Experience of organizing training on motivative counseling for primary care physicians

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EXPERIENCE OF ORGANIZING TRAINING ON MOTIVATIVE COUNSELING FOR PRIMARY CARE PHYSICIANS

Vysochyna Iryna Leonidivna

Doctor of Medical Sciences, professor, Head of Department of Family Medicine FPE, Dnipro State Medical University

Bashkirova Nataliya Sergiivna

Candidate of Medical Sciences, docent, Department of Family Medicine FPE, Dnipro State Medical University

Kramarchuk Volodymyr Victorovych

Assistant Professor, Department of Family Medicine FPE, Dnipro State Medical University

Abstract. In the modern model of training medical students, the leading role belongs to the formation of standardized skills, which are practiced according to unified algorithms, i.e. - hard skills. The advantage of this approach is the ability to test and control acquired skills and knowledge. However, further training of physicians cannot be rigidly tied to soulless algorithms and requires improved communication skills, especially in family medicine. After all, it is the primary level of medical care based on trusting and long-term relationships with the patient, establishing stable, healthy communication. In preventive medicine, you can often hear about compliance, although in the literal sense it is only a direct implementation of the patient's instructions. In recent years, more and more attention has been paid to the doctor's ability to motivate the patient to make lifestyle changes in order to maintain and strengthen the health of community members. At present, it is impossible to imagine a family doctor who does not use motivational counseling in his daily practice. At this stage, some doctors experience some gaps in their training and want to improve their communication skills (so-called soft skills). Motivational counseling trainings are constantly held at the Department of Family Medicine FPE of Dnipro State Medical University. The article describes the experience of teaching this topic to primary care physicians and confirms the effectiveness of our approach. The four-day intensive training allows you to immediately practice the acquired knowledge in a safe environment among your colleagues and clearly see its effectiveness. The participatory approach helps to attract invaluable experience of participants to solve clinical cases and situational problems. Based on Bloom's taxonomy of educational goals, our training provides a clear pursuit of the goal and consistent assimilation of the material to the highest level - the synthesis of new ideas. Thus, we managed to create a quality educational product for the formation of the necessary competencies in the communicative field of "patient-doctor", taking into account ethical and deontological professional principles.

Keywords: motivational counseling, soft skills, training, primary health care

Височина Ірина Леонідівна доктор медичних наук, професор, завідуюча кафедрою сімейної медицини ФПО, Дніпровський державний медичний університет

Башкірова Наталія Сергіївна кандидат медичних наук, доцент, кафедра сімейної медицини ФПО, Дніпровський державний медичний університет

Крамарчук Володимир Вікторович асистент кафедри сімейної медицини ФПО, Дніпровський державний медичний університет

ДОСВІД ОРГАНІЗАЦІЇ ТРЕНІНГУ З МОТИВАЦІЙНОГО КОНСУЛЬТУВАННЯ ДЛЯ ЛІКАРІВ ПЕРВИННОЇ ЛАНКИ МЕДИЧНОЇ ДОПОМОГИ

Анотація. В сучасній моделі підготовки студентів-медиків провідна роль належить формуванню стандартизованих навичок, які відпрацьовуються згідно уніфікованих алгоритмів, тобто - hard skills. Перевагою такою підходу залишається можливість перевірки та контролю напрацьованих навиків та знань. Проте подальша підготовка лікаря не може бути жорстко прив'язаною до бездушних алгоритмів та потребує вдосконалення комунікативних здібностей, особливо це важливо в сімейній медицині. Адже саме первинна ланка медичної допомоги заснована на довірливих та тривалих взаємовідносинах з пацієнтом, налагодженні стабільної, здорової комунікації. В профілактичній медицині дуже часто можна почути про комплаєнс, хоча в прямому розумінні це лише безпосереднє виконання пацієнтом вказівок лікаря. Останніми роками, все більше уваги приділяється вмінню лікаря мотивувати пацієнта до змін образу життя задля збереження та зміцнення здоров'я членів громади. Наразі неможливо собі уявити сімейного лікаря, який не використовує в своїй повсякденній практиці мотиваційне консультування. На цьому етапі деякі лікарі відчувають певні пробіли в своїй професійній підготовці та бажають покращити свої навички спілкування (так звані - м'які навички). На кафедрі сімейної медицини Дніпровського державного медичного університету постійно проводяться тренінги з мотиваційного консультування. В статті описано досвід викладання цієї теми для лікарів первинної ланки медичної допомоги та приводиться підтвердження ефективності напрацьованого нами підходу. Чотириденний інтенсивний тренінг дає змогу відразу відпрацьовувати набуті знання в безпечному середовищі серед своїх колег та наочно переконатись в його ефективності. Партисипативний підхід допомагає залучати безцінний досвід учасників для вирішення клінічних кейсів та ситуаційних завдань. Базуючись на Блумівській таксономії освітніх цілей, наш тренінг забезпечує чітке слідування поставленій меті та послідовне засвоєння матеріалу аж до найвищого рівня - синтезу нових ідей. Таким чином, нам вдалося створити якісний навчальний продукт задля формування необхідних компетенцій в комунікативному полі «пацієнт-лікар» з урахуванням етичних принципів та деонтологічних професійних засад.

