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Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wsub20
Addressing Adolescent Substance Use: Teaching SBIRT and MI to Residents a
a
b
Amy E. Whittle MD , Sara M. Buckelew MD MPH , Jason M. Satterfield PhD , Paula J. Lum MD b
b
MPH & Patricia O'Sullivan PhD a
Department of Pediatrics, University of California, San Francisco, CA, USA.
b
Department of Medicine, University of California, San Francisco, CA, USA. Accepted author version posted online: 26 Sep 2014.
To cite this article: Amy E. Whittle MD, Sara M. Buckelew MD MPH, Jason M. Satterfield PhD, Paula J. Lum MD MPH & Patricia O'Sullivan PhD (2014): Addressing Adolescent Substance Use: Teaching SBIRT and MI to Residents, Substance Abuse, DOI: 10.1080/08897077.2014.965292 To link to this article: http://dx.doi.org/10.1080/08897077.2014.965292
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ACCEPTED MANUSCRIPT Addressing Adolescent Substance Use: Teaching SBIRT and MI to Residents
Amy E. Whittle1, MD; Sara M. Buckelew1, MD, MPH; Jason M. Satterfield2, PhD; Paula J.
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Lum2, MD, MPH; Patricia O‟Sullivan2, PhD
1. Department of Pediatrics, University of California, San Francisco, CA, USA. 2. Department of Medicine, University of California, San Francisco, CA, USA.
Correspondence should be addressed to Amy E. Whittle, MD, Department of Pediatrics, University of California, 1001 Potrero Avenue, MS6E, San Francisco, CA, USA. Email: [email protected]
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ACCEPTED MANUSCRIPT ABSTRACT. Background: The American Academy of Pediatrics Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every adolescent preventive and all appropriate urgent visits. We designed an SBIRT curriculum as part of the adolescent block of a pediatric residency that combined online modules with an in-person
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workshop, faculty feedback on resident interactions with patients, and resident self-reflection on their motivational interviewing (MI) skills. Methods: To evaluate the curriculum, we measured resident satisfaction and self-reported confidence in using SBIRT and MI with teens using a retrospective pre/post questionnaire. We used qualitative analysis to evaluate the written comments from faculty observations of patient-trainee interactions and comments from residents‟ self-reflections on patient interactions. Results: Thirty-two residents completed the curriculum. Residents reported high satisfaction with the training. Comparing retrospective pre/post scores on the survey of resident self-reported confidence, measures increased significantly in all domains, including for both alcohol and other drug use. Regarding selfreported MI skillfulness also increased significantly. Analysis of specific faculty feedback to residents revealed subthemes such as normalizing confidentiality and focusing more on the patient‟s perspectives on substance use. Resident reflections on their own abilities with SBIRT/MI focused on using the ruler tool and on adapting the MI style of shared decisionmaking. Conclusions: A curriculum that combines online training, small group practice, clinical observations and self-reflection is valued by residents and can increase resident self-reported confidence in using SBIRT and MI in adolescent encounters. Future studies should examine to what extent confidence predicts performance using standardized measures of MI skillfulness in patient encounters.
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ACCEPTED MANUSCRIPT INTRODUCTION
Adolescent substance misuse has been called America‟s number one public health problem and is a significant, preventable cause of morbidity and mortality.1 The American
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Academy of Pediatrics (AAP) Bright Future preventive service guidelines recommend regular periodic screening for substance use beginning at the age of 11.2 Specifically, the AAP Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every preventive and all appropriate urgent visits.3 Adolescents stand to benefit from universal SBIRT that addresses not only abuse or dependence, but also intercepts risky patterns of use, especially in younger teens at greater risk of going on to develop more problematic use.4 Nevertheless, only one half of 10th graders nationwide are screened for alcohol and drug misuse at routine check-ups. 5 One third of pediatric training programs do not adequately cover alcohol and substance use in either formal teaching or practical experiences.6 In order to enhance the ability of pediatric clinicians to meet the standard of care recommended by the AAP, we received funding from the Substance Abuse and Mental Health Services Administration to develop and evaluate an SBIRT curriculum for pediatric residents. 7 We created a curriculum that blended asynchronous online learning with in-person didactics and observation of residents applying SBIRT. Regarding the “brief intervention” aspect of SBIRT, we focused on developing pediatric resident confidence and skillfulness in Motivational Interviewing (MI), a patient-centered evidence-based method of communication around behavioral change.8 Learning to use MI effectively requires both an understanding of the spirit of MI as well as specific skills, such as asking open ended questions and recognizing and
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ACCEPTED MANUSCRIPT responding appropriately to change talk9. As would be expected, graduate medical education for MI is more successful when instruction is more intensive, including experiential learning and feedback. 10 In our curriculum, residents learned about MI in web-based modules, practiced MI in a skills workshop, received feedback on their use of MI in patient encounters, and completed
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self-reflection checklists on their MI skillfulness. Our aims in evaluating the curriculum were to assess resident satisfaction with the curriculum, to evaluate changes in resident confidence around using SBIRT and MI, to evaluate qualitative feedback from faculty about resident use of SBIRT/MI, and to examine residents‟ self-reflections on their MI skillfulness.
METHODS
Setting & Participants The University of California San Francisco (UCSF) Pediatric Residency is a large (approx. 90 person total) residency program based at an urban academic center. The adolescent rotation is a required one-month rotation during the intern year that combines inpatient and outpatient clinical work at hospital-based adolescent clinics and community clinics. A subsegment of psychiatry interns also are required to complete the block. We invited all residents rotating on the adolescent block to participate in the study. The UCSF Institutional Review Board approved this study.
