Yesterday I drove two hours into the heart of the Welsh countryside, to a country hotel, to spend half a day on MI with a senior group of general practitioner trainers. The contrasts were sharp: sparkling green cloudless day, and inside, the challenge: how might we use MI in the rehabilitation of doctors who had entered the last procedure before being struck off for disciplinary offenses? If they don’t change their behaviour and attitudes, they are out. A rough world.
I enjoy looking at MI from the outside in, thinking backwards from everyday practice, and wondering, as those trainers must have, where on earth does this MI stuff fit in?
At the coffee break something happened: a conversation, a new development and a plan. It forced me to think backwards. Here’s what happened.
I’d met this doctor many times, at this sort of gathering, and at his practice, where he works in one of the most deprived rural towns in Western Europe. He’s Irish, incredibly phlegmatic and highly experienced (30 years in practice).
This what he said (more or less):
Steve, many of the “doctors in trouble” I supervise are not just resistant, which I can handle, but they seem to lack reflective capacity in their heads! Reflective conversations don’t get me very far. Would you be interested in something else I have discovered, which does change their behaviour? I don’t think its MI……
Then he described a sequence.
At Stage 1 they sit right alongside me in the consulting room, and with permission from my patients, I stop the action and ask the doctor questions about what I am doing and why. And we conduct the clinic together.
He described this in some detail, but it was the next stage that was really innovative.
At Stage 2, the next time we work together, I ask permission from the patients to be their advocate. I explain that I am training a doctor to be helpful, and that I want to sit next to them, the patient, and be their advocate. The patients really like this. I sit right next to them, facing the doctor in training, and ask the patient questions, and I also ask the doctor questions. So I slip in and out of two roles, which we all agree on at the outset. I am the patient’s advocate, and I am also sometimes the trainer of the doctor.
He described a third stage, but his observation about Stage 2 were very striking:
Steve, I see the most difficult “problem doctors” change in front of my eyes. They develop a reflective capacity right there in front of me. I have taken many through this procedure.
We agreed that I would come up with a camera crew and we would film the whole sequence in real-life practice, capture the reactions on film of all involved, and produce a DVD and then write a paper on the method.
MI is tied up there somewhere, but not in a familiar form. He uses a guiding style in Stage 2 for sure, and when questioning the doctor while sitting alongside the patient, I think he elicits change talk. Then the doctor has to act on the change talk immediately…. And behaviour changes…..
That’s a my provisional impression. It will be interesting to see if the videos reveal this, and other things too.
