Compassionate Curiosity: Mitigating the Effects of Bias Through Motivational Interviewing.

There is strong evidence that the implicit biases of health care professionals affect the treatment of patients, and that minority and other marginalized patients are disproportionately harmed. Assumptions made about patient knowledge or lack thereof function as judgments that are prone to bias, which then affect the education and advice imposed upon patients. We review how the motivational interviewing (MI) approach to patient engagement includes components of evidence-based bias-mitigating strategies, such as understanding circumstances from the patient's point of view, and therefore we propose that the MI approach can reduce the impact of bias in patient care.

Interface Between Motivational Interviewing and Burnout.

Background: The contemporary challenges of improving patient engagement in chronic disease management and addressing the growing problem of physician burnout are commonly viewed as separate issues. However, there is extensive evidence that person-centered approaches to patient engagement, such as motivational interviewing (MI), are associated both with better outcomes for patients and improved well-being for clinicians. Methods: We conducted an exploratory survey study to ascertain whether resident physicians who perceive that they embrace and utilize the MI approach also report less burnout. A total of 318 residents in several specialties were invited via email to complete a 10-question survey about patient engagement and the experience of burnout. Frequencies and percentages were calculated for all categorical/ordinal variables to describe survey participants and question responses. Correlation coefficients were obtained to assess relationships between all burnout and engagement questions. Results: A total of 79 residents completed the survey (response rate of 24.8%). There was broad agreement about the importance of patient engagement and the use of the MI approach, and approximately 60% of residents indicated that burnout was a problem. Two items related to residents' perceived use of MI were correlated with feeling a sense of personal accomplishment, one of the protective factors against burnout. Conclusion: Consistent with other studies indicating that person-centered approaches are associated both with better patient outcomes and provider wellbeing, our data suggest that residents' self-reported use of the MI approach in patient care may be related to less burnout. It appears that training in the MI approach in graduate medical education may be simultaneously good for patient outcomes and good for resident well-being.

Teaching resident physicians how to take care of their own health, and how to help patients take more responsibility for their health, are typically viewed as two separate challenges. However, studies have shown that patient-centered approaches have benefits both for patient health and clinician health. In our survey of resident physicians, we found that those who say they use motivational interviewing, a patient-centered approach, also report less burnout. This means that teaching resident physicians an effective way to interact with patients is also good for the trainees' health.

Motivational interviewing skills practice enhanced with artificial intelligence: ReadMI.

BACKGROUND: Finding time in the medical curriculum to focus on motivational interviewing (MI) training is a challenge in many medical schools. We developed a software-based training tool, "Real-time Assessment of Dialogue in Motivational Interviewing" (ReadMI), that aims to advance the skill acquisition of medical students as they learn the MI approach. This human-artificial intelligence teaming may help reduce the cognitive load on a training facilitator. METHODS: During their Family Medicine clerkship, 125 third-year medical students were scheduled in pairs to participate in a 90-minute MI training session, with each student doing two role-plays as the physician. Intervention group students received both facilitator feedback and ReadMI metrics after their first role-play, while control group students received only facilitator feedback. RESULTS: While students in both conditions improved their MI approach from the first to the second role-play, those in the intervention condition used significantly more open-ended questions, fewer closed-ended questions, and had a higher ratio of open to closed questions. CONCLUSION: MI skills practice can be gained with a relatively small investment of student time, and artificial intelligence can be utilized both for the measurement of MI skill acquisition and as an instructional aid.

PRESTO: Promoting Engagement for the Safe Tapering of Opioids.

