2019-20 TOW #7: Immunizations

A huge thanks to our amazing immunization experts Drs. Doug Opel and Annika Hofstetter for developing materials for next weeks’ TOW on immunizations. This is a timely topic given the measles outbreaks and back-to-school visits, and the relatively lower immunization rates for WA state compared to national rates. Hopefully, thanks to our colleagues here, we will continue to make inroads to protect our children.

Teaching materials for immunizations:

Take-home points:

  1. Why are issues around immunizations so important to know well as pediatricians? Immunizations are arguably the biggest success story of public health in the 20th century and the most important component of the recommended well child visit schedule. While vaccine safety has been extensively studied, no vaccine is 100% safe or 100% effective. This has contributed to the controversies around vaccines. Yet, we know vaccines are overwhelmingly effective to decrease morbidity and mortality from vaccine-preventable diseases.
  2. How many parents are vaccine hesitant? While only about 1% of parents are anti-vaccine (choosing no vaccines), about 1/3 are considered vaccine hesitant, and the vast majority (about 2/3) are vaccine accepters. Vaccine-hesitant parents are the ones where we may have the most influence to change their approach/decision.
  3. How is it best to bring up the topic of vaccines in clinic? As Doug Opel and team identified in a study in Pediatrics (see above), choosing a “presumptive stance” (i.e., “today your child is due for these vaccines”) rather than a more collaborative approach (e.g. “what vaccines did you want to give today?”) was associated with more likelihood of vaccines being accepted by parents. It’s always important to use good general communication skills including being open to questions, honest, respectful of parents, and not coming across as offended or defensive. The CHOP vaccine app has helpful info for parents as well.
  4. Why have vaccines developed such a negative reputation? Partly it’s because there are many more of them and that’s been worrisome to some parents. But mostly it’s been related to vaccines, especially MMR, being wrongly associated with causing autism. The study that first suggested this association was published in the Lancet and was eventually retracted as people recognized the poor study design and even falsified data. The lead author had his medical license revoked. Unfortunately, the repercussions of this unethical study were incredibly detrimental, and we are still dealing with them.
  5. What are the most controversial ingredients in vaccines? Those that have specifically raised concerns are thimerosol (a preservative that was taken out of most vaccines despite lack of evidence that it could cause neurological problems), aluminum (an adjuvant that helps vaccines work better – concentrations are less than what a baby ingests in breastmilk by age 6 months), animal-derived gelatin (used as a stabilizer in some vaccines – objectionable to some people in Muslim faith though there have been statements from imams that they can be given) and aborted fetal material (used as cell strains to grow MMR, varicella – of special concern to devout Christians or Catholics – the Vatican has said parents could accept these vaccines).

2018-19 TOW #46: Adolescent immuniztions

There’s a lot going on in adolescence, including trying to complete additional recommended vaccines, the most challenging being HPV and flu. We will review some of the barriers and recommendations to address this.

Materials for this week:

Key take-home points:

  1. What types of clinical settings do adolescents use? Most teenagers have a medical home in the US, and >90% of adolescent vaccinations are received in a pediatric, family medicine or community health clinic. A few receive vaccines in school clinics, internal medicine and OB-GYN settings.
  2. What are the recommended vaccines for pre-teens and adolescents? Starting at age 11, we recommend a 2-dose meningococcal series (1 dose at 11-12, 2nd at age 16), single dose of Tdap, 2-dose HPV vaccine series (separated by minimum of 5 months; it’s 3 doses if started at age 15 or older), and an annual influenza vaccine.
  3. What are adolescent immunization rates in the US? The 2016 National Immunization Survey showed that adolescents aged 13-15 years met the Healthy People 2020 goal of 80% coverage for Tdap (88% coverage) and first dose of meningococcal vaccine (82% coverage), but did not meet the HPV vaccine benchmark (50% of females, 38% of males). Flu vaccine rates are especially low for teens (49% of 13- to 17-year-olds).
  4. What are common barriers to adolescent immunizations? Provider/clinic factors include not offering vaccines at acute visits, and not having follow-up visits; family factors include not coming for annual wellness visits. There has been particular parental concern about the HPV vaccine safety and need for it at a younger age. The HPV vaccine is only effective against HPV strains before exposure to the strains. Even before teens start having sex, they may be at risk for HPV related disease. HPV DNA has been detected in cervicovaginal swabs from girls who report never having had vaginal intercourse, so the virus is also transmitted through other forms of sexual contact. Data suggest better immunogenicity to the vaccine when given at a younger age, and teens are motivated that it is only 2 doses if done before age 15.
  5. What are ways we can help increase vaccination rates? A strong provider recommendation is one of the most important factors that positively affects vaccination, as has been shown in several studies for the HPV vaccine. Other strategies are to review immunization records at visit, offer immunizations at each visit, and schedule follow-up visits for the next vaccines due. System-level approaches include family-oriented ones like text reminders to families, web-based education and social marketing, as well as clinician-focused ones like automatic EMR reminders and incentives.

