Accepted Manuscript

Title: Motivational interviewing training for medical students:

a pilot pre-post feasibility study

Authors: Antoine Chéret, Christine Durier, Nicolas Noël,

Katia Bourdic, Chantal Legrand, Catherine D’Andréa,
Evelyne Hem, Cécile Goujard, Patrick Berthiaume, Silla M.
Consoli

PII: S0738-3991(18)30309-4
DOI: https://doi.org/10.1016/j.pec.2018.06.011
Reference: PEC 5986

To appear in: Patient Education and Counseling

Received date: 28-2-2018

Revised date: 5-6-2018
Accepted date: 20-6-2018

Please cite this article as: Chéret A, Durier C, Noël N, Bourdic K, Legrand C, D’Andréa
C, Hem E, Goujard C, Berthiaume P, Consoli SM, Motivational interviewing training for
medical students: a pilot pre-post feasibility study, Patient Education and Counseling
(2018), https://doi.org/10.1016/j.pec.2018.06.011

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Motivational interviewing training for medical students: a pilot pre-

post feasibility study

Antoine Chéret1, Christine Durier2, Nicolas Noël1, Katia Bourdic1, Chantal Legrand3, Catherine

D’Andréa1, Evelyne Hem1, Cécile Goujard1, Patrick Berthiaume4, Silla M. Consoli-5-6

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1- Internal Medicine Unit, Le Kremlin-Bicêtre Hospital, APHP, France. 2- INSERM SC10-US19,

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Villejuif, France. 3- Direction of Care, Georges Pompidou Hospital, APHP, Paris, France. 4- Les

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formations Perspective Santé, Montréal, Québec. 5- Paris Descartes University, Sorbonne Paris

Cité, Paris, France. 6- Consultation-Liaison Psychiatry Unit, Department of Adult and Elderly

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Psychiatry, European Georges Pompidou Hospital, APHP, Paris, France
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Corresponding author information:

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Antoine Chéret, MD.D, PHD, Internal Medicine Unit,

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Hopital Bicêtre, AP-HP, 78, Avenue du général Leclerc, 94270 Le Kremlin-Bicêtre

antoine.cheret@aphp.fr
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Tel: 00/33/1/45/21/63/54
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Highlights
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 The effects of brief training in motivational interviewing (MI) for medical students were evaluated
 Medical students showed a clear improvement in MI skills

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There was a modest improvement in the students’ empathy, as perceived by the ‘patients’
 MI training by a non-specialist professional is feasible early in medical courses
 These results encourage the implementation of MI training during medical studies

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Abstract

Objective: To evaluate the impact of brief training in motivational interviewing (MI) from a non-

specialist professional for medical students.

Methods: Students (n=20) received three four-hour sessions of MI training over one week. They

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interviewed caregivers acting as patients in two standardised medical situations, six weeks before

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and three weeks after training. Global scores from the MITI-3.1.1 code, including “MI- Spirit”,

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were attributed to the audiotaped interviews by two independent coders, blind the pre- or post-

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training status of the interview. Secondary outcomes were: caregivers’ perception of students’

empathy (CARE questionnaire), students’ evaluation of self-efficacy to engage in a patient-centred

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relationship (SEPCQ score), and students’ satisfaction with their own performance (analogue scale).
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Results: MI-Spirit score increased significantly after training (p<0.0001, effect size 1.5). Limited
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improvements in CARE score (p=0.034, effect size 0.5) and one of the SEPCQ dimensions (sharing

information and power with the patient; p=0.047, effect size 0.5) were also noted. Students’
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satisfaction score was unaffected (p=0.69).

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Conclusion: These findings suggest that brief MI training can improve communication skills in

medical students.
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Practice implications: Such an intervention is feasible and could be generalised during medical
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studies.
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Keywords: Motivational Interviewing; Communication skills; Continuing Medical Education;

Interdisciplinary Medical Education

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 1. Introduction

Current ideas in medical ethics favour the promotion of greater patient autonomy, placing patients

at the heart of the healthcare system [1]. Practitioners must seek to establish a therapeutic alliance

with patients, encouraging them to accept care or adopt healthier behaviours. The practitioner’s

empathy towards the patient is a determining factor in therapeutic management [2-4]. The use of

patient-centred communication by physicians and the training of medical students in

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communication skills are also associated with higher levels of satisfaction and lower levels of

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psychological distress in patients, especially in cancer patients, and even better adherence to

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treatment [5-8]. Conventional approaches, which tend to be directive, may not be sufficiently

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effective, or even counterproductive if they impinge on the patient’s sense of freedom or need for

shared decisions. Several models of change, taking into account the patients’ perception of their
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illness, readiness to change and self-efficacy, have been developed to assist practitioners [9].
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Motivational interviewing (MI), for example, was developed by WR Miller at the start of the 1980s,
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initially for alcoholic patients [10]. It is defined as a collaborative, goal-oriented style of

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psychotherapy, to elicit and strengthen the motivation of the individual to move towards specific
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health goals by resolving ambivalence [11]. MI occurs within a relational context of empathy and

acceptance, this dependence on interpersonal communication being an essential component [12].

