Last night concluded our three-part Motivational Interviewing for Smoking Cessation CME Workshop for practicing physicians in the virtual world. And we did it in spite of hurricanes (three of our participating docs volunteered to help out in Joplin, MO) and tornadoes (breaking weather here in New England, as the third event got under way). You can read about the first two events of this continuing medical education series here and here.
Despite the biblical weather, we all arrived in Second Life at the appointed hour with surprisingly few technical glitches. No doubt the able problem solving skills of Chimera Cosmos and Jenn Forager, during the previous two workshops, had well prepared everyone to triage all those handy steps themselves!
But before our participating healthcare professionals arrived at this third event, they had a homework assignment. We posted machinima (videos shot in Second Life, created by Ariella Furman) of their event #2 role plays onto a community blog site which they were asked to visit, watch their own video, comment, and then comment on the video of at least one other participant. Our instructors, Suzanne Mitchell and Jay Lee, also posted coaching comments on each video entry. There was something powerful about watching those role-plays collectively. Patterns quickly emerged (oh, the power of video!) and it was amazing to see the variation in approach with just a few patient scenarios.
* The HCPs were very, very good at expressing empathy – reflecting back to the patient how hard it is to quit smoking, how frustrating it can be.
* Less in evidence was the knack of developing discrepancy with the patients, a key motivational interviewing skill (e.g. “On the one hand smoking is a very social thing for you, but on the other hand you are concerned about your breathlessness and coughing”).
* Rather, they relied heavily on information giving (e.g. “Let me tell you about treatment options…”)
* Repeatedly you hear the HCP’s use of the pronoun “we” when talking about what the patient will do (e.g. “WE’RE going to need to get that blood pressure down” or “What WE should do…”). This phrasing side-steps the patient self-efficacy that underlies MI.
So event #3 started with recap of those role play videos and a conversation – what did you learn from watching your own video? What patterns did you see? I was particularly taken with one HCP who said that she was surprised to discover the mismatch between her actual role-play and what happened in her own head. After that, Jay Lee lead us through some helpful treatment, quit plan, and pharmacological information and then it was up to the role-playing platforms to try it all again.
This time we stuck with the same cases from event #2, starting with the assumption that the patient was returning, after hearing all the medical information they needed, and the object of the role-play was specifically to discuss their smoking. Jay and Suzanne gave each HCP their opening line with the patient. For instance, “Glad you’ve got your blood pressure under control, Bill, that’s great. I remember the last time we talked about your smoking, is it alright if we continue that conversation today?” This way each role-play focused like a laser beam on exploring and excavating the reasons why this patient smokes and what they want to do about it. You could almost hear the mental wheels turning.
There was an observable shift in the patterns observed during event #2 and some dramatic changes in approach. During the role play, the audience members typed their thoughts and suggestions in local chat and the coaches gave advice and support. “Nice job showing empathy…” , “Try reflecting back what the patient is telling you…” “Point out the discrepancy in what she is saying…” “Be careful of making comparisons with other patients.” After each role play, the coach asked the HCP how they thought it went and asked the patient how it felt to them.
Only 8 minutes in length, it was amazing to see how much progress could be made on the smoking issue in each role play! I was struck by two things: 1) how much could be learned from just watching the other HCPs doing their role play and 2) how very difficult it is to use motivational interviewing well. As Cynthia Kear, this project’s leader, put it so well, “like a lot of complex things in life – it sounds simple on the surface, but when you get in there to actually do it, it’s more difficult than you imagined”.
After the hard work of role-playing, we all teleported down to the ground level, chatting about the experience and – what else? – dancing. It was great to hear everyone’s pleasure over something so simple and fun.
All in all, a very succesful workshop series. If you’d like to read more, you can read a from-the-event, live Twitter stream on CS2Day’s Twitter feed. The program’s sponsor CS2Day, with the California Academy of Family Physicians as the lead partner, should be very proud of their visionary leadership as they explore unchartered territory in continuing medical education.