Using simulated patients to develop doctors' skills in facilitating behaviour change: addressing childhood obesity

Heart health whispering: A randomized, controlled pilot study to promote nursing student perspective-taking on carers' health risk behaviors

BACKGROUND

Lifestyle counseling is described as a "major breakthrough" in the control of chronic diseases. Counseling can be challenging to nurses due their lack of motivation to counsel, hesitancy to appear non-judgmental, lack of empathy, and lack of time. Nurses voice their need for more training in counseling communication skills. Our main objective was to engage in ongoing development and testing of a promising Heart Health Whispering perspective-taking intervention on nursing students' clinical empathy, perceptual understanding, and client readiness to alter health risk behaviors.

METHODS

In this randomized controlled pilot study, the full intervention (perspective-taking instructions, practice, and video-feedback) and partial intervention (video-feedback only) comprised 24 and 18 nursing students, respectively. Quantitative data were collected with a 10-item pre- and post-intervention clinical empathy tool, a one-item 'readiness to change' health risk behavior tool plus similarity ratings on students' empathic accuracy were calculated. Data were analyzed using Independent Samples t Tests and mixed model ANCOVA models. Students' and actors' evaluative responses toward the intervention phases were collected by handwritten notes, and analyzed using content analysis and constant comparison techniques.

RESULTS

The main finding was that students in the full intervention group reported greater clinical empathy in the post versus baseline condition. Students underestimated their clinical empathy in comparison to carers' reports in the post-condition. In both intervention groups, carers reported more readiness to change in the post-condition. Carers identified favorable and unfavorable perceptions and outcomes of approaches taken by students. Students desired immediate and direct feedback after the video-dialogue and -tagging exercise.

CONCLUSIONS

Heart Health Whispering is a promising intervention to help educators in basic and continuing education to bolster nurse confidence in empathic conversations on health risk behaviors. This intervention incorporates commonly used strategies to teach empathic communication along with a novel video-analysis application of a perspective-taking task. Student and carer actor comments highlighted the value in opportunities for students to engage in self-evaluation and practicing the empathic process of taking the client's perspective on health risk behaviors.

Management of obesity: improvement of health-care training and systems for prevention and care

Although the caloric deficits achieved by increased awareness, policy, and environmental approaches have begun to achieve reductions in the prevalence of obesity in some countries, these approaches are insufficient to achieve weight loss in patients with severe obesity. Because the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed. Nonetheless, health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity. Modalities available for the treatment of adult obesity include clinical counselling focused on diet, physical activity, and behaviour change, pharmacotherapy, and bariatric surgery. Few options, few published reports of treatment, and no large randomised trials are available for paediatric patients. Improved care for patients with obesity will need alignment of the intensity of therapy with the severity of disease and integration of therapy with environmental changes that reinforce clinical strategies. New treatment strategies, such as the use of technology and innovative means of health-care delivery that rely on health professionals other than physicians, represent promising options, particularly for patients with overweight and patients with mild to moderate obesity. The co-occurrence of undernutrition and obesity in low-income and middle-income countries poses unique challenges that might not be amenable to the same strategies as those that can be used in high-income countries.

'I wouldn't get that feedback from anywhere else': learning partnerships and the use of high school students as simulated patients to enhance medical students' communication skills

BACKGROUND

This article evaluates whether the use of high school students as simulated patients who provide formative feedback enhances the capacity of medical students in their fifth year of training to initiate screening conversations and communicate effectively with adolescents about sensitive health issues.

METHODS

Focus group interviews with medical students (n = 52) and school students aged 15-16 (n = 107) were conducted prior to and following involvement in Learning Partnerships workshops. Prior to workshops focus groups with school students asked about attitudes to help-seeking in relation to sensitive health issues, and following workshops asked whether the workshop had made a difference to their concerns. Prior to workshops focus groups with medical students asked about their needs in relation to initiating conversations with adolescents about sensitive health issues, and following workshops asked whether the workshop had made a difference to their concerns. Surveys were also completed by 164 medical students and 66 school students following the workshops. This survey featured 19 items asking participants to rank the usefulness of the workshops out of 10 (1 = not at all useful, 10 = extremely useful) across areas such as skills and understanding, value of learning activities and overall value of the workshop. SPSS software was used to obtain mean plus standard deviation scores for each item on the survey.

