3. Motivational Interviewing During the Uncertain times of COVID-19 - Part 1 of 2

Vaccine recommendation fatigue is very real. We’ve all been experiencing it. But don’t beat yourself up over it!  Join Mustafa Alavi, MD and Christina Wells, MD, MPH, FAAFP as they host Rachel Caskey, MD, MA and Amy Christison, MD to help breakdown motivational interviewing (MI) into simple steps and lay the groundwork for addressing vaccine hesitancy. They address ways of dealing with a patient’s “no” or “not now” decision, without taking it personally or getting burn out.

This two-part series is intended for clinicians with any range of MI familiarity. In part two, they will share how to apply these techniques and share real world experiences.

Learning Objectives:
• Summarize the principles and main concepts of motivational interviewing
• Recognize a patient’s state of change
• Discuss ways to help patients make a more informed decision without building resistance against open communication.

Visit us at illinoisvaccinates.com/podcasts.

Chapters

• 0:00 Introduction
• 1:39 Episode Begins

Transcript

Speaker# 1

Welcome to Beyond the Needle A Physician's Guide to Increasing COVID19 Vaccination Rates. Brought to you from the Illinois Academy of Family Physicians through the Illinois Vaccinate or I-VAC grant. I am Carl Lambert, a family physician and a member of IAFP, and I'm an assistant professor of family medicine at Rush University Medical College.

I-VAC is a joint effort administered by the Illinois Chapter of American Academy of Pediatrics, ICAAP, the Extension for Community Health Outcomes, ECHO Chicago, and the Illinois Academy of Family Physicians. I-VAC funding for this podcast series is provided by the Office of Disease Control through the Illinois Department of Public Health. The goal of I-VAC is to ensure Illinoisans are being immunized against COVID-19 at every opportunity and that providers are prepared to immunize all eligible age groups. Support for providers is available through bootcamps, learning collaboratives, do it yourself toolkits and IVAC podcasts. For more information, visit IllinoisVaccinates.com. 

CME credit is available for each podcast through the Illinois Academy of Family Physicians. Information on how to receive credit can be found on the Illinois Vaccinates website under podcasts.  

In this podcast series, we will empower the primary care clinician to feel confident in implementing COVID-19 vaccination so their patients can receive the vaccine at a routine visit. 

You will hear from a variety of primary care clinicians and staff from across the state who have become experts on COVID-19 and the COVID-19 vaccine and implementation.  As primary care clinicians, this is the kind of work we've been doing throughout our careers. For centuries, we've been trusted allies in preventive health for individuals, families and communities. We will share the highs and the lows of our experiences and lessons learned throughout the pandemic. Thank you for joining us as we come together to vaccinate against COVID-19.   

Speaker 2

Good afternoon and thank you for joining us with a for our IVAC podcast series Motivational Interviewing. During the uncertain times of COVID19. I am Dr. Christina Wells. I'm a family medicine physician. I work at the University of Illinois at Mile Square Health Center, and I'm also a board member of the Illinois Academy of Family Physicians.

Speaker 3

And I'm Mustafa Alavi. I'm a delivering family physician with Erie Family Health Centers. And I'm really excited to be here with you, Dr. Wells. For this topic. I'm really excited for the guest panel that you have.

Speaker 2

Yeah, I'm excited as well about what we're going to learn about today. We know that we're facing vaccine hesitancy and uncertainty, and we know that we've had some difficult conversations. And so today, we have Dr. Christison and Dr. Caskey, who are going to help us break down the principles of motivational interviewing. And assist us with having some of those difficult conversations.

Speaker 4

Thank you so much for inviting us. I'm Dr. Rachel Caskey. I'm an internist and pediatrician at University of Illinois at Chicago, and also a health services researcher. I've spent much of the last ten to 15 years studying ways to improve vaccine uptake and ways to tackle vaccine hesitancy.

Speaker 5

My name is Amy Christison. I am the associate professor of pediatrics at the University of Illinois College of Medicine.  I'm a general nutrition and also obesity medicine certified and really focus a lot on shared decision making and motivational interviewing conversations with my patients and training others to do the same.

Speaker 3

And I'm so excited to have two experts in motivational interviewing here to help teach us the core concepts of what motivational interviewing is. Now, I see this day in and day out, as all of us do, as primary care clinicians. With COVID, we're two years into this pandemic right now. We're having conversations with our patients on a daily basis on how can we increase uptake of the COVID vaccine among all of our patients.