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Another crucial element of MI sessions is the focus on evoking and strengthening a particular style

of language.
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The training of medical students currently focuses heavily on the delivery of technical, biological

and pathophysiological information, and shifting from this traditional, paternalistic approach to a
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patient-centred approach remains challenging [13]. The education of future doctors could be

optimised through MI training programmes [14-15], as in some English-speaking and Swiss

universities [16-19]. More than 200 randomised clinical trials on MI and several meta-analyses

have shown MI to be effective for chronic disease management, and for promoting the therapeutic

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alliance, treatment adherence and changes to healthy behaviour [15,16,20]. Pre- and post-training

studies have evaluated the impact of very brief (around 2 hours) training in MI for medical studies.

They concluded that MI training increased the students’ knowledge and confidence regarding their

medical practice [21-23]. A randomised trial by Daeppen et al. reported improvements in MI

performance after an eight-hour training workshop, with higher scores for empathy and “MI Spirit”,

although the observed increase was not sufficiently large for for MI practice. However, as there was

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no before-after comparison, no information was provided about students’ performance before

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training [19].

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Our study specifically compared the MI skills of medical students during simulated interviews with

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standardised patients, before and after a short programme of MI training with a non-professional

trainer. We thus evaluated to the responsiveness of students to such interventions, which could
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easily be included in the medical curriculum. This study also measured changes in student empathy,
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as perceived by the “patients”, the students self-perceived self-efficacy to engage in a patient-
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centred relationship, and their satisfaction with their own performance relative to the goals fixed.
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2. Methods
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The research protocol and ethical aspects were approved by the Educational Committee of the
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Faculty of Medicine of Paris-Sud University.

2.1. Design and participants

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All the students in clinical internships (fourth or fifth year of medical courses) at the Immunology-

Infection-Inflammation-Endocrinology Division of Bicêtre Hospital, Assistance Publique Hôpitaux

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de Paris, with no prior training in MI, were eligible for this study. They were fully informed about

the study procedures and gave written consent.

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Two weeks before and two weeks after training, students took part in a simulated 15-minute

interview. Two caregivers were instructed, two weeks before the training, to play the role of a

patient consulting his doctor for the follow-up of either HIV infection or a chronic obstructive

pulmonary disease (COPD). Students were informed of the target behaviour before the interview:

improving treatment adherence for the HIV-infected patient and stopping smoking for the patient

with COPD. They were assigned, on the basis of their academic timetables and internship

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constraints, to two training groups. The order of the pre/post training interviews for each group was

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randomly determined: HIV patient first and COPD patient second, or vice versa (Figure 1).

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2.2. Measurements

The capacity of a practitioner to use MI was evaluated with the Motivational Interviewing
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Treatment Integrity (MITI 3.1.1) Code, an instrument currently in development [24]. In includes
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five global scores, for which the coder must assign a single number from a five-point scale (1=poor,
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5=excellent) to characterize the entire interaction. The Evocation score measures the extent to
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which the practitioner evokes the patient's own arguments for change, rather than imposing his/her
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own arguments. The Collaboration score measures the extent to which the practitioner places

himself in the position of the patient's partner, rather than as an expert. The Autonomy/support
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score measures the extent to which the practitioner supports and actively fosters the patient's

perception of choice, as opposed to attempting to control that choice. These three scores are
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averaged to obtain the “MI Spirit” score. The Empathy score measures the extent to which the

practitioner tries to understand the patient's point of view and to respond to it. The Direction score
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measures the extent to which the practitioner focuses on the target behaviour. The coding system

also involves several “Behavioural counts” (open and closed questions, simple and complex

reflections etc.). Only the global scores were calculated for this study [19,24]. Audiotaped

recordings of the consultations were rated by two independent researchers (PB,CL). PB received

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training in the use of MITI-3.1.1 in 2010 from Gaume and Fortini [19,25] and in the use of MITI-

4.2 in 2014, from the authors themselves [24,26]. Both these researchers received 36 hours of

training in the use of the Motivational Interviewing Skill Code (MISC) [27] from Gaume in 2014,

and had already participated in several analyses using the MITI code. Coders were blind to the

order of the interviews they analysed (before or after MI training). The average score attributed by

the two coders was calculated.