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ACCEPTED MANUSCRIPT Curriculum Based on a comprehensive literature review and expert consultations, two lead faculty created the SBIRT curriculum. One faculty member had extensive experience with using MI and the other underwent intensive advanced training in MI prior to designing the teaching exercises.
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Our SBIRT curriculum blended asynchronous online learning with in-person didactics and observations of residents in clinic. The curriculum consisted of four elements: 1) five webbased modules that combined brief (approximately 20 minute) narrated slide presentations with journal and popular press articles, (Table 1), 2) a 2-hour workshop with 3 to 6 residents to boost trainee skillfulness in using the CRAFFT (adolescent-specific screening tool) and applying MI principles (Table 2) conducted after residents had protected time to complete the modules, 3) faculty observation of resident-patient encounters with immediate feedback, and 4) learner selfreflection worksheets for evaluating their use of MI.
[TABLE 1 HERE]
[TABLE 2 HERE]
Evaluation and measures Each of the four elements of the curriculum was evaluated. Satisfaction. The satisfaction survey used was the Baseline Training Satisfaction survey mandated by grantees of the Center for Substance Abuse Treatment as part of the Government Performance and Results Act for Best Practices (GPRA). The survey examines learner
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ACCEPTED MANUSCRIPT satisfaction with trainings and self-perceived competence. Twenty-seven (84%) of residents completed this survey at the conclusion of their rotation. The survey included 24 questions using a 5-point Likert scale where 5 indicated very satisfied, as well as questions inviting comments on what was most useful about the training and how it could be improved.
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Confidence/Skillfulness. At the conclusion of the rotation, residents estimated their SBIRT and MI confidence and skillfulness prior to starting the curriculum compared to at its conclusion. We used a retrospective pre/post design to mitigate the effect “not knowing what one doesn‟t know.” 11,12 ,13 ,14 ,15 The items were developed from prior validated measures assessing clinician confidence in screening for adolescent risky behavior, including substance use.16 The 31-item survey used a 5-point Likert scale* where 5 indicated confidence and skillfulness. Observation of patient encounters. Residents were observed using SBIRT with patients during non-acute visits to the outpatient adolescent clinic and then given immediate feedback by the faculty observer. The observation feedback form included the list of expected behavior: explaining confidentiality, screening, and addressing the screening results appropriately. The form included areas for qualitative comments on these topics and on general strengths and areas for improvement. The vast majority of the observations were performed by the two lead faculty on the curriculum, Drs. Buckelew and Whittle. Self-assessment. Residents were asked to complete self-reflection worksheets after patient interactions that included a behavioral change discussion related to substance use or another topic such as medication adherence. The self-reflection worksheets consisted of a list of skills/behaviors adapted from two learning and assessment tools that condense principles of MI
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ACCEPTED MANUSCRIPT for a healthcare setting. The first was the Brief Negotiated Interview (BNI)17, which includes elements such as introducing the topic, providing feedback, enhancing motivation, and negotiating a plan. The second tool, the Behavioral Change Counseling Index (BECCI), includes elements focusing on the empathetic style of the practitioner.18 The form prompted residents to
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comment on the listed behaviors and make general comments about their strengths and area for improvements.
Statistical Analyses The satisfaction scores were assessed as means for each item. For the resident selfreported confidence, we calculated means and standard deviations for each retrospective pre and post measure and then calculated six domain scores. Each retrospective pre/post pair was compared using paired t-test. A P value of .05 was selected for significance. All statistical analyses were done using SPSS version 20.0. For qualitative comments, two of the authors reviewed and grouped them by content areas agreed to by consensus.
Qualitative analysis Qualitative comments from the faculty observations and the self-reflection worksheets were entered into a database. Drs. Whittle and Buckelew performed a directed content analysis of this data guided by categories derived from the teaching objectives of the curriculum (explaining confidentiality, screening, asking open-ended questions, using ruler tool, offering reflections, and demonstrating MI spirit including empathy and shared decision making).19 Both faculty evaluated the comments and generated subthemes within these categories. Generic
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ACCEPTED MANUSCRIPT comments that did not comment on a specific aspect of a behavior were not coded for subthemes (eg “Good job with affirmations”). All discrepancies were discussed until concordance was reached.
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RESULTS
Resident Demographics Between June 2012 and May 2013, 32 of the 36 residents rotating on the adolescent block agreed to participate in the study, of which 27 (84%) were pediatric interns and 5 (16%) were psychiatry interns. Of the four that declined to participate, two were psychiatry and two were pediatric residents. Four (11%) of participants were male. All were in their first year of residency.
Resident Satisfaction Twenty seven (84%) of residents completed the satisfaction survey. All residents reported that they were either “satisfied” or “very satisfied” with the overall quality of the curriculum. With regard to their perception of being effective when dealing with adolescent substance use: 43% of residents agreed or strongly agreed, 34% were neutral, and 23% disagreed. Nearly all (95%) “strongly agreed” or “agreed” that the curriculum enhanced their skills and that they expect to use the information gained. When asked to comment about the most useful part of the training, 11/27 (41%) residents cited the role-playing exercises. One resident found valuable the “role playing and getting direct
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ACCEPTED MANUSCRIPT feedback about it and going step by step through the MI,” while another appreciated “practicing with examples that I had seen in clinic.” Another resident commented “almost every outpatient encounter in my pediatric clinics involves patient or parent desire to change behavior. These skills are incredibly valuable in dealing with these situations. Essential to any primary care
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provider!” Residents comments on areas for improvement included practicing MI with longer scenarios, having two sessions for practice, and incorporating standardized patients.
