Disease prevention efforts generally include the behavior change of patients' personal habits, such as smoking, diet issues, and misuse of substances, yet less than 10% of physicians feel that they can be successful in modifying patients' behaviors (1). Traditional methods of advice giving and education have been noted to increase resistance, rather than to motivate patients (2). With the Liaison Committee on Medical Education (LCME) and the Association of American Medical Colleges (AAMC) including communication skill development (3, 4) as one of the core competencies for medical students, educating medical students to not only better communicate, but to also promote a focus on collaborative approaches in medical decision making for behavior change, is an increasing focus in recent years (5—8). Motivational interviewing (MI) is a directive, patient-centered approach for eliciting behavior change in patients, with evidence for its effectiveness being established in randomized clinical trials (9). Clinicians counsel patients through reducing resistance, developing discrepancy, exploring ambivalence and supporting the patients' self-efficacy, thus increasing the intrinsic motivation to change (2). Although originally developed to counsel patients with alcohol and drug problems, it is now used for helping patients with tobacco cessation, weight loss, and medication adherence (10—12).

Studies utilizing various models for teaching MI to medical students continue to gain ground in the literature with different approaches and curricular models being described and favorable outcomes being reported. An MI curriculum starting in the first year of medical school and continuing in the family medicine clerkship (6, 13) and a 10-hour MI training for first-year students (8) are examples in which MI is introduced early in medical student education. Curricular models in the clinical years include a single 2-hour workshop for third-year students during their psychiatry clerkship (5), MI as part of a 4-week curriculum on behavior change for third-year students during internal medicine (7), and a single MI training session for fourth-year students (14). Curriculum evaluation data are emerging with results supporting improvements in students' knowledge of MI, confidence, and skill level after MI skill training (5—8, 13, 14).

The purpose of this study was to teach students MI skills in a 3-hour session, as opposed to longer curricula utilized in the majority of other studies (6—8, 13), and assess their confidence and knowledge during the psychiatry clerkship using smoking cessation as the target behavior. This study includes a larger sample size compared with the other brief MI intervention study of third-year students (5) and was led by faculty (psychiatrists and psychologists) without formal training in MI, as opposed to curricula in other studies that were developed by faculty with MI training (5, 6, 8). We sought to determine if more novice MI professionals could impart motivational interviewing knowledge and confidence with medical students, as experts in MI may not always be available. Given that a previous study showed that student role plays were just as effective in teaching basic MI skills as standardized patients (13), and because no funding was available for standardized patients for the current study, we chose role playing as the educational approach.

Using a pretest/posttest design, 98 students were given a 10-item questionnaire developed by the authors which utilized a Likert-type response scale of 1 (not at all confident or not at all true) to 5 (extremely confident or very true) during the psychiatry clerkship orientation. This questionnaire assessed their knowledge and confidence in health behavior change, as has been done in at least one other study (8). This questionnaire was distributed by the clerkship coordinator, and consent indicated that participation was voluntary and that neither participation nor lack of participation would impact student grades. To assure confidentiality, no names appeared on the questionnaires; they were number coded so that pre- and postclerkship answers could be compared. Students received a 3-hour presentation on the principles of MI on the second day of the clerkship. About half this time was spent introducing the principles of MI, utilizing video clips to compare and contrast with traditional medical interviewing, and students practiced their skills through role play scenarios for the remainder of the time. Students were encouraged to utilize these skills with patients; however, no formal reinforcement of those skills took place, such as rotating with a faculty member who utilized motivational interviewing in a systematic fashion. At the end of the clerkship, the questionnaire was readministered. This study received Wright State University institutional review board approval.

Of the 98 students, 88 consented to have their results included in this study (90% response rate). Based on 88 pre- and postclerkship responses, paired t tests results (p<0.05; Boneferroni correction p<0.005) showed significant increases in students' knowledge and confidence regarding MI for the following: setting an agenda for MI (p<0.001, d=0.897), expressing empathy and reflecting a patient's emotions during an interview (p<0.001, d=0.759), assessing a patient's "stage of change" (p<0.001, d=1.223), understanding the key concepts of MI (p<0.001, d=1.430), a major task in MI is to reduce resistance in the patient (p=0.004, d=0351), using discrepancies as a tool in MI (p=0.002, d=0.395), giving a brief intervention to a patient with no history of mental illness (p<0.001, d=0.584), giving a brief intervention to a patient with a history of major depression (p<0.001, d=0.886), and giving a brief intervention to a patient with schizophrenia (p<0.001, d=0.860).

These results show that students can gain basic knowledge, and increased confidence in working with patients for promoting behavioral change, even with a brief introduction and role play session, taught by nonexperts in motivational interviewing theory. We find it encouraging that students, who will undoubtedly be increasingly tasked with showing outcomes in behavior change of their patients, showed increased confidence in using a brief intervention for smoking cessation in patients without histories of mental illness as well as those with histories of depression and schizophrenia. As patients with schizophrenia tend to be among the most intensely addicted with very low quit rates (15), in our opinion it is especially encouraging that the students developed greater confidence in counseling this population. However, perhaps these students, with limited real-world experiences, are overly confident in their abilities to work with patients who have schizophrenia and smoke in promoting behavioral change.

Interpreting results of this study should be done in light of several limitations, which include the lack of psychometric data for the survey because it was author-generated, short follow-up with the postclerkship test (i.e., 6-weeks time lapse between administration of the pre- and postclerkship tests), no assessment of actual skill in delivering motivational interviewing, and a lack of a comparison group. Additionally, as with all self-report measures, response bias in socially desirable directions is a concern. We also do not know whether or not students actually practiced these skills in the clinical setting. Lastly, although one of the pros to our approach in teaching MI skills to students is that utilizing nonexpert faculty allows a clerkship or medical school to introduce MI into the curriculum for minimum time and money, one wonders if the educational experience might suffer as the skills transmitted may not be as sharp as one might expect with expert faculty. Further studies are needed to shed light on this.

As for our continued work in the area, future directions include developing a formative feedback exercise utilizing standardized patients to actually assess motivational skills gained rather than simply the student's confidence that such skills would be utilized. By using a standardized patient exercise to evaluate, reinforce skills, and provide feedback, students should be able to feel greater confidence in learning the basic principles and techniques of MI. Further, by using common clinical scenarios such as working with patients to achieve better control of diabetes or weight loss, it is hoped that students will see greater applicability regarding using MI techniques beyond just nicotine addiction, and that MI is an advanced communication skill that all physicians could utilize. Implementing educational opportunities for students in other clerkships, such as family medicine, would further allow students to practice their skills and emphasize the applicability of motivational interviewing by physicians.

The questionnaire used in the study is available upon request. At the time of submission, the authors reported no competing interests.