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Communication skills were also evaluated with the Self-Efficacy in Patient-Centeredness

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Questionnaire (SEPCQ), completed by the students [28]. SEPCQ quantifies the ability of a health

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professional to engage in patient-centred, rather than disease-centred, relationships. It provides a

global score and three factorial subscores: "exploring the patient's perspective", "sharing

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information and power" and "dealing with communication challenges". Cronbach internal
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consistency reliability estimates for factorial and total score ranged from 0.74-0.93 and 92-95,
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respectively; the test-retest correlations were 0.62, 0.47, 0.69, and 0.87 [28].
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Students’ empathy, as perceived by the caregivers playing the role of the “patients” during the
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simulated consultations, was measured with the Consultation And Relational Empathy (CARE)

Questionnaire [29]. The Cronbach reliability and test-retest correlation scores were 0.92 and 0.70,
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respectively [29,30].
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Finally, at the end of the simulated consultation, students were asked to assess their self-satisfaction
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with the interview ("Do you feel, at the end of this meeting with your patient, that you performed

well in your attempts to achieve the defined goal with your patient?”) on a visual analogue scale (0
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to 10).

2.3.Training

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Students received three four-hour sessions of basic MI training in French, over a one-week period.

The trainer (SMC) was a Professor of Psychiatry from a Faculty of Medicine different from that at

which the students were enrolled. He did not belong to an association of MI trainers, but was used

to teaching doctor-patient relationship and communication skills as part of the medical curriculum

and to graduate physicians. He had also been involved in “consultation-liaison psychiatry”, and his

intervention was frequently requested to help patients with difficulties adhering to medical

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treatments, but also by care teams confronted with difficult patients or situations of relational

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blocking. He was therefore used to dealing with resistance and ambivalence on the part of patients

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or practitioners. Training was largely inspired by books on MI [11], and by the training kit

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developed by Fortini and Daeppen at Lausanne University Hospital [25].Training was based on four

types of teaching aids:

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1) Viewing and commenting on video clips illustrating motivational and non-motivational doctor-
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patient interactions, in various types of medical conditions: quitting smoking, alcohol dependence,
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being overweight, non-compliance with antiretroviral regimens.

2) Lectures and the distribution of memory aids, in the form of printed documents taken from the
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slides used during the training sessions, including "take-home messages".

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3) Practical exercises: asking open-ended questions; making simple and complex "reflections";

exploring ambivalence; dealing with patient resistance; expressing empathy; affirming the
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patient’s initiatives and skills; supporting the patient’s self-efficacy; supporting the patient’s

discourse about change to encourage changes in behaviour; summarising.

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4) Role-playing, based on several situations, each involving two students. We deliberately chose a

non-medical situation (conflict between a mother and a student asking her for pocket money to go

out for fun, the day before a university examination) for the first situation. This first situation was

chosen so as to allow students to begin with an informal, fun situation, to encourage them to relax

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 and to avoid confronting students with performance anxiety related to their professional roles from

the outset. The 10-minute role-playing sequences were filmed and then analysed with the students,

who were given constructive feedback, supporting, as far as possible, the comments made by the

students themselves and valuing their knowledge to encourage movement in the direction of the

motivational mindset. All the other situations concerned changes to healthier behaviour in a

medical setting, but with a goal different from that used for the first or the second simulated

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interview, before or after MI training: compliance in hypertension or diabetes, or increasing

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physical activity.

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Both groups thus encountered the same MI situations during role playing, which were independent

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of the target behaviour for the two clinical situations of the simulated interviews, to prevent one

group being favoured over the other.

2.4. Statistical analysis U

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Sample size was calculated for the primary objective of this study: the assessment of the effect of
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training on students’ MI Spirit scores. In an ongoing intervention study on the effect of a MI

training of nurses involved in an HIV patient-education programme lasting six months, an increase
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of 0.5 was observed for MI Spirit score between baseline and the six-month visit in the control

group of nurses, in the absence of any MI training (the intervention group of this study consisted of
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the same nurses following different HIV patients after having been provided with specific MI
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training by professional trainers, but with other patients).

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Referring to such a floor effect of time and personal involvement on MI Spirit, we calculated that a

sample size of 16 students had a power of 84% to detect a minimum difference in means of 0.5
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between ‘before’ and ‘after training’ scores, assuming a standard deviation of 1.0 and a correlation

between scores of 0.8, in a two-tailed paired t-test with an alpha risk of 5%. The effect size

(Cohen’s dZ) is 0.8, which may be interpreted as large (0.8) rather than small (0.2) or moderate (0.5)

[31]. The sample size was increased to 20 to allow for students withdrawing from the study.

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Confounding due to order effects was minimised by balancing the order of MI situations

(COPD/HIV or HIV/COPD) between two groups of 10 students.