Resident Self-report of Confidence Twenty nine residents completed the retrospective pre-post confidence survey (81%). Using a paired samples test, residents reported increased confidence regarding every skill queried. Residents reported significant improvement in all domain scores (Table 3).
[TABLE 3 HERE]
Faculty Feedback from Observations of Resident-Patient Interactions Faculty completed a total of 46 observations; 14 residents were observed once and 16 residents were observed twice. Subthemes emerged around confidentiality, screening, openended questions, reflections, and MI spirit (Table 4). For example, regarding confidentiality, two subthemes were normalizing the process and describing limits accurately.
[TABLE 4 HERE]
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ACCEPTED MANUSCRIPT Resident Self-Reflection on MI Skills Seven residents turned in a total of 24 self-reflection MI worksheets following patient encounters. Subthemes emerged around reflections, the ruler, and MI spirit (Table 5). Residents commented on forgetting to use the ruler or feeling awkward when doing so. Regarding MI
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style, relevant subthemes focused on developing a plan for the patient‟s future behavior, guiding the patient instead of directing, and understanding the patient‟s perspective more.
DISCUSSION
Teaching adolescent clinicians SBIRT offers a unique set of challenges including patient confidentiality, specialized screening tools, and the developmental differences among adolescents. We developed, implemented, and evaluated a curriculum to teach GME learners how to use SBIRT when seeing adolescent patients that blended online learning with an inperson workshop, feedback around patient visits, and self-reflection. The curriculum was highly valued by residents and boosted their self-rated confidence about using both SBIRT and MI with adolescents. Limitations of the retrospective pre/post design include social desirability bias and recall bias.20 Our study design did not allow us to compare self-reported confidence with actual clinical practice or patient outcomes. Our qualitative analysis of the faculty observation feedback and of the self-reflection worksheets is not designed to provide an assessment of resident overall skillfulness in MI or how skillfulness changed after completion of the curriculum. Rather, the analyses serve to inform medical educators about the ways in which residents struggle with
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ACCEPTED MANUSCRIPT effective use of SBIRT and MI and opportunities for enhancing teaching on these topics. Due to the relatively small number of comments, our findings may lack generalizability. MI is perhaps the most challenging aspect of teaching SBIRT to GME learners. While the principles of MI are simple, becoming competent in MI proves difficult.21 Physicians face
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particular hurdles including lack of time to train in MI and to counsel patients. Faculty time to observe trainee-patient interactions is often limited and many faculty lack the expertise in MI to coach effectively. In our own study, one challenge to performing observation of MI was the inability to predict which patient encounter would necessitate using MI; of the patient interactions observed, fewer than half involved a patient that screened positive for substance use. Our observations were limited to well visits; we might have been able to observe more positive screen visits in an urgent care setting, especially for those adolescents without a primary care home. Curriculums using standardized patients have been demonstrated to improve pediatric resident performance in SBIRT.22 23 However, standardized patients are costly and timeconsuming to use in GME training. In this study, we used self-reflection as a means to continue leaners‟ engagement with the principles of MI. We arrived at the self-reflection form after determining that this was a more efficient way to reinforce MI principles given limited faculty time for patient observations. The number of self-reflections reported in this study was small; part of the low numbers likely had to do with the fact that there was no dedicated time for faculty to review these checklists. Doing so would likely have been highly educational, especially when residents recorded attitudes inconsistent with MI spirit, such as the resident who commented that she needed to “create a future plan no matter their readiness.” One resident used the ruler
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ACCEPTED MANUSCRIPT concept inappropriately, asking the patient why they were not higher on the scale (instead of asking why they are not lower, which elicits reasons for wanting to change.) In the future, we plan to ask residents to complete at least three self-reflections prior to participating in the 2-hour seminar. In this way, we aim to help residents target their practice to the behaviors that are most
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challenging for them and to identify areas of confusion or misunderstanding. While the number of self-reflections was relatively small, we believe this technique has promise to extend formal MI teaching and reinforce it in the clinical setting. In summary, SBIRT is an essential topic for GME learners who will treat adolescent patients. Our blended online and in-person curriculum was well received and boosted resident self-rated skillfulness in all areas of SBIRT. Self-reflection may offer a means to help trainees reinforce principles of MI while sparing faculty time.
FUNDING
This work was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS) through Cooperative Agreements U79TI020296 and U79TI020295. The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.
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ACCEPTED MANUSCRIPT AUTHOR CONTRIBUTIONS
AW and SB designed the curriculum and the evaluation design, with the input of PL, JS, and PO. AW and SB created the curriculum materials, taught the workshops, and collected and
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compiled the data. PO completed the statistical analysis. AW wrote the manuscript and SB, PL, JS, and PO provided substantial editorial input.
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ACCEPTED MANUSCRIPT REFERENCES 1
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TABLE 1 Online Modules Video
Learning Objective #1
Learning Objective #2
Learning Objective #3
Epidemiology of Substance Use in Adolescents
State the trends of use amongst adolescents of common substances like alcohol, tobacco and marijuana.
Describe the potential adverse consequences of common substances of abuse.
Identify reliable sources to obtain more information about current adolescent substance use trends and risks of these substances.
What is SBIRT?
Identify what SBIRT stands for.
State perceived barriers to using SBIRT in adolescent encounters.
Explain when it is appropriate to use SBIRT.
Screening Adolescents for substance use
State the components of the CRAFFT screening tool for adolescent substance use.
Learn how to score the CRAFFT screening measure.
Describe how to intervene depending on the results of the CRAFFT.