And all of us hear different reasons and different concerns about the vaccine. People are hesitant. People are scared for things that they're reading online. And we all are learning to approach this in a different way. And we need some skills and tools to help approach this. Now, if I saw a scenario like this on a board question, my gut always thinks go straight to the answer that says motivational interview.

That's always the answer. Motivational interviewing. But what does that even really mean? I think I know what it is. But, Dr. Christison, can you help guide us and tell us what what is motivational interviewing?

Speaker 3

Now, that's a great question. So motivational interviewing is what's a conversation style, and it really elicits a person's concerns and ways you might think about changing. We don't really do motivational interviewing to people or do MI to them. This is really a conversation that we have with folks. And so when I think about MI or motivational interviewing, I really think about with a spirit of what it is.

And I like to summarize it in the acronym CAPE. C-A-P-E.

C is for compassion. And motivational interviewing. What drives it is really, truly wanting what's best for the person in front of you.  It is based upon how they define it for themselves.  

A is for accept, which is probably the most difficult thing for us as clinicians.  That we accept their autonomy to choose, it doesn't mean we give up on them. But it just means that we accept that 

And P is for partnership to come alongside with them about this conversation in considering their own reasons for change, or maybe leaving things the way they are 

And E – it’s eliciting their own sort of impressions about why they might want to change what makes them ambivalent about it, or maybe what a plan might look like if they're considering change.

So, Dr. Caskey, what are your thoughts about that? If you'd like to add about your impressions of what it is? 

Speaker 4

I love that acronym of CAPE. And I particularly like that part of this is accepting in the autonomy of individuals to make their own decisions. And even if those decisions don't always align with our recommendations or our preferences. And I think that's hard. And again, I want to emphasize that we're not giving up on our patients. It's really just accepting that at that moment they're not quite ready to maybe take on some of the things that we might recommend that we recommend or wish for them. 

Speaker 5

But knowing that, I think everybody's at different places or stages for each person and it's not constant.

And that's the cool thing, I think, about primary care, medicine, We have this wonderful longitudinal relationship with our patients. And so there's always an opportunity to have another conversation. And it's really refreshing and sometimes surprising what you discover as you invite patients in to find out where they are with how they might consider changing some sort of behavior or how they manage a certain condition of their own.

Speaker 4

So let's talk a little bit about how to break this down in the context of real world care. And I think this is important because as was mentioned early on, you know, the term motivational interviewing, maybe something many of you are comfortable with or it might be something that frankly engender is a bit of fear because all you can think of is, oh, my gosh, how would I fit this into my already very busy clinical encounters with patients.

So I want to share with you what I call the micro motivational interviewing around vaccines. And this is something I work with a lot with students and residents and other faculty and peers, because this should not take long. This is something that's meant to be very brief. Vaccines are often something we tackle at the end of our visits historically.

And that may not be your practice, but often they're at the end of the visit. It's sort of one of those closing statements of what, The last recommendations of the visit. And so if there is resistance or concerns expressed by your patients, I want you to think about just three quick responses. First, simply ask what the concern is.

Don't get confrontational. Don't resist the concern. Just ask. What are your concerns? Followed by an affirming statement - Many people share those concerns. Many of my patients have expressed that before. I've heard that before. Chances are you have not. There's nothing new you've heard with vaccine hesitancy. You're right. We've all heard it all. So it's very likely that you can say a very earnest statement that “I've heard that concern before.” Others share that concern.  And then finally, give a simple single summary statement. Vaccines are held to high safety standards. COVID infection can lead to very serious disease. I recommend you receive the COVID vaccine today, but the decision is up to you. Period. If you let it lie after that. If it's accepted. Wonderful. If it's not, hold it for future conversations.  And we're going to talk more about that as we go. 

Speaker 5

Yeah. well, On one hand, it makes me feel more comfortable listening to you map it out that way because, you know, a lot of folks that I talk to and were thinking motivational interviewing are like. I don't have this kind of time.  But when you map it out that way, I feel like I can envision myself actually getting this done because it's not like 100 hours in front of this patient trying to convince somebody to do this.

Speaker 4

That's right.