Data were analysed with t-tests; correlations and effect sizes were also calculated. The effects of the

order of MI situations and differences between the two coders were assessed in a repeated-measures

analysis of variance (ANOVA). Reliability was assessed by calculating intraclass correlation

coefficients (ICC) between the two coders. Principal component analysis (PCA) was performed on

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post- minus pre-training differences, to assess relationships between MI Spirit (MITI), Empathy

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(MITI), Empathy (CARE), Self-efficacy to engage in a patient-centred relationship (SEPCQ) and

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the visual analogue scale score for self-satisfaction.

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We also performed a repeated-measures ANOVA with sociodemographic characteristics. All

analyses were conducted with SAS 9.3 software.

3. Results U
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3.1. Study population
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All but one of the eligible students agreed to participate in the study and conducted the interviews,

completed the questionnaires and attended all the MI training sessions (Figure 1).
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The sociodemographic characteristics of the students did not differ between the two groups

(defined on the basis of the order of MI situations: COPD/HIV or HIV/COPD); median age was
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23 years (22 to 34 years), and 70% of the students were women. All but two of the students were
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in their 5th year of medical training (Table 1).

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3.2. Comparisons of MITI global scores before and after MI training

Mean MI Spirit score increased from 2.0 to 2.9 (p<0.0001) between the two interviews (Table 2),
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showing that the students’ performance was significantly better after training. The three subscales

making up the MI Spirit score (Evocation, Collaboration, Autonomy/Support) and Empathy score

also increased between the two interviews. Direction score did not improve, but was already good

before training. Correlations between each global score measured before and after training were

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positive, but moderate and non-significant (except for Evocation). Effect size exceeded 1.5 for MI

Spirit score.

3.3.Comparisons of MITI scores between the two groups

As shown in Table 3, for MI Spirit, the interaction between group and time was significant

(p=0.038). The significant main effect of time (p<0.0001) must therefore be interpreted in the light

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of this interaction. The MI Spirit scores for students in the HIV/COPD group increased by 1.2,

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whereas those for students in the COPD/HIV group increased by only 0.6. However, this

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interaction effect was not as clear-cut for the subscales other than Evocation. Using the same

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model with individual data from the two coders, the difference between coders was found to be

non-significant for MI Spirit scores (p=0.23) and there was no coder-by-group interaction

(p=0.66).
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3.4. Coding reliability
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The reliability of the series of scores obtained before training for the two coders was fair to
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excellent [31], with ICCs of 0.46 and 0.63 for Direction; 0.55 and 0.71 for Autonomy/Support;

0.60 and 0.75 for Collaboration; 0.77 and 0.87 for Evocation; 0.82 and 0.90 for Empathy and 0.67
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and 0.81 for MI Spirit, for single measures and mean values, respectively, highlighting the

similarity of the MITI scores attributed by the two coders.

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3.5. Effect of sociodemographic covariates on MI Spirit

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The sociodemographic covariates had no impact on the effect of training on MI Spirit score

(Appendix Table 1). There was a similar impact of training on the increase in empathy for both

men and women.

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 3.6. Comparisons of CARE, SEPCQ and self-satisfaction analogue scale scores before and after

MI training

No significant global improvement in these scores was noted, due to high variability between

students. For example, the mean increase in SEPCQ score was 5.05 but the standard deviation was

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14.07 (Tables 2 and 3). The exceptions were a limited increase in CARE score (p=0.034) and self-

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estimated capacity to share information and power (SEPCQ subscale) (p=0.047), both of which

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displayed moderate effect sizes of 0.5. No significant interaction between time and group was

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detected other than for the SEPCQ dimension ‘sharing information and power’ (p=0.013), which

increased for the students of the HIV/COPD group (mean difference=+7.2) but not for those of the

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other group (mean difference=-0.4). A significant strong correlation was found between the
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improvements in MI Spirit and its empathy subscale (Pearson r=0.61, p=0.004) but there was no
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correlation between MI and SEPCQ. In the principal component analysis, the first dimension was
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mainly related to MITI “MI Spirit”, “MITI” empathy global score and CARE empathy score. The
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second dimension was associated with self-efficacy (SEPCQ) score and self-satisfaction score on a

visual analogue scale (Figure 2).

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4. Discussion and Conclusion

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4.1. Discussion
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This pilot study indicated a potential improvement in motivational interviewing skills in the short

term, following a brief training course, among students representative of the population in which
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the intervention might be applied. These findings are consistent with those of previous studies

targeting medical students [19,21]. Our objective was not to prove that students would be able to

apply MI to their future patients without any further supervision after such a short training

intervention, but to show that they were able to improve their relationship skills and their ability to

11
apply the principles of MI. Students’ skills improved in terms of encouraging support and

autonomy, evoking patient’s problems and working with the patient to initiate the process of change

in health behaviour.