Brief Interventions and Motivational Interviewing
Describe the basic outline of a brief intervention.
Name three common communication strategies used in motivational interviewing.
Distinguish between scenarios in which a brief intervention is appropriate or not.
Referral to Treatment
Describe when to refer an adolescent patient to treatment.
State potential elements of adolescent substance use treatment, including medications.
Identify the role of harm reduction and what to do if a patient refuses treatment.
TABLE 2 2-Hour Workshop Element
Time (min)
Activities
CRAFFT & privacy
20
Review of the questions in the CRAFFT and how to interpret score. Review of methods for explaining confidentiality to parents and adolescents.
Review of principles of motivational interviewing
10
Overview of the fundamental principles of MI and evidence behind its use in adolescent substance use. Discussion of empathy and guiding style versus directive or following style.
Role play using “elicit-provideelicit” model
25
Role play using ONLY openended questions and reflections
30
Residents practice asking e.g. “What do you know about the risks of (e.g. marijuana use)?” providing relevant information about risk, then asking “What do you think about that?” Review of facts about risks of alcohol, marijuana, and other drugs of abuse that are salient to a teen population. Residents talk to in pairs: one discusses a real-life issue that they would like to change while the other responds by only asking open-ended questions or providing reflections. Debrief afterwards.
Review of the ruler and role play of use
20
Introduction to the reasons for using the ruler and how to frame questions to maximize motivation. Practice in pairs using this tool.
Video example of SBIRT
15
Residents watch video while looking for MI behaviors such as open-ended questions, reflections, and the ruler.
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TABLE 3 Self-reported confidence (1 = low, 5 = high) reported pre (retrospectively) and post
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Measure
Mean pre (S.D.)
Mean post (S.D)
Screening for alcohol use*
2.9 (0.8)
4.2 (0.5)
Screening for other drug use*
2.9 (0.7)
4.1 (0.5)
Setting the stage to talk about substance use*
3.1 (0.6)
4.4 (0.5)
Overall MI skillfulness*
1.8 (0.7)
3.5 (0.6)
Using MI related to alcohol use*
2.4 (0.7)
3.8 (0.6)
Using MI related to other drug use*
2.5 (0.7)
3.8 (0.6)
*p< 0.001
TABLE 4 Faculty Observations of Resident-Patient Interactions Skill area
Description
Sub-theme
Examples
Confidentiality
Explaining to parent and adolescent the extent to which information shared may be kept private between patient and provider
Normalizing concept of confidentiality
“Really nice job explaining and normalizing confidentiality.”
Accurately describing limits of confidentiality
“Remember to mention that you may have to discuss with attending (physician).”
Screening
Using CRAFFT appropriately
Appropriate degree of detail
“If patient says not engaged in behaviors do not need to dig deeper.” “Maybe (do not) mention glue specifically – could be seen as insulting.” “Could have fleshed out more eg definition of binge drinking.”
Open-ended questions
Asking questions that cannot be answered with a one-word answer
Specific examples of how openended questions were used or could have been used
“Maybe ask „How's your sleep?‟ vs. „Are you waking up?‟” “Asked the question "What was the last thing you fought about?”
Reflections
Statement back to the patient summarizing what was just said, ideally highlighting change talk
Specific instances in which reflections were used or could have been used
“(Offer) reflection on „nice to me‟ statement eg „so, parents are nicer to you when xyz.‟” “(Said) „Sounds like your job is important enough that you wouldn't risk losing it.‟ - fantastic!”
MI spirit
Demonstrating shared decision making in which patient‟s concerns are respected; showing empathy
Focusing on patient‟s reasons for change
“Identified the positive associated with smoking.” “Try to explore some of her own reasons for not using.” “(Ask) „Do you know why we recommend not smoking marijuana?‟” “Maybe a question re „How did you stop smoking marijuana? Some teens would have a hard time with that, great that you didn‟t.‟”
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TABLE 5 Resident Self-Reflection Worksheets Skill area
Description
Sub-theme
Examples
Reflections
Statement back to the patient summarizing what was just said, ideally highlighting change talk
Identifying underlying emotion
“(Said) „I understand it could be scary to lose your boyfriend if you ask him to change.‟”
Ruler
Using a scale from 0 to 10 to assess readiness to change
Not remembering to use the tool
“I find I do not use the "ruler readiness" tool often, but I do think it would be helpful to begin the conversation about behavior change.” “Could have used ruler or other evaluation for readiness to both quantify and comment on improvements he has made.”
Incorporation of ruler tool into natural conversation
“Learn how to adopt ruler to unconventional problem.” “Felt awkward and forced using readiness ruler.” “Did not use the ready ruler because I was concerned she would feel too forced.” “I felt uncomfortable incorporating ruler technique but I should have tried to assess readiness regardless.” “Work to involved readiness ruler more smoothly.”
Inappropriate use of ruler (eg asking why patient isn‟t lower on scale or what it would take to get them higher)
“…did ask for details about barriers and why not further along on readiness (did not ask why was further back though).”
Desire to create a plan
“Learn how to work with patient and create a future plan no matter their readiness.” “Work on involving family in plan.” “Come up with an action plan. Not tackles too many things to change.”
Aiming for guiding vs. leading or following
“Continue to work on teaching and guiding, not preaching.” “Reiterated that I am here to help, provide support, but she has to make change when she is ready.”
Eliciting patient‟s understanding
“Would want to delve deeper; assess patient knowledge.” “Would have liked to spend more time focusing on reasons to quit that specifically mattered to this patient individually.”