ABSTRACT: Twenty-four percent of all U.S. opioid overdose deaths involve a prescription opioid. Changing prescribing practices is considered a key step in reducing opioid overdoses. Primary care providers (PCPs) commonly lack the patient engagement skills needed to address patient resistance to taper or end opioid prescriptions. We developed and evaluated a protocol aimed at improving PCP opioid-prescribing patterns and modeled on the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach. We conducted a time series trial comparing provider opioid prescribing 8 months before and 8 months after training with the PRomoting Engagement for Safe Tapering of Opioids (PRESTO) protocol. The 148 Ohio PCPs who completed PRESTO training gained confidence in their ability to engage their patients on the topics of opioid overdose risk and potential opioid tapering. Promoting Engagement for Safe Tapering of Opioids participants had decreased opioid-prescribing over time, but this was not significantly different from Ohio PCPs who had not received PRESTO training. Participants completing PRESTO training had small, but significant increased buprenorphine prescribing over time compared with Ohio PCPs who had not received PRESTO training. The PRESTO approach and opioid risk pyramid warrant further study and validation.

Computer-Supported Experiential Learning-Based Tool for Healthcare Skills.

Care experiences and health outcomes may suffer greatly because of healthcare professionals' deficient educational preparation and practices. The limited awareness about the impact of stereotypes, implicit/explicit biases, and Social Determinants of Health (SDH) may result in unpleasant care experiences and healthcare professional-patient relationships. Additionally, as healthcare professionals are no less prone to have biases than other people, it is essential to deliver the learning platform to enhance healthcare skills (e.g., awareness of the importance of cultural humility, inclusive communication proficiencies, awareness of the enduring impact of both SDH and implicit/explicit biases on health outcomes, and compassionate and empathetic attitude) of healthcare professionals which eventually help to raise health equity in society. Moreover, employing the "learning-by-doing" approach directly in real-life clinical practices is less preferable wherein high-risk care is essential. Thus, there is a huge scope to deliver virtual reality-based care practices by engaging the digital experiential learning and Human-Computer Interaction (HCI) approach to enhance patient care experiences, healthcare experiences, and healthcare skills. Thus, this research provides the Computer-Supported Experiential Learning (CSEL) approach-based tool or mobile application that facilitates virtual reality-based serious role-playing scenarios to enhance the healthcare skills of healthcare professionals and for public awareness.

Social Accountability and Regional Health Priorities in Medical Education.

Social accountability in medical education refers to the commitment of medical schools to address priority health concerns of the community. Over a 2-year period, 200 Family Medicine clerkship students ranked the topics most emphasized in the first 2 years of medical school. These rankings did not align with the community health priorities of the region in which the medical school is located. While the basic science and introductory clinical material covered early in medical school is necessary, our data suggest that emphasizing the implications of this foundational curricula for addressing the regions' health priorities is worthy of greater consideration.

An Interactive Game with Virtual Reality Immersion to Improve Cultural Sensitivity in Health Care.

Purpose: Biased perceptions of individuals who are not part of one's in-groups tend to be negative and habitual. Because health care professionals are no less susceptible to biases than are others, the adverse impact of biases on marginalized populations in health care warrants continued attention and amelioration. Method: Two characters, a Syrian refugee with limited English proficiency and a black pregnant woman with a history of opioid use disorder, were developed for an online training simulation that includes an interactive life course experience focused on social determinants of health, and a clinical encounter in a community health center utilizing virtual reality immersion. Pre- and post-survey data were obtained from 158 health professionals who completed the simulation. Results: Post-simulation data indicated increased feelings of compassion toward the patient and decreased expectations about how difficult future encounters with the patient would be. With respect to attribution, after the simulation participants were less inclined to view the patient as primarily responsible for their situation, suggesting less impact of the fundamental attribution error. Conclusion: This training simulation aimed to utilize components of evidence-based prejudice habit breaking interventions, such as learning more about an individual's life experience to help minimize filling in gaps with stereotyped assumptions. Although training simulations cannot fully replicate or replace the advantages that come with real-world experience, they can heighten awareness in the increase of increasing the cultural sensitivity of clinicians in health care professions for improving health equity.

Turning "Lose-Lose" into "Win-Win": What Is Good for Them Is Good for Us!