RESULTS

The Learning Partnerships workshops assisted medical students to improve their skills and confidence in communicating with adolescents about sensitive health issues such as mental health, sexual health and drug and alcohol use. They also assisted young people to perceive doctors as more likely potential sources for help.

CONCLUSIONS

These findings suggest that the innovative methods included in Learning Partnerships may assist in broader education programs training doctors to be more effective helping agents and aid the promotion of adolescent friendly health care. This research provides evidence that a new way of teaching may contribute to enhancing doctors' capacity and willingness to initiate screening conversations and enhance adolescents' preparedness to seek help. This has implications for educational design, content and communication style within adolescent health.

An obesity educational intervention for medical students addressing weight bias and communication skills using standardized patients

BACKGROUND

In order to manage the increasing worldwide problem of obesity, medical students will need to acquire the knowledge and skills necessary to assess and counsel patients with obesity. Few educational intervention studies have been conducted with medical students addressing stigma and communication skills with patients who are overweight or obese. The purpose of this study was to evaluate changes in students' attitudes and beliefs about obesity, and their confidence in communication skills after a structured educational intervention that included a clinical encounter with an overweight standardized patient (SP).

METHODS

First year medical students (n = 127, 47% female) enrolled in a communications unit were instructed to discuss the SPs' overweight status and probe about their perceptions of being overweight during an 8 minute encounter. Prior to the session, students were asked to read two articles on communication and stigma as background information. Reflections on the readings and their performance with the SP were conducted prior to and after the encounter when students met in small groups. A newly constructed 16 item questionnaire was completed before, immediately after and one year after the session. Scale analysis was performed based on a priori classification of item intent.

RESULTS

Three scales emerged from the questionnaire: negative obesity stereotyping (7 items), empathy (3 items), and counseling confidence (3 items). There were small but significant immediate post-intervention improvements in stereotyping (p = .002) and empathy (p < .0001) and a very large mean improvement in confidence (p < .0001). Significant improvement between baseline and immediate follow-up responses were maintained for empathy and counseling at one year after the encounter but stereotyping reverted to the baseline mean. Percent of students with improved scale scores immediately and at one year follow up were as follows: stereotyping 53.1% and 57.8%; empathy 48.4% and 47.7%; and confidence 86.7% and 85.9%.

CONCLUSIONS

A structured encounter with an overweight SP was associated with a significant short-term decrease in negative stereotyping, and longer-term increase in empathy and raised confidence among first year medical students toward persons who are obese. The encounter was most effective for increasing confidence in counseling skills.

Working with young people: evaluation of an education resource for medical trainees

AIM

Many health professionals report interest in consulting more effectively with young people but have unmet training needs. We set out to evaluate a teaching resource in adolescent health and medicine that was designed for Australian trainees in specialist medicine.

METHODS

Thirty-two paediatric and adult trainees of the Royal Australasian College of Physicians completed a pre-evaluation questionnaire to assess attitudes and confidence in working with young people. They were then provided with a training resource and, 6 weeks later, completed a post-evaluation questionnaire. Repeated-measures anovas were used to assess changes in attitudes, self-reported knowledge and confidence by trainee type. χ(2) -tests were used to compare variation in the use of and opinions about the resource.

RESULTS

Trainees' awareness of the health issues that affect young people, confidence in working with young people and confidence in their knowledge greatly improved after using the resource. Beforehand, adult medicine trainees scored lower than paediatric trainees. A relatively higher rate of improvement resulted in similar scores between trainee types after using the resource, which was rated equally highly by the different groups of trainees.

CONCLUSIONS

As a result of significant gains in the confidence of specialist medicine trainees after access to the resource, it will now be made available for Australian trainees in specialist medicine.

Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial

OBJECTIVE

To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years.

DESIGN

Randomised controlled trial.

SETTING

22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia.

PARTICIPANTS

Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010.

INTERVENTION

Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or "usual care" (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment.

MAIN OUTCOME MEASURES

Children's body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents' body mass index (all 15 months post-enrolment).

RESULTS

118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference -0.1 (95% confidence interval -0.7 to 0.5; P=0.7)) and body mass index z score (-0.05 (-0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score -0.20 (SD 0.25, range -0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight.