MI spirit
Demonstrating shared decision making in which patient‟s concerns are respected; showing empathy
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Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wsub20
Addressing Adolescent Substance Use: Teaching SBIRT and MI to Residents a
a
b
Amy E. Whittle MD , Sara M. Buckelew MD MPH , Jason M. Satterfield PhD , Paula J. Lum MD b
b
MPH & Patricia O'Sullivan PhD a
Department of Pediatrics, University of California, San Francisco, CA, USA.
b
Department of Medicine, University of California, San Francisco, CA, USA. Accepted author version posted online: 26 Sep 2014.
To cite this article: Amy E. Whittle MD, Sara M. Buckelew MD MPH, Jason M. Satterfield PhD, Paula J. Lum MD MPH & Patricia O'Sullivan PhD (2014): Addressing Adolescent Substance Use: Teaching SBIRT and MI to Residents, Substance Abuse, DOI: 10.1080/08897077.2014.965292 To link to this article: http://dx.doi.org/10.1080/08897077.2014.965292
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ACCEPTED MANUSCRIPT Addressing Adolescent Substance Use: Teaching SBIRT and MI to Residents
Amy E. Whittle1, MD; Sara M. Buckelew1, MD, MPH; Jason M. Satterfield2, PhD; Paula J.
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Lum2, MD, MPH; Patricia O‟Sullivan2, PhD
1. Department of Pediatrics, University of California, San Francisco, CA, USA. 2. Department of Medicine, University of California, San Francisco, CA, USA.
Correspondence should be addressed to Amy E. Whittle, MD, Department of Pediatrics, University of California, 1001 Potrero Avenue, MS6E, San Francisco, CA, USA. Email: [email protected]
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ACCEPTED MANUSCRIPT ABSTRACT. Background: The American Academy of Pediatrics Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every adolescent preventive and all appropriate urgent visits. We designed an SBIRT curriculum as part of the adolescent block of a pediatric residency that combined online modules with an in-person
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workshop, faculty feedback on resident interactions with patients, and resident self-reflection on their motivational interviewing (MI) skills. Methods: To evaluate the curriculum, we measured resident satisfaction and self-reported confidence in using SBIRT and MI with teens using a retrospective pre/post questionnaire. We used qualitative analysis to evaluate the written comments from faculty observations of patient-trainee interactions and comments from residents‟ self-reflections on patient interactions. Results: Thirty-two residents completed the curriculum. Residents reported high satisfaction with the training. Comparing retrospective pre/post scores on the survey of resident self-reported confidence, measures increased significantly in all domains, including for both alcohol and other drug use. Regarding selfreported MI skillfulness also increased significantly. Analysis of specific faculty feedback to residents revealed subthemes such as normalizing confidentiality and focusing more on the patient‟s perspectives on substance use. Resident reflections on their own abilities with SBIRT/MI focused on using the ruler tool and on adapting the MI style of shared decisionmaking. Conclusions: A curriculum that combines online training, small group practice, clinical observations and self-reflection is valued by residents and can increase resident self-reported confidence in using SBIRT and MI in adolescent encounters. Future studies should examine to what extent confidence predicts performance using standardized measures of MI skillfulness in patient encounters.
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ACCEPTED MANUSCRIPT INTRODUCTION
Adolescent substance misuse has been called America‟s number one public health problem and is a significant, preventable cause of morbidity and mortality.1 The American
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Academy of Pediatrics (AAP) Bright Future preventive service guidelines recommend regular periodic screening for substance use beginning at the age of 11.2 Specifically, the AAP Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every preventive and all appropriate urgent visits.3 Adolescents stand to benefit from universal SBIRT that addresses not only abuse or dependence, but also intercepts risky patterns of use, especially in younger teens at greater risk of going on to develop more problematic use.4 Nevertheless, only one half of 10th graders nationwide are screened for alcohol and drug misuse at routine check-ups. 5 One third of pediatric training programs do not adequately cover alcohol and substance use in either formal teaching or practical experiences.6 In order to enhance the ability of pediatric clinicians to meet the standard of care recommended by the AAP, we received funding from the Substance Abuse and Mental Health Services Administration to develop and evaluate an SBIRT curriculum for pediatric residents. 7 We created a curriculum that blended asynchronous online learning with in-person didactics and observation of residents applying SBIRT. Regarding the “brief intervention” aspect of SBIRT, we focused on developing pediatric resident confidence and skillfulness in Motivational Interviewing (MI), a patient-centered evidence-based method of communication around behavioral change.8 Learning to use MI effectively requires both an understanding of the spirit of MI as well as specific skills, such as asking open ended questions and recognizing and
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ACCEPTED MANUSCRIPT responding appropriately to change talk9. As would be expected, graduate medical education for MI is more successful when instruction is more intensive, including experiential learning and feedback. 10 In our curriculum, residents learned about MI in web-based modules, practiced MI in a skills workshop, received feedback on their use of MI in patient encounters, and completed
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self-reflection checklists on their MI skillfulness. Our aims in evaluating the curriculum were to assess resident satisfaction with the curriculum, to evaluate changes in resident confidence around using SBIRT and MI, to evaluate qualitative feedback from faculty about resident use of SBIRT/MI, and to examine residents‟ self-reflections on their MI skillfulness.
METHODS
Setting & Participants The University of California San Francisco (UCSF) Pediatric Residency is a large (approx. 90 person total) residency program based at an urban academic center. The adolescent rotation is a required one-month rotation during the intern year that combines inpatient and outpatient clinical work at hospital-based adolescent clinics and community clinics. A subsegment of psychiatry interns also are required to complete the block. We invited all residents rotating on the adolescent block to participate in the study. The UCSF Institutional Review Board approved this study.