2018-19 TOW #30: Race and Medicine

Happy February! As we celebrate Black History Month in February, we are covering a critical topic affecting all children: bias and racism.* A big thank you to the input of many people on this topic and the efforts happening at SCH/UW, including our amazing residents and faculty in D-Comm, INCLUDE curriculum team, and the Center for Diversity and Health Equity (CDHE). Given the national dialogue and health disparities, it’s more important than ever that we use our roles as physicians to address bias and racism. While we honor the significant work that has come before us, we acknowledge there’s much more work yet to do. I’m grateful our children in Seattle Public Schools are also getting specific education this week with a national Black Lives Matter at school week.

*Note: This is a really big topic – try to review at least one article. In clinic, I suggest you watch Dr. Jones’ or Dr. Roberts’ TED talks and discuss how you have observed racism affecting health and personal ways we can try to make a difference.

Materials for this week:

Take-home points for this week – structured as a charge to each of us, as outlined from the article by Hardeman et al. in the NEJM

  1. Learn about, understand and accept racism – in ourselves and in our institutions. As Hardeman et al, describe “Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals. If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.” Those who have had white privilege must be able to understand and recognize what that means to see the effects of racism in our society. Watch Dr. Camara Jones’ TED talk on the gardener story and effect of differential preference over time.
  2. Understand how racism has shaped our narrative and the rhetoric we have used in medicine to erroneously relate race to biologic differences. Medical schools are now recognizing the need to address the curriculum to better deconstruct race as a social rather than biologic construct, and we need more change (see Rebekah’s article above and R3 Paul Homer’s RCP this year). We must continue to educate ourselves about our societal and institutional structural racism and approaches to address this through writers such as Ta-Nehesi Coates, local writer Ijeoma Oluo, and UW-trained sociologist Robin DiAngelo. PBS’ Black Culture Connection features writers, community influencers, and movies/documentaries.
  3. Define and name racism – develop consistent definitions and use accurate vocabulary – Dr. Jones describes race as “the societal box into which others put you based on your physical features.” Racism is a “system that encompasses economic, political, social and cultural structures, actions and beliefs that institutionalize and perpetuate an unequal distribution of privileges, resources and power between White people and people of Color.” (Hilliard, 1992). We should shift our focus in medicine and health research from identifying race to identifying racism and its effects on health. We also need to name and discuss the concepts of race and racism with our children, especially white children. Great article about this in the Washington Post by a child development professor who also is in a mixed-race family. Most children by the ages of 5-6 have developed some sense of racial identity. We have found children’s books to be a great way to broach the conversations at our house. There’s also Teaching children about race – Modules 13 and 14 from the UW I-LABS (includes many fantastic video training resources about child development).
  4. Provide clinical care and conduct research that contributes to equity – As physicians we have opportunities to be change-makers and it starts with therapeutic alliances with patients and becoming aware of the resources available to us as pediatricians. Our residents are now shaping our own INCLUDE curriculum with talks from local experts like Roberto Montenegro MD PhD and Tumaini Coker MD MPH. As part of INCLUDE, this spring interns will receive a day-long Equity, Diversity and Inclusion training from the CDHE.
  5. Be aware of and join local efforts. UW President Ana Marie Cauce launched a Race and Equity Initiative in 2015 for the UW community to acknowledge and confront bias and racism at all levels. The Department of Pediatrics continues active efforts to address diversity and equity, thanks to the leadership and vision of many, including our residency’s Diversity Committee and CDHE. There are so many ways to continue to inform ourselves, and here are a few more:

2018-19 TOW #22: Newborn concerns

For many of us, one joy of general pediatrics is the chance to care for babies. As we welcome them into the world, they seem to bring us hopefulness and renewed faith in the human potential. As Henry David Thoreau said, “Every child begins the world again.”