The observed difference was significant, regardless of the students’ sociodemographic

characteristics, and of the coder. It was large, exceeding a Cohen’s d effect size of 1.5 on average

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for MI Spirit score, corresponding to an effect twice that anticipated. However, mean post-

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intervention MI Spirit score was lower than that obtained in studies on medical students from

Switzerland or English-speaking countries [16,19,32]. It would be interesting to determine the

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reasons for this difference and the contributions of the nature of training, cultural variables and

academic background.

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The change in MI Spirit score depended on group (HIV/COPD or COPD/HIV) and was related to
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the target behaviour of the second, post-training, simulated consultation with a patient. The target
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behaviour "stop smoking" was derived from the field of addiction, and the objective was to resolve
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the ambivalence linked to tobacco addiction [33]. This was clearly a health issue better understood

by the students than treatment adherence in HIV infection.

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Our students were already at an advanced stage of their medical training, and thus had a clear
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understanding of health objectives, resulting in a high score for Direction, not affected by training.

This score measures the degree to which clinicians maintain appropriate focus on a specific target
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behaviour but, unlike the other global scales, high scores for clinicians on this scale do not
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necessarily reflect better use of MI [19,24]. However, we were unable to investigate the effect of

study year on scores, due to the presence of only two fourth-year students. An ability to determine
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which types of healthier behaviour would benefit patients in different medical conditions seemed to

have been well acquired by these students after several years at university, highlighting the

deficiencies in the learning of other skills important for MI, and thereby identifying key

requirements for their incorporation into future medical training.

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Empathy is a major indicator of the nature of the therapeutic relationship [34], and a key

determinant in therapeutic management [2,34]. The MITI Empathy score does not contribute to the

“MI Spirit” score, but it was assessed among the five global MITI scores. It significantly improved

after the intervention. One of the original features of this work was its measurement of the benefits

of MI training in terms of both the students’ empathic abilities, as assessed by the coders listening

to audio recordings of the simulated interviews, and through the evaluations made by the “patients”

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immediately after the interviews, with a good covariation, as shown by the PCA. Despite the

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predominance of female students in this study and the known tendency of women to be more

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empathic than men [35-36], similar benefits were observed in students of both sexes. Kelm reported

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a lack of empathy among medical students and a decline of empathy during medical training [37].

The nature of modern medical education, with its emphasis on emotional detachment, affective
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distance and clinical neutrality, may have contributed to this decline [38-39]. Regardless of this
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debate, our results indicate that this training made it possible to strengthen the capacity of students
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to empathise with the patient for the well-being of both patients and physicians [40].
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The change in students’ self-efficacy was significant in terms of their ability to share information
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and power with the patient. These results are consistent with those of two studies conducted with

students in their third year of medical training, demonstrating positive changes in students’
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confidence after eight hours of training [41], and a shorter training period of two hours [21]. The
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global score and the other two dimensions of the SEPCQ (the ability to adopt the patient's
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perspective, and the ability to manage relational conflicts), and students’ satisfaction with the odds

of achieving the target goal during the simulated interviews were not affected by our training. The
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absence of correlation between MI Spirit and self-efficacy might be explained by the students’

interest in and commitment to the MI training, which may have led them to a certain form of

modesty and awareness of the work that remains to be done to be "good" in this field. This is an

important aspect to take into account, to limit students’ feelings of worthlessness and failure in

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future training. Their improvement may have required more prolonged training, the implementation

of repeated supervision sessions or a gratifying return in this sense from real patients.

Our MI training programme resembled other programmes in many ways [16,18,22]. A satisfaction

survey found that 90% of students were satisfied with the MI training (data not shown) and

appreciated this course of three half-days of training in the same week, whereas 10 to 14 hours of

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training delivered as a block was deemed to be excessive in a previous study [32].

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This is the first intervention study using different validated instruments simultaneously to evaluate

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the effects of motivational interviewing training during medical education. A simple 'before-and-

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after’ design, with no control group and with the subject as his/her own control, was used in this

pilot study, as this approach can separate between-subject variability from the effect of the training.

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Some uncertainty will always remain about whether the effect observed was definitely due to the
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training, because measurements were not made for a group not receiving the training, so we can
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only assume that the training may have made the difference. Acceptability was maximal in this
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representative population of students, with no missing data, allowing a straightforward analysis

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without the pitfalls of handling drop-outs and with no loss of statistical power. This design was

useful for measuring the immediate impact of a short-term intervention but we did not carry out
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short-term monitoring-reinforcement and maintenance interventions for the acquired knowledge

and we did not check the potential effectiveness of the skills acquired by students with real patients.
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We cannot rule out the possibility that the improvement in the relational and communication skills
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of the 20 students could also be explained by factors independent of the MI intervention: an effect

of practical training after several years of theoretical teaching, of incentives relating to identification
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with a model provided by the seniors supervising the students. However, although these effects are

also plausible, an effect over such a short time (a few weeks) seems unlikely. Indeed, caregivers did

not have to follow a specific script (scenario) and the patient's change discourse was not evaluated.