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ACCEPTED MANUSCRIPT Curriculum Based on a comprehensive literature review and expert consultations, two lead faculty created the SBIRT curriculum. One faculty member had extensive experience with using MI and the other underwent intensive advanced training in MI prior to designing the teaching exercises.
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Our SBIRT curriculum blended asynchronous online learning with in-person didactics and observations of residents in clinic. The curriculum consisted of four elements: 1) five webbased modules that combined brief (approximately 20 minute) narrated slide presentations with journal and popular press articles, (Table 1), 2) a 2-hour workshop with 3 to 6 residents to boost trainee skillfulness in using the CRAFFT (adolescent-specific screening tool) and applying MI principles (Table 2) conducted after residents had protected time to complete the modules, 3) faculty observation of resident-patient encounters with immediate feedback, and 4) learner selfreflection worksheets for evaluating their use of MI.
[TABLE 1 HERE]
[TABLE 2 HERE]
Evaluation and measures Each of the four elements of the curriculum was evaluated. Satisfaction. The satisfaction survey used was the Baseline Training Satisfaction survey mandated by grantees of the Center for Substance Abuse Treatment as part of the Government Performance and Results Act for Best Practices (GPRA). The survey examines learner
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ACCEPTED MANUSCRIPT satisfaction with trainings and self-perceived competence. Twenty-seven (84%) of residents completed this survey at the conclusion of their rotation. The survey included 24 questions using a 5-point Likert scale where 5 indicated very satisfied, as well as questions inviting comments on what was most useful about the training and how it could be improved.
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Confidence/Skillfulness. At the conclusion of the rotation, residents estimated their SBIRT and MI confidence and skillfulness prior to starting the curriculum compared to at its conclusion. We used a retrospective pre/post design to mitigate the effect “not knowing what one doesn‟t know.” 11,12 ,13 ,14 ,15 The items were developed from prior validated measures assessing clinician confidence in screening for adolescent risky behavior, including substance use.16 The 31-item survey used a 5-point Likert scale* where 5 indicated confidence and skillfulness. Observation of patient encounters. Residents were observed using SBIRT with patients during non-acute visits to the outpatient adolescent clinic and then given immediate feedback by the faculty observer. The observation feedback form included the list of expected behavior: explaining confidentiality, screening, and addressing the screening results appropriately. The form included areas for qualitative comments on these topics and on general strengths and areas for improvement. The vast majority of the observations were performed by the two lead faculty on the curriculum, Drs. Buckelew and Whittle. Self-assessment. Residents were asked to complete self-reflection worksheets after patient interactions that included a behavioral change discussion related to substance use or another topic such as medication adherence. The self-reflection worksheets consisted of a list of skills/behaviors adapted from two learning and assessment tools that condense principles of MI
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ACCEPTED MANUSCRIPT for a healthcare setting. The first was the Brief Negotiated Interview (BNI)17, which includes elements such as introducing the topic, providing feedback, enhancing motivation, and negotiating a plan. The second tool, the Behavioral Change Counseling Index (BECCI), includes elements focusing on the empathetic style of the practitioner.18 The form prompted residents to
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comment on the listed behaviors and make general comments about their strengths and area for improvements.
Statistical Analyses The satisfaction scores were assessed as means for each item. For the resident selfreported confidence, we calculated means and standard deviations for each retrospective pre and post measure and then calculated six domain scores. Each retrospective pre/post pair was compared using paired t-test. A P value of .05 was selected for significance. All statistical analyses were done using SPSS version 20.0. For qualitative comments, two of the authors reviewed and grouped them by content areas agreed to by consensus.
Qualitative analysis Qualitative comments from the faculty observations and the self-reflection worksheets were entered into a database. Drs. Whittle and Buckelew performed a directed content analysis of this data guided by categories derived from the teaching objectives of the curriculum (explaining confidentiality, screening, asking open-ended questions, using ruler tool, offering reflections, and demonstrating MI spirit including empathy and shared decision making).19 Both faculty evaluated the comments and generated subthemes within these categories. Generic
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ACCEPTED MANUSCRIPT comments that did not comment on a specific aspect of a behavior were not coded for subthemes (eg “Good job with affirmations”). All discrepancies were discussed until concordance was reached.
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RESULTS
Resident Demographics Between June 2012 and May 2013, 32 of the 36 residents rotating on the adolescent block agreed to participate in the study, of which 27 (84%) were pediatric interns and 5 (16%) were psychiatry interns. Of the four that declined to participate, two were psychiatry and two were pediatric residents. Four (11%) of participants were male. All were in their first year of residency.
Resident Satisfaction Twenty seven (84%) of residents completed the satisfaction survey. All residents reported that they were either “satisfied” or “very satisfied” with the overall quality of the curriculum. With regard to their perception of being effective when dealing with adolescent substance use: 43% of residents agreed or strongly agreed, 34% were neutral, and 23% disagreed. Nearly all (95%) “strongly agreed” or “agreed” that the curriculum enhanced their skills and that they expect to use the information gained. When asked to comment about the most useful part of the training, 11/27 (41%) residents cited the role-playing exercises. One resident found valuable the “role playing and getting direct
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ACCEPTED MANUSCRIPT feedback about it and going step by step through the MI,” while another appreciated “practicing with examples that I had seen in clinic.” Another resident commented “almost every outpatient encounter in my pediatric clinics involves patient or parent desire to change behavior. These skills are incredibly valuable in dealing with these situations. Essential to any primary care
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provider!” Residents comments on areas for improvement included practicing MI with longer scenarios, having two sessions for practice, and incorporating standardized patients.
