5As+5Rs model and offers objective criterion-referenced evaluation of BTI learning in nursing students.

Igniting activation: Using unannounced standardized patients to measure patient activation in smoking cessation

Introduction

Despite a decline, smoking rates have remained high, especially in communities with lower income, education, and limited insurance options. Evidence shows that physician-initiated counseling on smoking cessation is effective and saves lives, and that specific skills are needed to appropriately lead this type of patient-physician communication. Residency is a critical moment for future physicians and may be the optimal time to learn, practice, and refine this skillset. Unannounced Standardized Patients (USPs) have been found to be effective, incognito evaluators of resident practices.

Methods

This study introduced rigorously trained actors (USPs) into two urban, safety-net clinics to assess resident ability to engage, activate, and counsel a pre-contemplative smoker. A complementary chart review assessed appropriate documentation in the patient's electronic health record (EHR) and its relationship to counseling style and prescribing practices.

Results

Resident scores (% well done) on patient education and engagement were low (33% and 23%, respectively). Residents who coupled cessation advice with an open discussion style activated their patients more than those who solely advised cessation across all comparable measures. On EHR documentation, residents who accurately documented smoking history were more likely to directly advise their patient to quit smoking when compared to residents who did not document (t(97) = 2.828, p = .006, Cohen's D = 0.56).

Conclusions

Results highlight the need to reinforce training in patient-centered approaches including motivational interviewing, counseling, and shared decision-making. Future research should focus on the effects of smokers in pre-contemplation on physician counseling style and examine the relationship between medical training and provider communication to guide interventions.

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Counseling, documentation, and prescribing all vary when residents meet an Unannounced Standardized Patient (USP) smoker.

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Patients are activated to quit smoking when a provider couples cessation advice with an open discussion of pros and cons.

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Training in motivational interviewing and shared decision-making can enhance patient-provider cessation communication.

Effects of Trained Health Professionals' Behavioral Counseling Skills on Smoking Cessation Outcomes

Background

There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects.

Purpose

We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes.

Methods

Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year.

Results

On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers' characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03-1.42) and 1.26 (1.05-1.50), respectively.

Conclusions

This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.