Ключові слова: мотиваційне консультування, м'які навички, тренінг, первинна медична допомога

Formulation of the problem. Mastering the profession of a doctor requires a person to have a high level of acquired knowledge, skills and responsibilities, which is the key to a highly professional specialist in the future. In the modern model of higher education in medical schools, attention is mainly paid to the formation of student standardized skills (hard skills), i.e. those that are performed according to a certain algorithm (ideal skill scenario). in turn allows to form medical competencies. An objective structured clinical examination (OSCE) introduced in the last year of study in all medical universities of Ukraine is an indicator of the level and assessment of acquired clinical skills. [1]

Further development of the doctor directly in medical practice expands the professional horizon, so we have to deal not only with complex comorbid patients with atypical disease, different clinical scenarios, but also to take into account the psychological characteristics of patients. , build trust in the model of "patient-doctor", use emotional intelligence, master the techniques of stress management, pay attention to detail. All this can be achieved with a good specialist skill of motivational counseling, which, unfortunately, cannot be sufficiently formed at the undergraduate level of training of future physicians. [2,3]

Motivational counseling (MC) is a style of joint communication to strengthen the patient's own motivation and desire for change. The main principles are: empathy (empathy); non-standard, critical thinking; avoidance of disputes; use of resistance; support of faith and hope; contrasting problems as goals, not as style. Tasks of MK: to help the patient to understand the problem, to provide information about it; help determine if he is ready to change something in his behavior; together with the patient to find motives (reasons) for changes; to help determine how actions can and should be taken to implement planned changes. [4,5]

Analysis of recent research and publications. Motivational counseling was formed on the basis of a client-oriented approach to the treatment and prevention of addictions. The direct term "motivational counseling" was introduced in 1983 by the American physician W. Miller. This concept was later developed by a British scientist - S. Rollnick. Their joint work W. Miller & S. Rollnick "Motivational interviewing: Preparing people to change addictive behavior" (1991) was recognized as a world psychological bestseller. Currently, MC is a widely recognized and effective tool in the preventive activities of physicians of various profiles.

The aim of the article. To analyze the experience of organizing training for primary care physicians on motivational counseling of patients.

Presentation of the main material. The training "Motivational counseling in the practice of a general practitioner - a family doctor" was organized and conducted at the Department of Family Medicine FPE of the Dnipro State Medical University (DSMU). 60 primary care physicians were trained. In accordance with the main tasks of training cadets in the training with MC, a multilevel integrative method of assessing this skill was used, which improved the communication skills of family physicians and directly the method of motivational counseling of patients.

At the first stage of assessing the level of mastery of motivational counseling skills, family doctors were asked to get acquainted (icebreaker exercise) with further self-assessment of their own skills on a scale from 0 to 10, where 0 - do not use this skill, and 10 - consider myself an expert in this sphere. Our data showed that the score of motivational counseling skills was directly correlated with the age and experience of the doctor (r = 0.789, p <0.01), i.e. doctors with more experience rated their skills higher, and 7 doctors (11% of respondents) rated their skills in motivational counseling of their own patients to the maximum (10 points), which raises questions about motivation for these family doctors and questions about the purpose of their training. On the other hand, it can be seen as an attempt to seize the initiative from the coach and give more meaning to his words, which was further leveled by using a participatory approach with active participation of all participants in the learning process and free involvement of students in solving problems.