Resident Self-report of Confidence Twenty nine residents completed the retrospective pre-post confidence survey (81%). Using a paired samples test, residents reported increased confidence regarding every skill queried. Residents reported significant improvement in all domain scores (Table 3).
[TABLE 3 HERE]
Faculty Feedback from Observations of Resident-Patient Interactions Faculty completed a total of 46 observations; 14 residents were observed once and 16 residents were observed twice. Subthemes emerged around confidentiality, screening, openended questions, reflections, and MI spirit (Table 4). For example, regarding confidentiality, two subthemes were normalizing the process and describing limits accurately.
[TABLE 4 HERE]
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ACCEPTED MANUSCRIPT Resident Self-Reflection on MI Skills Seven residents turned in a total of 24 self-reflection MI worksheets following patient encounters. Subthemes emerged around reflections, the ruler, and MI spirit (Table 5). Residents commented on forgetting to use the ruler or feeling awkward when doing so. Regarding MI
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style, relevant subthemes focused on developing a plan for the patient‟s future behavior, guiding the patient instead of directing, and understanding the patient‟s perspective more.
DISCUSSION
Teaching adolescent clinicians SBIRT offers a unique set of challenges including patient confidentiality, specialized screening tools, and the developmental differences among adolescents. We developed, implemented, and evaluated a curriculum to teach GME learners how to use SBIRT when seeing adolescent patients that blended online learning with an inperson workshop, feedback around patient visits, and self-reflection. The curriculum was highly valued by residents and boosted their self-rated confidence about using both SBIRT and MI with adolescents. Limitations of the retrospective pre/post design include social desirability bias and recall bias.20 Our study design did not allow us to compare self-reported confidence with actual clinical practice or patient outcomes. Our qualitative analysis of the faculty observation feedback and of the self-reflection worksheets is not designed to provide an assessment of resident overall skillfulness in MI or how skillfulness changed after completion of the curriculum. Rather, the analyses serve to inform medical educators about the ways in which residents struggle with
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ACCEPTED MANUSCRIPT effective use of SBIRT and MI and opportunities for enhancing teaching on these topics. Due to the relatively small number of comments, our findings may lack generalizability. MI is perhaps the most challenging aspect of teaching SBIRT to GME learners. While the principles of MI are simple, becoming competent in MI proves difficult.21 Physicians face
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particular hurdles including lack of time to train in MI and to counsel patients. Faculty time to observe trainee-patient interactions is often limited and many faculty lack the expertise in MI to coach effectively. In our own study, one challenge to performing observation of MI was the inability to predict which patient encounter would necessitate using MI; of the patient interactions observed, fewer than half involved a patient that screened positive for substance use. Our observations were limited to well visits; we might have been able to observe more positive screen visits in an urgent care setting, especially for those adolescents without a primary care home. Curriculums using standardized patients have been demonstrated to improve pediatric resident performance in SBIRT.22 23 However, standardized patients are costly and timeconsuming to use in GME training. In this study, we used self-reflection as a means to continue leaners‟ engagement with the principles of MI. We arrived at the self-reflection form after determining that this was a more efficient way to reinforce MI principles given limited faculty time for patient observations. The number of self-reflections reported in this study was small; part of the low numbers likely had to do with the fact that there was no dedicated time for faculty to review these checklists. Doing so would likely have been highly educational, especially when residents recorded attitudes inconsistent with MI spirit, such as the resident who commented that she needed to “create a future plan no matter their readiness.” One resident used the ruler
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ACCEPTED MANUSCRIPT concept inappropriately, asking the patient why they were not higher on the scale (instead of asking why they are not lower, which elicits reasons for wanting to change.) In the future, we plan to ask residents to complete at least three self-reflections prior to participating in the 2-hour seminar. In this way, we aim to help residents target their practice to the behaviors that are most
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challenging for them and to identify areas of confusion or misunderstanding. While the number of self-reflections was relatively small, we believe this technique has promise to extend formal MI teaching and reinforce it in the clinical setting. In summary, SBIRT is an essential topic for GME learners who will treat adolescent patients. Our blended online and in-person curriculum was well received and boosted resident self-rated skillfulness in all areas of SBIRT. Self-reflection may offer a means to help trainees reinforce principles of MI while sparing faculty time.
FUNDING
This work was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS) through Cooperative Agreements U79TI020296 and U79TI020295. The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.
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ACCEPTED MANUSCRIPT AUTHOR CONTRIBUTIONS
AW and SB designed the curriculum and the evaluation design, with the input of PL, JS, and PO. AW and SB created the curriculum materials, taught the workshops, and collected and
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compiled the data. PO completed the statistical analysis. AW wrote the manuscript and SB, PL, JS, and PO provided substantial editorial input.
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ACCEPTED MANUSCRIPT REFERENCES 1
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TABLE 1 Online Modules Video
Learning Objective #1
Learning Objective #2
Learning Objective #3
Epidemiology of Substance Use in Adolescents
State the trends of use amongst adolescents of common substances like alcohol, tobacco and marijuana.
Describe the potential adverse consequences of common substances of abuse.
Identify reliable sources to obtain more information about current adolescent substance use trends and risks of these substances.
What is SBIRT?
Identify what SBIRT stands for.
State perceived barriers to using SBIRT in adolescent encounters.
Explain when it is appropriate to use SBIRT.
Screening Adolescents for substance use
State the components of the CRAFFT screening tool for adolescent substance use.
Learn how to score the CRAFFT screening measure.
Describe how to intervene depending on the results of the CRAFFT.