It cannot be ruled out that simulated patients faced with more empathic students in simulated

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consultations after training would display less resistance to change. These significant results were

obtained thanks to the intervention of a non-specialist MI trainer, suggesting that such training is

both feasible and easy to implement. However, they raise the question as to whether someone

specifically trained to teach other MI techniques would have a greater positive effect on the

acquisition of relationship skills.

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4.2 Conclusion

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Our findings show that a simple course of basic training in MI, easy to implement, even with a

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health professional who is not specifically a dedicated MI trainer, can increase medical students’

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communication skills and empathy. The integration of sustained training in MI early in medical

studies would be beneficial for both medical students and patients. Confirmatory studies could be

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carried out, at a larger scale, on the effects of such training on both the students’ relationship
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abilities and health behaviour changes in real patients.
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4.3 Practice implications
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Our findings show that simple basic training in MI with a non-specialist MI trainer, can increase the
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relationship scores of medical students and improve their communication strategies. They

demonstrate the feasibility and ease of implementation of this type of intervention in medical
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training and encourage the generalisation of MI training during medical studies. Nevertheless, the

benefits of this type of training should be maintained and increased by the long-term supervision of
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students, with MITI used as a feedback tool [18,42], to ensure that a sufficiently high level is
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reached for the use of MI in practice.

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Authors’ contributions

AC, CD, KB and SMC came up with the original idea and designed the study. AC, CD, KB and

SMC developed the search strategy for the study and performed the search and screening processes.

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PB and CL analysed audio tapes. EH and CDA played the role of the patients. All the authors

developed the thematic coding and data analysis was performed by CD, AC, SMC. AC, CD, and

SMC wrote the first draft of the manuscript. All the authors reviewed and revised the manuscript

and all the authors approved the final version.

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Ethics approval

This study was approved by the Educational Committee of the Faculty of Medicine of Paris-Sud

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University.

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Conflicts of interest
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None
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Funding
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This research was funded by the Infection, Immunology, Endocrinology Inflammation and Geriatric

Units, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, France, and the French General
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Medical Council, which provided feedback on clarity and approved the manuscript for publication.
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Statement
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We confirm that all patient/personal identifiers have been removed or disguised so the
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patient(s)/person(s) described are not identifiable and cannot be identified through the details of the

story.

Acknowledgements

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We thank the students and the University Paris Sud XI Faculty of Medicine, Prof. J.L. Teboul

(medical education co-ordinator at Paris Sud University Faculty of Medicine), Prof. P. Chanson,

Prof. C. Goujard, Prof. D. Vittecoq, Prof. O. Lambotte, and Dr C. Duverny, the heads of the

medical units in which the students were doing their internships.

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FIGURE LEGENDS

Figure 1: Flowchart of the study

SEPCQ: Self-Efficacy in Patient-Centeredness Questionnaire; MITI: Motivational Interviewing

Treatment Integrity; CARE: Consultation And Relational Empathy

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Figure 2: Circle of correlations between scores in a principal component analysis (68% of the total

variance). Post- minus pre-training differences for MI Spirit, MI Empathy, CARE, SEPCQ and the

visual analogue scale score for self-satisfaction.

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Table 1: Baseline characteristics of medical students

HIV/COPD COPD/HIV
Total P-
group group
N=20 value
N=10 N=10

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Age (years) 23 [22-34] 23 [22-34] 24.5 [22-28] 0.12

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Sex Male /Female 6 (30) / 14 (70) 4 (40) / 6 (60) 2 (20) / 8 (80) 0.63

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Marital status Single /Couple 14 (70) / 6 (30) 7 (70) / 3 (30) 7 (70) / 3 (30) 1.00

Children 1 (5) 0 (0) 1 (10) 1.00

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N
Experience as 8 (40) 5 (50) 3 (30) 0.65
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assistant nurse
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Nurse 0 (0)
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Year of medical 4th 2 (10) 2 (20) 0 (0) 0.47

studies 5th 18 (90) 8 (80) 10 (100)

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Physical activity 13 (65) 6 (60) 7 (70) 1.00

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Current smoker 4 (20) 3 (30) 1 (10) 0.58

Alcohol consumption 0 (0)

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>10 glasses/w

Drug user 0 (0)

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 Chronic disease 3 (15) 3 (30) 0 (0) 0.21

Weight (kg) 58 [43-79] 60 [45-79] 55.5 [43-65] 0.29

Height (cm) 168 [153-183] 170.5 [153-183] 168 [156-175] 0.47

BMI (kg/cm²) 20.48 20.71 20.39 0.27

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[17.44-25.5] [18.36-25.5] [17.44-22.5]

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The data are presented as median [min-max] or n (%); P-values are given for Wilcoxon or Fisher’s

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exact tests for group comparisons.