In order to interest the audience in further learning, special attention was paid to information on the benefits / benefits of a good consultant in practice. In addition, at the beginning of the cycle, the "Circle of Thoughts" method was used, where doctors had the opportunity to voice their expectations from training. Based on the analysis of doctors' expectations from this training, formation of rules of conduct in the group and the possibility of adjusting the curriculum within 10-20% directly by students with simulation of clinically important topics, the group formation phase was coordinated and caused minimal emotional repercussions. Among the standard and vague formulations of expectations from training such as improving one's knowledge and learning something new were motivational counseling among palliative patients, communication skills with aggressive or overly anxious patients, "why I cannot motivate patients to change", to become confident in yourself, conveying your own opinion to patients.

Every day at the beginning of the class, participants were invited to take part in icebreaker exercises, which were designed to establish communication between participants, promote trusting relationships, create a "safe" environment for skills. The presentation of short theoretical material in the form of a lecture-interview was aimed at discussing the latest international approaches aimed at increasing the motivation of patients to change behavior. Theoretical aspects of effective motivational counseling were presented gradually, in order to keep the cadets' attention throughout the course. During the training we used presentations, flip charts, videos, drawing, small group work and round table in general created our own algorithms and strategies, reflected on most practical tasks, conducted questionnaires before, during and after the training, which allowed to involve all levels of perception information and activate various sensory-perceptual functions of our listeners. After discovering the basic theoretical constructs that exist in counseling, participants immediately practiced the acquired knowledge in small groups with colleagues and had the opportunity to adapt them to different situations, going beyond the comfort zone and developing their own soft skills.

The proposed situational scenarios within the training at the Department of Family Medicine FPE DSMU were as close as possible to the most common in the practice of the doctor through prior collection of information by the focus group, and the introduction of the principle of "peer to peer" allowed our participants experience, developed technologies and approaches, complex cases and mistakes, including their own changes. Discussing mistakes, in our opinion, has a special therapeutic effect, because the burden of failure can be reduced by exchanging views, joint search for the most successful strategies to prevent negative experiences in the future.

In our own experience, we can say that the discussion about the qualities of the "ideal" consultant always causes a great revival of the conversation. Subsequently, we conducted a survey on the percentage of compliance of each participant with the "idealized" portrait, which was formed by the group through joint efforts. According to our data, the average compliance rate of the ideal training participants was 74% (SD = 11.8%). The list of qualities that doctors believe are most important and often included in the list of ideals were quite broad formulations - professionalism, conciseness, restraint, endurance, self-confidence, good looks. Among the significant signs that doctors believe are detrimental to the counseling process were the following: aggression, distraction, panic, exaggeration, manipulation of fears, indifference, immorality, lack of confidence.

OARS (Open question, Affirmation, Reflective listening, Summarizing) has generally been well received by physicians, although the formulation of open-ended questions has been difficult due to the standard use of short closed questions in daily practice to clarify complaints and anamnestic data for a limited time. time of reception of family doctors. It should be noted that the test of the ability to formulate open-ended questions was tested at the end of the training using the method of "Hot Chair", which took place as follows - one participant had to sit on a chair located in the center surrounded by others (except back) and 5 minutes to answer to any questions from other participants. The task of the audience was to constantly formulate "open" questions about medical problems and lifestyle. At the same time, doctors who were fascinated by the game unknowingly returned to the usual survey using "closed" questions and after calculating the ratio of "closed" and "open" questions in all groups was constant and was 3: 1. Discussion of the results and reflection at the end of the game surprised the doctors-listeners because of the statement of this fact. Participants in the training in the role of "respondents" - those who answered the questions on the "hot chair", usually indicated that they had some fear at the beginning that the questions might reveal some secret problems, but generally felt comfortable and interested, so by their own example, they personally felt that affirmations improve conversation. Participants in the training in the role of "interviewers" sought to find something hidden in the lifestyle and behavior of colleagues, initially felt excitement, but at 4 minutes on the contrary confusion and difficulty in conducting the survey, in our opinion, most likely due to lack of overall strategy. Subsequently, some "respondents" after this test admitted that the exercise helped them to understand the hidden problems in their own way of life, the existence of which they had previously ignored and / or denied.