Brief Interventions and Motivational Interviewing
Describe the basic outline of a brief intervention.
Name three common communication strategies used in motivational interviewing.
Distinguish between scenarios in which a brief intervention is appropriate or not.
Referral to Treatment
Describe when to refer an adolescent patient to treatment.
State potential elements of adolescent substance use treatment, including medications.
Identify the role of harm reduction and what to do if a patient refuses treatment.
TABLE 2 2-Hour Workshop Element
Time (min)
Activities
CRAFFT & privacy
20
Review of the questions in the CRAFFT and how to interpret score. Review of methods for explaining confidentiality to parents and adolescents.
Review of principles of motivational interviewing
10
Overview of the fundamental principles of MI and evidence behind its use in adolescent substance use. Discussion of empathy and guiding style versus directive or following style.
Role play using “elicit-provideelicit” model
25
Role play using ONLY openended questions and reflections
30
Residents practice asking e.g. “What do you know about the risks of (e.g. marijuana use)?” providing relevant information about risk, then asking “What do you think about that?” Review of facts about risks of alcohol, marijuana, and other drugs of abuse that are salient to a teen population. Residents talk to in pairs: one discusses a real-life issue that they would like to change while the other responds by only asking open-ended questions or providing reflections. Debrief afterwards.
Review of the ruler and role play of use
20
Introduction to the reasons for using the ruler and how to frame questions to maximize motivation. Practice in pairs using this tool.
Video example of SBIRT
15
Residents watch video while looking for MI behaviors such as open-ended questions, reflections, and the ruler.
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TABLE 3 Self-reported confidence (1 = low, 5 = high) reported pre (retrospectively) and post
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Measure
Mean pre (S.D.)
Mean post (S.D)
Screening for alcohol use*
2.9 (0.8)
4.2 (0.5)
Screening for other drug use*
2.9 (0.7)
4.1 (0.5)
Setting the stage to talk about substance use*
3.1 (0.6)
4.4 (0.5)
Overall MI skillfulness*
1.8 (0.7)
3.5 (0.6)
Using MI related to alcohol use*
2.4 (0.7)
3.8 (0.6)
Using MI related to other drug use*
2.5 (0.7)
3.8 (0.6)
*p< 0.001
TABLE 4 Faculty Observations of Resident-Patient Interactions Skill area
Description
Sub-theme
Examples
Confidentiality
Explaining to parent and adolescent the extent to which information shared may be kept private between patient and provider
Normalizing concept of confidentiality
“Really nice job explaining and normalizing confidentiality.”
Accurately describing limits of confidentiality
“Remember to mention that you may have to discuss with attending (physician).”
Screening
Using CRAFFT appropriately
Appropriate degree of detail
“If patient says not engaged in behaviors do not need to dig deeper.” “Maybe (do not) mention glue specifically – could be seen as insulting.” “Could have fleshed out more eg definition of binge drinking.”
Open-ended questions
Asking questions that cannot be answered with a one-word answer
Specific examples of how openended questions were used or could have been used
“Maybe ask „How's your sleep?‟ vs. „Are you waking up?‟” “Asked the question "What was the last thing you fought about?”
Reflections
Statement back to the patient summarizing what was just said, ideally highlighting change talk
Specific instances in which reflections were used or could have been used
“(Offer) reflection on „nice to me‟ statement eg „so, parents are nicer to you when xyz.‟” “(Said) „Sounds like your job is important enough that you wouldn't risk losing it.‟ - fantastic!”
MI spirit
Demonstrating shared decision making in which patient‟s concerns are respected; showing empathy
Focusing on patient‟s reasons for change
“Identified the positive associated with smoking.” “Try to explore some of her own reasons for not using.” “(Ask) „Do you know why we recommend not smoking marijuana?‟” “Maybe a question re „How did you stop smoking marijuana? Some teens would have a hard time with that, great that you didn‟t.‟”
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TABLE 5 Resident Self-Reflection Worksheets Skill area
Description
Sub-theme
Examples
Reflections
Statement back to the patient summarizing what was just said, ideally highlighting change talk
Identifying underlying emotion
“(Said) „I understand it could be scary to lose your boyfriend if you ask him to change.‟”
Ruler
Using a scale from 0 to 10 to assess readiness to change
Not remembering to use the tool
“I find I do not use the "ruler readiness" tool often, but I do think it would be helpful to begin the conversation about behavior change.” “Could have used ruler or other evaluation for readiness to both quantify and comment on improvements he has made.”
Incorporation of ruler tool into natural conversation
“Learn how to adopt ruler to unconventional problem.” “Felt awkward and forced using readiness ruler.” “Did not use the ready ruler because I was concerned she would feel too forced.” “I felt uncomfortable incorporating ruler technique but I should have tried to assess readiness regardless.” “Work to involved readiness ruler more smoothly.”
Inappropriate use of ruler (eg asking why patient isn‟t lower on scale or what it would take to get them higher)
“…did ask for details about barriers and why not further along on readiness (did not ask why was further back though).”
Desire to create a plan
“Learn how to work with patient and create a future plan no matter their readiness.” “Work on involving family in plan.” “Come up with an action plan. Not tackles too many things to change.”
Aiming for guiding vs. leading or following
“Continue to work on teaching and guiding, not preaching.” “Reiterated that I am here to help, provide support, but she has to make change when she is ready.”
Eliciting patient‟s understanding
“Would want to delve deeper; assess patient knowledge.” “Would have liked to spend more time focusing on reasons to quit that specifically mattered to this patient individually.”
MI spirit
Demonstrating shared decision making in which patient‟s concerns are respected; showing empathy
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