Speaker 5

So I feel like that's a really important thing. And, you know, I love that whole sort of approach of asking them, you know, what concerns them. You know, just really kind of understand that. Right. And then the other response I thought was pretty cool, though, is this notion of like a normalizing statement that, you know, the fact that they're not alone in thinking what they're thinking is very empowering. And it makes me feel like you've really heard me and you don't judge me, that you are seeing.  Other people feel the same way. I've heard this a lot. And that just makes me want to have more of a conversation. You. Like that just opens a door run like Dr. Caskey let me tell you more. Let me tell you more of what I think, because I feel you're like you're welcoming me in and feeling like I'm not judged.

Speaker 4

I'm so glad my micro motivation all interviewing worked for you today. 

Speaker 5

I am like getting more and more activated, going through this and contemplated to contemplate making a change. I'm just saying. 

And I love your response. To that. Thank you. Because I do think it is important to just right, You're not resisting, right? You're not. Even if you get a laundry list of why someone doesn't want a vaccine, You don't have to tackle that. That's OK. Let those concerns lie and just say, OK, that's you know, that is fine. You're not alone. So I appreciate your your thoughts on that. Thank you. 

Yeah. And you kind of brought up kind of brought up this sort of feeling of resistance. And I always tell a lot of my students and residents that are training training with me and my clinic.

Speaker 3

When you sense that resistance and stuff, you stop, drop and roll, kind of like when your fire on the door is really a great way to try to reduce that resistance. I feel like when you push more, people want to push back and to be able to let it lie, like you said, I think is very, very powerful. You're not trying to push them any further and you know, I feel like this is more of a dance rather than wrestling.

Speaker 4

I think that's a great analogy. Yes. An elegant dance, not wrestling. And there is research to show that combating vaccine resistance or hesitancy with data, facts, p values, CDC statistics does nothing but cause people to dig their heels in deeper. It's just that resistance is really hard for patients to manage. So it's there's good reasons that have actually been studied to not go there and not sort of fight.

Speaker 5

Yeah. So, you know, you kind of talk about like a simple summary to share in terms of information. And I love to also maybe highlight an approach that a lot of us use is that ask tell ask approach to sharing information even. I love to start with just asking for permission even and then so that if they seem hesitant, to just say, is it okay if I share some information with you?

Speaker 4

And then that summary of how that's very simple can be a really great way of sharing information. But, you know, I heard you say before, like, just like you said they tell us like a million pieces of evidence that you've been reading about the data of why that person should get a vaccine, but maybe some personal stories or stories of other patients and, you know, maybe the information that made them think.  You know, I think it's okay for me to get a vaccine, for instance, and then maybe following up with asking, what do they make of this information? How they think about this. So that whole ask is a really great way of also sharing some of that summary information. What are your thoughts? 

Speaker 5

And then keep the conversation going. Right. It's OK if no is the answer today. Hopefully we're going to see that individual back in the near future. And we just keep the same conversation going. And I think if it's if patients feel like you are not resisting them and not wrestling with them, to your analogy, over time, there's really good data to show that a lot of patients that are sort of fence-sitters, if we will.  Right, those that have some questions they're a little cautious.

They're not sure. Over time, the majority actually will ultimately get vaccinated for routinely recommended vaccines. But it might just take this micro motivational interviewing two, three, four or five times. 

Speaker 4

Well, I don't know. Like, I feel like when people don't do as I've recommended, I start getting kind of sad about my lack of effectiveness with my patients.  Maybe they don't trust what I have to say. They seem skeptical about what I've shared. I kind of get tired of having to confront that thing.  And I think I think others share that. And particularly as clinicians, this is common, right and we've spent a lot of time and energy and love to get good at working with patients.

Speaker 4

Right. And so I think your reaction is really normal. And I know a lot of trainees have expressed that over the years, too. It just feels so personal. And so I think another thing we need to think about is when someone is declining a vaccine similar to if they're declining anything else you recommend, they are not declining you, Right. They're making an autonomous health care decision. It is not personal. And so I think sharing personal stories about vaccines is a great way to have a conversation and discuss. But you cannot take the decisions personally. Similarly, where I wouldn't take a decision personally if someone didn't want to get a mammogram or any other recommendation, medical recommendation I made.