HIV/COPD group: HIV+ patient for antiretroviral treatment adherence (before training) followed by

COPD patient for smoking cessation (after training) U

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COPD/HIV group: COPD patient for smoking cessation (before training) followed by HIV+ patient
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for antiretroviral treatment adherence (after training)
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Table 2: Comparison of scores for Motivational Interviewing (MI), the Consultation and

Relational Empathy (CARE) questionnaire, the Self-Efficacy in Patient-Centeredness

Questionnaire (SEPCQ) before and after training and the self-satisfaction scale

Before Training After After-Before Correlation Effect t test

Training Difference size

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Mean SD Mean SD Mean SD dz P

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MI Spirit 1.98 0.51 2.88 0.53 0.90 0.59 0.37 1.54 <0.0001

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Evocation 1.70 0.62 2.75 0.85 1.05 0.78 0.48* 1.35 <0.0001

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Collaboration 2.08 0.59 3.03 0.53 0.95 0.67 0.29 1.42 <0.0001

Autonomy/Support 2.15 0.71 2.85 0.71 0.70

U 0.77 0.41 0.91 0.0006
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Direction 4.55 0.43 4.6 0.42 0.05 0.51 0.27 0.6663
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Empathy 2.15 0.86 3.00 0.69 0.85 0.95 0.27 0.90 0.0007
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CARE Score 24.05 6.80 30.90 9.69 6.85 13.38 -0.29 0.51 0.0337

SEPCQ Score 62.55 10.90 67.60 9.31 5.05 14.07 0.038 0.1248
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Exploring the patient’s

26.20 5.24 26.90 3.45 0.70 4.86 0.44 0.5269
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perspective

Sharing information and power 21.95 5.08 25.35 5.45 3.40 7.16 0.077 0.47 0.0471
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Dealing with communication

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14.40 4.36 15.35 3.28 0.95 4.61 0.30 0.3678

challenges
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Self-satisfaction with the odds of

6.23 1.55 6.43 2.01 0.20 2.19 0.26 0.6885
achieving the target goal

No. of participants =20

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Correlations: Pearson coefficient for the correlation between the scores obtained before and after

training (n=20). *All non-significant except for Evocation (p=0.03)

Effect size: dz =mean difference/SDdiff., p: P-value of t test for After-Before comparisons (paired

data)

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Table 3: Analysis of scores for Motivational Interviewing (MI), Consultation and Relational Empathy (CARE), and the Self-Efficacy in

Patient-Centeredness Questionnaire (SEPCQ) before and after training and between the two groups of students

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HIV/COPD group (N=10) COPD/HIV group (N=10) ANOVA

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Before After Difference Before After Difference Group Time Group.

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Training Training Training Training Time

ED Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD p p p

MI Spirit 1.90 0.50 3.07 0.51 1.17 0.60 2.05 0.53 2.68 0.51 0.63 0.45 0.56 <0.0001 0.038

Evocation 1.85 0.71 3.25 0.75 1.40 0.74 1.55 0.50 2.25 0.63 0.70 0.67 0.017 <0.0001 0.040
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Collaboration 2.00 0.62 3.15 0.58 1.15 0.78 2.15 0.58 2.90 0.46 0.75 0.49 0.81 <0.0001 0.19
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Autonomy/ Support 1.85 0.53 2.80 0.67 0.95 0.69 2.45 0.76 2.90 0.77 0.45 0.80 0.20 0.0005 0.15
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Direction 4.65 0.41 4.80 0.35 0.15 0.34 4.45 0.44 4.40 0.39 -0.05 0.64 0.042 0.67 0.40

Empathy 1.95 0.69 3.15 0.58 1.20 0.82 2.35 1.00 2.85 0.78 0.50 0.97 0.86 0.0005 0.099
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CARE Score 25.20 8.62 30.30 9.11 5.10 13.25 22.90 4.51 31.50 10.70 8.60 13.99 0.81 0.037 0.57

SEPCQ

Score 61.30 12.51 70.90 9.47 9.60 16.16 63.80 9.54 64.30 8.32 0.50 10.51 0.54 0.11 0.15

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Exploring
27.20 6.68 27.20 4.64 0 5.70 25.20 3.33 26.60 1.84 1.40 4.03 0.45 0.53 0.53
the patient’s perspective

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Sharing information and power 19.90 4.77 27.10 4.72 7.20 7.08 24.00 4.74 23.60 5.80 -0.40 5.10 0.87 0.024 0.013

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Dealing with commu-nication
14.20 3.61 16.60 3.47 2.40 4.35 14.60 5.19 14.10 2.69 -0.50 4.60 0.46 0.36 0.16

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challenges

Self-satisfaction ED 6.05 1.88 6.85 1.86 0.80 2.10 6.40 1.22 6.00 2.17 -0.40 2.23 0.71 0.68 0.23