Note: this is a great topic for you senior residents to lead the discussion!

Materials for this week:

Take-home points:

  1. Attachment: babies thrive when their caregivers are thriving. Given what we now know about neural wiring in the first 1000 days of life, it is critical to support parents’ ability to care for and connect with their infants. Mothers should be screened for post-partum depression and referred for treatment, as needed. Observe and comment on how parents are comforting babies in visits, such as talking and holding (and possibly the 5 S’s-suck, swaddle, swing, shush, side-lying). Help parents beware of how phone use and screen time may interfere with interaction with babies. We have to debunk the misguided idea of “spoiling them” by holding them too much-in fact, we know that infant brains shows positive effects with high nurturing. Promoting First Relationships (PFR) offers a great framework for supporting parents with these concepts in clinic visits. All of the great PFR handouts are available on the TOW mainpage sidebar with your UW NetID here.
  2. Helping parents be experts: provide parents encouragement, point out what they are doing well to connect and care for babies, and how they are the most important people in their infant’s life. Give them tools (such as PFR handouts) and resources like www.text4baby.com where they can sign up for texts based on baby’s birth date that give tailored resources, reminders, and tips.
  3. Normal newborn behaviors and findings: parents need to know about common things that can seem worrisome (sneezing, hiccupping, spitting up, primitive reflexes, rashes, crying, etc). Review some common skin findings here.
  4. Nutrition: helping babies grow/gain weight is a central concern in the first few months of life, and we need to provide guidance and reassurance on appropriate weight gain and support for breastfeeding. Whether breastfed or not, all babies should be cuddled and held with nurturing interactions during feeding. We can teach about reading babies cues of hunger and fullness from the beginning. Breastfed babies (fully or partially breastfed) should be on a vitamin D supplement of 400 IU per day to prevent rickets.
  5. Sleep: providing a safe sleep environment is key to babies thriving-babies should be on their backs and in their own sleeping unit without extra blankets or stuffed animals to avoid suffocation and SIDS. Co-sleeping/ Bed-sharing is the highest cause of death under 3 months, and is especially dangerous if parents smoke or drink alcohol. Ask open-ended questions about where baby is sleeping and in what position to facilitate honest conversations. Review evidence and encourage room-sharing rather than bed sharing. The AAP has sleep guidelines that recommend co-rooming. Also review positional plagiocephaly and how to avoid it (tummy time, rotate positions in crib and get babies out of containers (e.g. swings, carseats, babyseats) when not sleeping)!

2018-19 TOW #3: Well child care/ health supervision

The beginning of the academic year is a great time to review our central tenets in providing effective well child care (WCC). WCC can be very rewarding as a pediatrician, especially if you have the right tools and knowledge. We all recognize that providing comprehensive WCC is difficult in a 15-20 minute visit, so we have to prioritize. We are also being called upon to consider new models of care to truly impact social determinants of health and chronic diseases over the lifetime, as one of our own amazing gen peds faculty, Dr. Tumaini Coker, discusses below and is actively researching.

Materials for this week:

Take-home points for this week:

