What grabbed me about ICMI 3?Reflections from a friendly critical medical practitioner investigator Chris Butler Head of Institute of Primary Care and Public Health Cardiff University Director, Wales School of Primary Care Research
ICMI3 Inputs• What is the theory?• What is it in practice?• How do we measure it?• How do we best train clinicians to deliver it?• How do clients respond?• Can it work?• Does it work?• What effect does training practitioners in a certain way have on participants in a given context• Is it worth it?• How do we influence policy makers and practitioners?
Watkins et al• Single centre• “A research nurse randomised patients… The same nurse then assigned intervention group patients to 1 of 4 therapists using an opaque sealed envelope..”• Medication and medication adherence not reported• Cause of death not reported
Robling et al• Objective To evaluate the effectiveness on glycaemic control of a training programmein consultation skills for paediatric diabetes teams.• Gave a clear, useful answer for payers of health care• Not to be confused with a failure of MI
Fidelity measurement?• “My over-riding reaction is one of mild shock at the state of research on MI in health care. Researchers have lurched into trials of a really complex interpersonal intervention and only 7/50 have bothered to assess fidelity? ”
Measurement, respondent burden and risk of biasRisk ofinclusion andattrition biasandapplicabilitylimitations Clinician and participant respondent burden
ICMI3 Processes• Strong values base• Fantastic venue and organisation• In- and outward looking!• Bold, eclectic and welcoming!• Loved the nexus between erudite, wise psychotherapists with the researchers, trainers and clinicians at the sharp end of emergency care and in resource poor setting
ICMI3 Outputs• Behaviour change is important!• Showing MI can and does work, and that is worthwhile is difficult. But we are making progress!
Healthy behaviours:The Caerphilly Collaborative Cohort Study Non-smoking: non-smoking including ex-smokers Body weight: BMI (weight/height²) of under 25 Diet: less than 30% of calories from fats and three or more portions of fruit and/orvegetables a day (too few men consumed five portions). Exercise: walk two or more miles to work each day, or cycled ten or more miles towork each day, or regular ‘vigorous’ exercise Alcohol intake: drinking within the guidelines, abstainers not included. - Every item was carefully validated - The Caerphilly Health and Social needs StudyNon-smoking, overweightetc…. .closely similar to the abovePLUS: regular aspirin taking
Outcome events:During the 30 year follow-up:Diabetes:recorded in the GP notes plus a raised fasting blood glucoseVascular disease:a myocardial infarct or an ischemic strokeCancer:a registered canceror a death certified as cancerAll-cause deaths:deaths with certified causeDementia:clinical diagnosis by a psychogeriatrician Every event was carefully validated against accepted clinical criteria
Healthy REDUCTIONS over the following 30 years behaviours Diabetes Vascular Cancer All-cause in 1980 disease deathsNon-smoking No significant 21% 29% 33% relationship (11% to 31%) (16% to 37%) (26% to 40%) All relationships adjusted for age and social class
REDUCTIONS IN: Healthy Lifestyles Diabetes Vascular disease Cancer All-cause deaths None (172 men) 0 0 0 0 Any two (813 men) 16% 30% 13% 15% Any three (436) 37% 35% 7% 30% Four/five (112) 48% 38% 18% 35% Significance 0.0005 0.0005 0.41. 0.0005If all the men had been advised to take up one additional healthy behaviour…and if only half complied…..→ reductions of at least 12% in diabetes; 6% in vascular disease; 5% in deaths NOTE: The 48%, 38% etc. reductions in the table are relative reductions. The 12%, 6% etc. in the note below the table are absolute reductions.
Healthy behaviours and cognitive impairment: Reductionsadjusted age and social class Healthy (and baseline cognitive function) lifestyle Any cognitive Dementia Impairment (79 men) (219 men) No healthy behaviour 0 (0) 0 (0) Any two 48% (48%) 47% (44%) Any three 59% (58%) 69% (72%) Four or five 66% (59%) 76% (68%) Significance 0.001 (0.002) 0.003 (0.01) Adjusted for age and social class (and NART at baseline)
Uptake of healthy behaviours: Non-smoking Low body weight 0.8% take up all 5 behaviours Diet: 8% take up four of more Exercise: Source: Welsh Health Survey 2008 Alcohol intake
Within the UK, over 95% ofNHS clinical contacts are made in generalpractice and around 80% of health problemsare managed at this level. Over 300 milliongeneral practice consultations take place inthe UK each year; these encompass healthpromotion, prevention and screening as wellas acute and chronic care.
Debate: MI Takes more time and 2minutes of playing the piano may notbe satisfactory and “could creep me out”
Depression in primary care• Family docs are the depression experts• 20% of adults in some practices on SSRIs• SSRIs effectiveness for mild depression?• SSRIs: a sticking plaster or a lasting solution?• ?Opportunity for MI? Recovery form depression is all about behaviour change• Strategies from BCC – “Typical day” – “Brainstorming solutions”
When does MI stop being MI, and turn into good communication? Does MI take more time?• “Well I have examined you and my findings suggest you don’t have a bacterial infection. Yu have no pus on your tonsils, your nose is running, which is more in keeping with a virus, and your glands are not enlarged. Viruses don’t respond to antibiotics. If I have thought this was a bacterial infection, I would have prescribed antibiotics. But we try to limit antibiotics these days to only those that really will benefit, largely because of antibiotic resistance. We want to keep the antibiotics back so they will work when you really need them…”
Can you recognise MI in this?• “Sounds like you are taking quite a hit with this illness“• “So. Your thoughts about antibiotic treatment for this illness”• “You sound as though you are kind of hoping for some antibiotics?”• “Shall we together consider some of the advantages and disadvantages of antibiotic treatment for this condition?”• ‘What do you think will help you most in getting through this?”
Use of NPTs and communication skills training for LRTI Four groups – Usual care 68% – CRP 39% – Communication skills 33% – Both 23% Communication skills training: Seminar 11 key tasks e.g. exploring patients’ fears and expectations, asking patients’ opinion on antibiotics, and outlining the natural duration of cough in lower respiratory tract infection Peer review of transcripts with simulated patients
Exciting areas for MI• “Personalised medicine”• Cost effectiveness• Uptake into policy and guidelines• Outcome focus: clinician satisfaction, burnout, frequency of engaging clients about behaviour change• Patients: satisfaction with processes of care, “enablement”• Individual control vs. social determinants
A student in my clinic a few weeks back said ...• “We saw this woman two weeks ago, and we told her…”• “….these people…”
Miller…• “You have what you need. Together we will find it.”
Who>whatGiven that the clinician is a precious and influential instrument (Balint= “The drug doctor” )• The first medical ethic: do not harm!• The second medical ethic: beneficence!• MI will help me not harm you• MI will help me help you• MI will help met to be able to continue to help you• (State employed doctors in the Western Cape in South Africa: 76%=burnout, 30% mild to moderate depression, focus on depersonalising patients).
My definition of MI: Charles Butler and Maya Rollnick