Difference: After-Before; p-values: repeated-measures ANOVA for the Group effect, Time effect (before/after), and group-by-time interaction
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Appendix Table 1: MI Spirit analysis of sociodemographic variable effects (Covariables: Sex, Age in 2 classes, BMI in 3 classes, Marital
status, Assistant nurse, Physical activity, Current smoker)

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 R I
Group All ANOVA P-value
HIV/COPD COPD/HIV

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Before After Before After Before After Covar Group Time Group Covar
.Time .Time

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All N 10 10 10 10 20 20 - 0.56 <0.0001 0.038 -
Mean 1.9 3.07 2.05 2.68 1.98 2.88

N
SD 0.5 0.51 0.53 0.51 0.51 0.53
SEX

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Female N 6 6 8 8 14 14

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Mean 2.06 3.03 2.02 2.65 2.04 2.81 0.93 0.57 <0.0001 0.067 0.26
SD 0.42 0.62 0.48 0.35 0.43 0.5
Male N 4 ED 4 2 2 6 6
Mean 1.67 3.13 2.17 2.83 1.83 3.03
SD 0.59 0.37 0.94 1.18 0.67 0.62
Age (years)
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22-23 N 8 8 4 4 12 12
Mean 2 3.23 1.92 2.79 1.97 3.08 0.26 0.94 <0.0001 0.15 0.18
SD 0.49 0.37 0.67 0.32 0.53 0.4
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24-34 N 2 2 6 6 8 8
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Mean 1.5 2.42 2.14 2.61 1.98 2.56

SD 0.47 0.59 0.45 0.62 0.52 0.58
Body Mass Index (kg/cm²)
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17-19 N 3 3 4 4 7 7
Mean 1.83 3.28 2.04 2.88 1.95 3.05 0.51 0.49 <0.0001 0.020 0.16
SD 0.33 0.54 0.57 0.16 0.46 0.39
20 N 4 4 3 3 7 7
Mean 1.92 2.83 2 2.28 1.95 2.6
SD 0.55 0.58 0.44 0.48 0.47 0.58
21-25 N 3 3 3 3 6 6

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Mean 1.94 3.17 2.11 2.83 2.03 3
SD 0.75 0.44 0.75 0.73 0.68 0.57

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Marital Status
Single N 7 7 7 7 14 14

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Mean 2.05 3.12 2.17 2.83 2.11 2.98 0.067 0.53 <0.0001 0.043 0.70
SD 0.38 0.61 0.55 0.51 0.46 0.56

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Couple N 3 3 3 3 6 6

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Mean 1.56 2.94 1.78 2.33 1.67 2.64
SD 0.67 0.1 0.42 0.33 0.52 0.4
Assistant Nurse ED
Yes N 5 5 3 3 8 8
Mean 2.13 3.2 1.94 2.61 2.06 2.98 0.50 0.67 <0.0001 0.041 0.74
SD 0.43 0.45 0.77 0.54 0.53 0.54
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No N 5 5 7 7 12 12
Mean 1.67 2.93 2.1 2.71 1.92 2.81
SD 0.5 0.58 0.46 0.53 0.51 0.54
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Year of Medical Studies

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4th N 2 2 - - 2 2
Mean 1.33 2.75 - - 1.33 2.75 ND
SD 0.24 0.12 - - 0.24 0.12
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5th N 8 8 10 10 18 18
Mean 2.04 3.15 2.05 2.68 2.05 2.89
SD 0.45 0.55 0.53 0.51 0.48 0.56
Physical Activity
Yes N 6 6 7 7 13 13
Mean 1.97 3.14 2.07 2.74 2.03 2.92 0.47 0.52 <0.0001 0.043 0.84
SD 0.64 0.31 0.64 0.53 0.62 0.47

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No N 4 4 3 3 7 7
Mean 1.79 2.96 2 2.56 1.88 2.79

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SD 0.21 0.77 0.17 0.51 0.21 0.66
Current Smoker

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Yes N 3 3 1 1 4 4
Mean 1.78 2.78 1.5 2.83 1.71 2.79 0.29 0.41 <0.0001 0.055 0.84

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SD 0.25 0.84 - - 0.25 0.69

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No N 7 7 9 9 16 16
Mean 1.95 3.19 2.11 2.67 2.04 2.9
SD 0.59 0.31
ED 0.52 0.53 0.54 0.51
Chronic Disease
Yes N 3 3 - - 3 3 ND
Mean 1.89 3.17 - - 1.89 3.17
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SD 0.63 0.44 - - 0.63 0.44

No N 7 7 10 10 17 17
Mean 1.9 3.02 2.05 2.68 1.99 2.82
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SD 0.5 0.56 0.53 0.51 0.51 0.54

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A

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