Simply telling patients what to do with respect to medical recommendations or lifestyle changes often does not have the desired impact, contributing to frustration for both patients and physicians. Therefore, this "educate and advise" approach can be a "lose-lose" proposition-bad for the patient, and bad for the physician. Broader adoption of efficacious approaches to patient engagement, such as motivational interviewing, can help make the process of addressing patients' behavioral responsibilities regarding chronic disease prevention and management a "win-win" for the health and satisfaction of patients and physicians alike. Greater emphasis on evidence-based patient engagement skills is necessary in medical education.

Exam Room Culture.

If the minds of patients could be read, one would likely discover thoughts related to the culture of the clinical environment. "Do I belong here?" "Will I be judged?" "Is it safe to be honest?" We consider what physicians can do to create a culture in the exam room that corresponds to features found in the cultures of successful organizations. These characteristics include an emphasis on psychological safety for patients, a willingness to be vulnerable on the part of the physician, and a sincere focus on the patient's purpose. Our conclusion is that by prioritizing such elements, the clinical encounter may be more satisfying and productive for the patient and physician alike.

Advancing Motivational Interviewing Training with Artificial Intelligence: ReadMI.

BACKGROUND: Motivational interviewing (MI) is an evidence-based, brief interventional approach that has been demonstrated to be highly effective in triggering change in high-risk lifestyle behaviors. MI tends to be underutilized in clinical settings, in part because of limited and ineffective training. To implement MI more widely, there is a critical need to improve the MI training process in a manner that can provide prompt and efficient feedback. Our team has developed and tested a training tool, Real-time Assessment of Dialogue in Motivational Interviewing (ReadMI), that uses natural language processing (NLP) to provide immediate MI metrics and thereby address the need for more effective MI training. METHODS: Metrics produced by the ReadMI tool from transcripts of 48 interviews conducted by medical residents with a simulated patient were examined to identify relationships between physician-speaking time and other MI metrics, including the number of open- and closed-ended questions. In addition, interrater reliability statistics were conducted to determine the accuracy of the ReadMI's analysis of physician responses. RESULTS: The more time the physician spent talking, the less likely the physician was engaging in MI-consistent interview behaviors (r = -0.403, p = 0.007), including open-ended questions, reflective statements, or use of a change ruler. CONCLUSION: ReadMI produces specific metrics that a trainer can share with a student, resident, or clinician for immediate feedback. Given the time constraints on targeted skill development in health professions training, ReadMI decreases the need to rely on subjective feedback and/or more time-consuming video review to illustrate important teaching points.

Promoting Motivational Interviewing in Primary Care: More Than Intention.

INTRODUCTION: Interacting with patients in a manner that furthers self-responsibility for health is an important skill for primary care clinicians. Motivational interviewing (MI) is such an approach to patient engagement, but it remains to be more widely implemented. In a program training health professionals and health professions students in MI, we examined posttraining attitudes and intentions regarding the utilization of MI. Of particular interest was how posttraining intentions were associated with self-reported action 1 month later. METHODS: We obtained immediate posttraining and 30-day follow-up data from 209 participants regarding intent to utilize the MI approach (self-reported implementation at the follow-up interval), impact on confidence with patient interaction, and perceived importance of the training. We analyzied frequencies and percentages for all categorical/ordinal variables to describe the participants and the survey question responses. RESULTS: While 91.5% of participants intended to incorporate MI into their approach with patients (to a moderate or great extent) at posttraining, only 48.7% reported that they had actually implemented the MI approach (to a moderate or great extent) 30 days later. However, another 32.1% indicated that they had occasionally utilized MI. Attitudes toward the importance of MI training and the impact of training on confidence remained strong over the 30 days. CONCLUSION: Achieving more widespread implementation of the MI approach in the primary care setting is likely to be less dependent on convincing clinicians about its importance for patient engagement, but rather on the translation of intent to actual practice and implementation.

Flipped Exam Room.