Analyzing the process and duration of changes in doctors' own lives, it was found that the period from the beginning of reflection on behavioral changes to immediate action took participants on average from 6 months to 2 years, which did not meet expectations about the speed of new lifestyles of their patients. , however, most cadets believed that the patient should change for up to 1 month. Thus, the attending physicians had the opportunity to look at the so-called "reverse side of the coin" - a problem on the part of the patient.

It should be noted that during the training course we encountered a number of problems that are not unique or special in adult learning - the presence of "silent participants", excessive self-confidence of some participants in their own skills and fear of losing credibility, the habit of talking only from an expert position. and a rigid directive approach, lack of time to work in small groups despite a four-day marathon, the experience of some participants of psychological breakdown when comparing their own practice with the ideal and / or latest modern practices in motivational counseling today. The problem with the "silent participants", we usually solved with the help of the "Circle of Thoughts" method and the formation of personal open- ended questions, general reflection in a large group after the proposed and conducted exercises and cases. Finally, all participants had the opportunity to freely express future plans for implementation of changes in their own practice, among which, according to our analysis of training results, were: systematization of accumulated knowledge, initiating meetings with patients for effective motivational counseling, efforts to find incentives to changes in their own practice.

We evaluated the effectiveness of the training using the analysis of the results of test control of 20 questions, which was conducted at the beginning and end of training. According to our data, at the end of the training there was a statistically significant increase in the number of correct answers in 60 respondents from 12.23 (SD = 2.2) at the beginning of the training to 18.47 (SD = 1.6) after its completion (t- test = -6,721, p = 0,000005), which, first of all, indicates the effectiveness of our training on methods of obtaining the skills of effective motivational counseling in outpatient practice of physicians. Given that soft skills are almost impossible to assess, our additional survey on the level of self-esteem by doctors of counseling skills on a 10-point scale also had a significant increase, from 5.21 at the beginning of the cycle to 8.45 at the end of training (t-test = -6.571, p = 0.000006).

motivational counseling patients family medicine

Conclusions

1. Motivational counseling is a scientifically sound tool in the hands of a primary care physician in preventive activities, through which he helps the ambivalent patient to find the strength and motivation to modify lifestyle.

2. Participatory training allowed physicians to improve the skills of effective motivational counseling of patients and minimize teaching difficulties (the presence of "silent participants", overconfidence of some participants, lack of time to work in small groups, experiencing psychological breakdown when comparing their own practice with the latest modern practices in motivational counseling).

3. Score self-assessment of mastering the skill of motivational counseling was directly correlated with the age and experience of family physicians (r = 0.789, p <0.01), although this fact more characterized its own, subjective component against the identified gaps in the methodology of motivational counseling in practice.

References:

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2. Matviec', L. G. (2019). Vazhnye podhody k nalazhivaniju kommunikacij mezhdu vrachom i pacientom s zavisimost'ju ot psihoaktivnyh veshhestv [Important approaches to establishing communication between doctor and patient with addiction to psychoactive substances]. Family Medicine - Family Medicine, (5-6), 14-18 [in Ukrainian].

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Література:

1. Перцева Т.О., Шпонька І.С., Гударян О.О., Фастовець О.О. Досвід організації комплексного практично-оріентованого іспиту зі спеціальності “Стоматологія” за принципами OSCE. Медична освіта. (2), 2018, с. 82-85

2. Матвієць, Л. Г. Важные подходы к налаживанию коммуникаций между врачом и пациентом с зависимостью от психоактивных веществ. Family Medicine, (5-6), 2019, с. 14-18.

3. Szczekala K., Wiktor K., Kanadys K., Wiktor H. Benefits of Motivational Interviewing application for patients and healthcare professionals. Polish Journal of Public Health. 128(4) 2018.

4. Magill M., Apodaca T. R., Borsari B., Gaume J., Hoadley A., Gordon R. E., Moyers T. A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of consulting and clinical psychology. 86(2), 2018, р. 140.

5. Бабінець Л., Боровик І., Мігенко B. Холістичний підхід у формуванні комунікативної компетентності майбутніх лікарів. Family Medicine. (4), 2021, с. 53-56.

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