So we can make it personal. We can make the conversation personal. We can talk about how we've been vaccinated against COVID. My children my family members, so forth. But again, we cannot take it personally if the decision is not aligned with what our recommendation is. And I think this is an area I've grown a lot in the more recent years to not take these things personally because they do weigh on you.  And I do worry that leads to burnout and other dissatisfaction with patient care. And instead just allow people to make those decisions and slowly keep trying. 

Speaker 5

Yeah, I feel like that frustration comes from a really good place, though. So, you know, I see so many health care clinicians that are really frustrated and I think they really, truly want what's best for their patients.

They think for every day it comes from a really great place and they get frustrated when their patients go against this and they feel personally responsible. And you would almost like a failure that they don't come alongside with the recommendations. And somehow your success is contingent upon your patients doing what you asked them or recommended for them to do.

Speaker 4

And that's a big responsibility. You shoulder a great deal. And I remember early in my career where I, I took that responsibility really seriously. I wanted so much for my patients to be better and to be safe than, you know, when they didn't do as I asked and recommended, I took that personally and I felt like it was a personal failure because I didn't do what I trained to do.

Speaker 4

And that was to make people's lives better. So I don't think it comes from a bad place, but then that notion of accepting autonomy and just realizing in this moment that patient's not ready. And it's not really about me. It's really about them. And maybe even showing some compassion to yourself as well as to them that in that moment it's just not the right time can be very empowering.

It reduces that burden and lifts off of your shoulders. And it's not like it's not like you don't care and you have dissociated. It's more just recognizing the situation for what it it's it's just not the right moment. And boy, is that a. It really is. I think that is of great way to conclude this discussion is giving our self a break, right?  So that we don't burden and shoulder the a negative response around a vaccine. But yet trying to keep motivated to keep the discussion going thing.

Speaker 3

It was fantastic. Thank you, Dr. Caskey and Dr. Christison. And just to recap, Dr. Christison, can you summarize for us what motivational interviewing is for the audience and your and the acronym that was so helpful?

Speaker 4

Absolutely. So motivational interviewing is a conversation style, and it really elicits another person's own reasons or ways that they might consider changing and it's not what we do to people, but it's just something that you engage and partner with others about. So the spirit behind it is, see, compassion really wanting what's best for that person, developing a accepting their own, and finally to choose a partner.

Speaker 4

So this is less of a practical situation where you're telling them what to do, but really coming alongside them and then trying to invite them to the table and invite their perspectives of what's important to them, why it's important to them, why they're ambivalent, why are they hesitant? And then if they are ready, what is the next step, whether planned in a way that is really resonating with them?

Speaker 3

And Dr. Caskey, I thought you hit the nail on the head with micro motivation and how we talk about vaccines at the end of the visit, I'm often just lifting my laptop up about to go, and then I look through their vaccines and then I'm like, oh, they haven't had their COVID vaccine yet, or they need their booster. How do I best address this? What I need to see in my next patient? And can you recap for the audience as well? There's three simple things you mentioned for approaching micro motivation.

Speaker 4

Certainly. So three simple questions. Simply ask, what are your concerns? You don't have to address them. Just ask, acknowledge or affirm that it's normal to have concerns. Other patients have them, other people have them. Just affirm that that is normal and summarize with your medical recommendation and this is really important. Vaccines are a medical recommendation. So I usually say something like, as a reminder, vaccines are held a very high safety standards.

COVID is a very serious infection, could lead to serious disease. I recommend that you get the COVID vaccine today, but it's important for you to make that decision.

Speaker 2

Wonderful. Thank you both. Dr. Christensen and Dr. Caskey, this has been a great informational session we know that. We have learned a lot today, and we appreciate the information that you have shared. Do either of you have any additional closing thought that she would like to leave with us today?

Speaker 4

I'll just remind everyone to feel free to use personal stories, but don't take the answers personally.

Speaker 5

At the end of all of this. A really great takeaway, too, is that notion that, you know, all of us experience vaccine recommendation fatigue.  So there are some things you may come away with thinking that you want to try some of this, but there are some days you're not going to feel if you're exhausted.  Don't beat yourself up over it because we've all been there. 

Speaker 2

Wonderful. Wonderful. So thank you both again for all the information that you have shared today. This has been, again, very informational. We thank you for joining us today. This was awesome and a lot of fun. Stay tuned for part two.