Medical education has taken a decided turn toward the "flipped classroom," in which in-class lectures are de-emphasized and engaged learning is promoted. The time has also come to make some changes in what is being taught in clinical medicine, specifically with respect to the patient-physician interaction. Because the daily management of chronic illness is primarily the responsibility of the patient, clinical encounters that prioritize patient engagement and activation are critical. The traditional medical encounter, characterized by data gathering to make a diagnosis followed by prescribing or recommending treatment to the patient, can work well for acute illnesses or injuries, but effective chronic disease management requires substantial patient ownership of their health. In a "flipped exam room," interactions with patients emphasize patient responsibility for health, such that priority is given to eliciting patient goals, what the patient knows, and how they desire to proceed with management of their health concerns and conditions. Just as medical students find engaged learning approaches to be more acceptable and satisfying, patients find collaborative interaction approaches on the part of their physicians to be more satisfying, and such approaches are associated with better outcomes. More attention to training students and residents in "flipped exam room" patient interaction skills is necessary.

Professionalism: self-control matters.

BACKGROUND: Many of the behaviors that constitute professionalism require self-control. AIM: To investigate the extent to which self-control is a component of resident professionalism, rated both by residents and their program directors. METHODS: 366 residents in 13 residency programs were invited to participate in a survey study of professionalism. Participating residents completed the Professionalism - Documentation of Competence (ProDOC) (a 15-item measure of professionalism developed for the study), a 10-item version of the Marlowe-Crowne Social Desirability Scale, and the Brief Self-Control Scale. Independently, program directors of participating residents completed the ProDOC with reference to each of their participating residents. RESULTS: 215 residents agreed to participate in the study (58.7% response rate). Resident ProDOC scores were significantly related to social desirability and self-control. Self-control alone accounted for approximately 25% of the variance in resident ProDOC scores, and approximately 17% of the variance in ProDOC scores when shared variance with social desirability was controlled. There was no correlation between resident and program director ProDOC scores. CONCLUSIONS: Self-control is an important facet of human behavior and interpersonal interaction, including the behaviors that constitute medical professionalism. The lack of correlation between residents' self-ratings of professionalism and their program directors' ratings underscores the difficulty in understanding and measuring this competency.

Implementation of a process-oriented cultural proficiency curriculum.

The authors implemented a process-oriented cultural proficiency curriculum in their family medicine residency program, emphasizing the understanding of each individual patient through skilled interviewing rather than promoting the acquisition of knowledge about specific cultural groups.

Prescribing happiness: positive psychology and family medicine.

Although mental health promotion is consistent with the philosophy of family medicine, it is largely unclear what behaviors or interventions comprise mental health promotion in practice. A recent effort in psychology, known as "positive psychology," has endeavored to better understand happiness, meaning in life, character strengths, and how these all can be developed. Because happiness is associated with multiple benefits, including better health, it behooves family physicians to become familiar with and incorporate positive psychology into their practices. This article reviews examples of the work in positive psychology, including gratitude, capitalization, "satisficing," character strengths, and learned optimism. Potential applications of each area in medical education, physician well-being, and patient care are described.

A longitudinal study of attitudes toward physician-assisted suicide and euthanasia among patients with noncurable malignancy.

This longitudinal study investigated whether attitudes toward physician-assisted suicide (PAS) and euthanasia (E) are stable among patients with noncurable malignancy, and whether depression and various coping strategies were related to such attitudes. Thirty patients with noncurable malignancies completed questionnaires measuring attitudes toward PAS and E, depression, and coping. Three months later, and subsequently at six-month intervals, repeated measures were obtained from 24 patients. There was a trend for patients to become less supportive of legalizing PAS and E from the initial to last attitude measurement. Depression was unrelated to attitude change. There were significant changes on two coping dimensions: use of social support for emotional reasons and use of religious resources. Our findings should be considered in clinical, legislative, and ethical debates.