CONCLUSIONS

Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

Novel study design to assess the utility of the copd assessment test in a primary care setting

The quality of a consultation provided by a physician can have a profound impact on the quality of care and patient engagement in treatment decisions. When the COPD Assessment Test (CAT) was developed, one of its aims was to aid the communication between physician and patient about the impact of COPD. We developed a novel study design to assess this in a primary care consultation. Primary care physicians across five countries in Europe conducted videoed consultations with six standardised COPD patients (played by trained actors) which had patient-specific issues that the physician needed to identify through questioning. Half the physicians saw the patients with the completed CAT, and half without. Independent assessors scored the physicians on their ability to identify and address the patient-specific issues, review standard COPD aspects, their understanding of the case and their overall performance. This novel study design presented many challenges which needed to be addressed to achieve an acceptable level of robustness to assess the utility of the CAT. This paper discusses these challenges and the measures adopted to eliminate or minimise their impact on the study results.

Childhood obesity in secondary care: national prospective audit of Australian pediatric practice

OBJECTIVE

In many countries, pediatricians offer skilled secondary care for children with conditions more challenging than can readily be managed in the primary care sector, but the extent to which this sector engages with the detection and management of obesity remains largely unexplored. This study aimed to audit the prevalence, diagnosis, patient, and consultation characteristics of obesity in Australian pediatric practices.

METHODS

This was a national prospective patient audit in Australia. During the course of 2 weeks, members of the Australian Paediatric Research Network prospectively recorded consecutive outpatient consultations by using a brief standardized data collection form. Measures included height, weight, demographics, child and parent health ratings, diagnoses, referrals, investigations, and consultation characteristics. We compared the prevalence of pediatrician-diagnosed and measured obesity (body mass index ≥95th percentile) and top-ranked diagnoses, patient, and consultation characteristics in (a) obese and nonobese children, and (b) obese children with and without a diagnosis.

RESULTS

A total of 198 pediatricians recorded 5466 consultations with 2-17 year olds, with body mass index z-scores calculated for 3436 (62.9%). Of the 12.6% obese children, only one-third received an "overweight/obese" diagnosis. Obese children diagnosed as overweight/obese were heavier, older, and in poorer health than those not diagnosed and incurred more Medicare (government-funded health system) cost and referrals.

CONCLUSIONS

Obesity is infrequently clinically diagnosed by Australian pediatricians and measurement practices vary widely. Further research could focus on supporting and normalizing clinical obesity activities from which pediatricians and parents could see clear benefits.

Medical undergraduates' use of behaviour change talk: the example of facilitating weight management

BACKGROUND

Obesity, an increasing problem worldwide, is a leading cause of morbidity and mortality. Management principally requires lifestyle (i.e. behavioural) changes. An evidence-base exists of behaviour change techniques for weight loss; however, in routine practice doctors are often unsure about effective treatments and commonly use theoretically-unfounded communication strategies (e.g. information-giving). It is not known if communication skills teaching during undergraduate training adequately prepares future doctors to engage in effective behaviour change talk with patients. The aim of the study was to examine which behaviour change techniques medical undergraduates use to facilitate lifestyle adjustments in obese patients.

METHODS

Forty-eight medical trainees in their clinical years of a UK medical school conducted two simulated consultations each. Both consultations involved an obese patient scenario where weight loss was indicated. Use of simulated patients (SPs) ensured standardisation of key variables (e.g. barriers to behaviour change). Presentation of scenario order was counterbalanced. Following each consultation, students assessed the techniques they perceived themselves to have used. SPs rated the extent to which they intended to make behavioural changes and why. Anonymised transcripts of the audiotaped consultations were coded by independent assessors, blind to student and SP ratings, using a validated behaviour change taxonomy.

RESULTS

Students reported using a wide range of evidence-based techniques. In contrast, codings of observed communication behaviours were limited. SPs behavioural intention varied and a range of helpful elements of student's communication were revealed.

CONCLUSIONS

Current skills-based communication programmes do not adequately prepare future doctors for the growing task of facilitating weight management. Students are able to generalise some communication skills to these encounters, but are over confident and have limited ability to use evidence-based theoretically informed techniques. They recognise this as a learning need. Educators will need to tackle the challenges of integrating theoretically informed and evidence based behaviour change talk within medical training.