  1. Why well child care? Through WCC visits, we have a unique opportunity to identify and address important social, developmental, behavioral, and health issues that can have significant and long-lasting effects on children’s lives into adulthood. Pediatricians provide the vast majority of WCC to children in the US, which differs from other countries’ health systems where general practitioners or nurses provide it. As society changes, one of our current pediatric challenges is to adapt WCC to better address issues that most impact adult health including poverty, low education, environmental exposures, and ACEs (Adverse Childhood Experiences). Newer models of care including the medical home with integrated care, group visits, home visitation programs, and health navigators are all being utilized and studied to improve WCC.
  2. What ages do we recommend WCC visits and why? We have >20 visits recommended with children between ages 0-18. Currently there are 6 visits recommended between birth to age 1 (newborn, 2-4 weeks, and 2, 4, 6 and 9 months). Visits are spaced out over the next 2 years (15, 18, 24, 30 months) and then annually after age 3. The timing for these has been largely influenced by providing vaccines, which is the most evidence-based prevention strategy we use in pediatrics; and by Bright Futures, developed by the maternal and child health bureau in the 1990s to standardize recommendations and care.
  3. How do we prioritize topics for WCC? For each recommended well child check from newborn to age 21, Bright Futures includes guidelines for screening and a “menu” of 5 possible anticipatory guidance topics. Even with these pared down, there’s a lot to cover, so we often still have to do more focusing. There’s some data that parents can only retain up to 3-4 recommendations from a visit. It’s also not just what we say, but how we say it that matters. To support parents feeling engaged and supported, we can use the tools of Promoting First Relationships in primary care. We can show we welcome parents’ concerns and acknowledge their needs and efforts. Through specific positive feedback, we can highlight what we see them doing well to engage in responsive parenting, recognize their child’s needs, and to find joy in interacting with their child.
  4. What’s the evidence for effective components of anticipatory guidance? Unfortunately, the studies are difficult to do and the data is limited. Because of this, the US Preventive Services Task Force often gives a Category 1 (Insufficient Evidence to Evaluate) rating to pediatric screenings, such as for lead, and cannot say whether outcomes are improved because of the intervention. There are several pediatric preventive health interventions with good supporting evidence including Reach Out and Read, promotion of breastfeeding, the “back to sleep” campaign, and avoidance of physical discipline.
  5. In the limited time we have, what’s most important to cover? Most important is that we address parents’ concerns and set an agenda with them. While I confess I don’t love or routinely remember mnemonics, “CHECUP” is a good list for basics to review that is more or less mapped to the order of topics in the visit, starting with parent concerns.
  • C – Concerns (or questions)
  • H – History (interval hx, past medical, birth, family, social)
  • E – Environment (home, typical day, nutrition, sleep)
  • C – Child (development, growth, voiding)
  • U – Unanswered questions (inquire about further concerns)
  • P – Prioritized anticipatory guidance

2018-19 TOW #1: Agenda setting

Welcome to TOW 2018-19!

About TOW: I’m excited to kick off another year of continuity clinic teaching and our TOW series. A big welcome to our fabulous new crew of interns! TOW is intended to provide standard teaching topics that allow us to review key aspects of outpatient care for children. Each month I try to include a range of topics so that if you’re on a clinic month you’ll have variety, from well visits to acute care issues that affect all ages, including social determinants of health. The format is structured around case-based resources and review materials that can stimulate discussion. For each topic, I write a brief bulleted highlight of the topic that everyone can review by email, whether they are in clinic that week or not. I’ve created a blog format with hyperlinked resources and key-word linked, so hopefully it’s easy to access anytime. There are 50 topics per year over a 2 year cycle, and you can also review archived topics (including age-based well visit review from last year’s set). The scheduled topics for the year will be posted on the blog sidebar. Here’s the blog link you can bookmark: http://depts.washington.edu/uwpeds/tow/

This week’s topic is agenda setting, which we are doing early in the year to review the importance of setting an agenda in outpatient visits, which by nature have fixed times and require prioritizing. Agenda setting allows us to make sure we have addressed the most important concerns for the family, and balance these with our own agenda for the visit. This is really important in building relationships with families and helping them feel that we are responsive to their needs.

Materials for this week:

Take-home points for setting the agenda:

  1. What is agenda setting? A brief dialogue at the beginning of the visit between patient/family and clinician to ensure we can agree on the most important priorities for the visit. It can be as simple as opening with “What concerns do you want to be sure we discuss today?” or “What are your priorities for today’s visit?” Asking “what else?” until no more concerns come up can help us elicit all concerns and set priorities. We can then follow with adding ours: “Thank you. That’s really helpful – I agree those are important. I also want to be sure we talk about X today. Is that okay?”
  2. Why agenda setting is important? Multiple reasons: Agenda setting helps us 1) address the most important family concerns (we can easily fill the time with our own agenda/priorities in well child checks), 2) avoid trying to do too much with one visit and running behind, and 3) not hearing about a major issue until the end of a visit – “the doorknob complaint.” Some studies have found that up to half of patient complaints and symptoms were not elicited in an interview. The likelihood of psychosocial complaints being brought up without asking about them is especially low.
  3. What are barriers to agenda setting? Our biggest concern is that it will take too much time. Actually, doing agenda setting well has been found to add just seconds to the visit and helps avoid the doorknob complaints that can take a lot of time. Another concern is that too many issues will be elicited. Adult studies have found that patients typically have 2-3 concerns (up to 5), and this seems to be similar for pediatric visits. When a long list does occur, this may have some diagnostic meaning – like parental anxiety/depression.
  4. What if there are too many issues to address in one visit? This is important for us to acknowledge if we can’t get to everything and work with parents to prioritize. Parents will accept addressing some items later if their importance is validated, an attempt is made to deal with the most pressing ones, and it is discussed at the outset. We can also use respectful redirection/ interruption to get back on track when parents digress.
  5. How do we use this in a way that still keeps us on time? The 5-step patient-centered beginning of interview is one suggested approach: 1) Set stage with welcome, introductions, privacy/ confidentiality, ensuring comfort, 2) elicit chief concerns and set agenda (may be helpful to inform them how much time you have available), 3) use open-ended questions and attentive listening (this is where it’s really important to not interrupt right away), 4) elicit more specifics, 5) check accuracy, ask more questions, summarize, then move into clinician-centered phase (exam, etc.).

TOW #49: Adverse Childhood Experiences (ACEs)

We are fortunate to be in a time in pediatrics when the neuroscience is catching up with what we have long known about social determinants of health affecting children’s development. The original study on Adverse Child Experiences (ACEs) was published 20 years ago in a collaboration between the CDC and Kaiser. Growing understanding of the science behind toxic stress outcomes is generating renewed interest and investment in early childhood programming, such as here in King Co with the Best Starts for Kids program, and nationally in programs like the AAP Resilience Project, among others.

A big thanks to the fantastic advocacy of Drs. Colleen Gutman (Chief ’17) and Abby Grant who helped prepare these resources to inform your clinic practices. These materials also build on and relate to the approaches we have discussed in Promoting First Relationships (PFR).

Resources for this week:

Take-home points on ACEs/Trauma-informed care:

  1. Ecobiodevelopmental framework (EBD) – As reviewed in the AAP Technical Report, “an emerging, multidisciplinary science of development supports an EBD framework for understanding the evolution of human health and disease across the life span.” Science has shown significant associations between the “ecology of childhood” and many developmental outcomes and life course trajectories.
  2. ACEs definition: Adverse childhood experiences (ACEs) are experiences in early life that have detrimental effects on child development and adult health outcomes including abuse, neglect, being exposed to intimate partner violence, mental illness, and drug addiction. In addition, poverty and racism can exacerbate the effects of other ACEs.
  3. Toxic stress definition: Adversity and maltreatment in childhood are thought to affect development and health through chronic exposure to stress. This repeated and ongoing activation of stress response pathways is termed “toxic stress”, in contrast with normal, healthy, physiologic stress response mechanisms. Children experiencing adversity and maltreatment have been shown to have elevations in inflammatory cytokines and dysregulation of their HPA axis, and their brains may develop differently.
  4. Protective factors: Thankfully, the presence of a positive, nurturing adult is powerful in protecting against the negative effects of toxic stress. While there is great variability in genetic susceptibility to stress reactivity, nurturance mediates and protects against the negative effects of toxic stress and adversity (not just in humans, but across animal species, too).
  5. Pediatricians’ role in addressing ACEs/toxic stress: we are being called upon to take more active roles in developing and implementing science-based strategies to reduce toxic stress in early childhood, and hopefully thereby tackle some of the pressing disparities in learning, behavior, and health. We can become knowledgeable about the concepts and resources on trauma-informed care (as above). We can take a “universal precautions” approach and treat everyone with respect and humility. We can be aware of somatic symptoms that may be signals of untreated stress/trauma. We can also give special attention to care provided to those who are affected by trauma to help build nurturing and resilience, and avoid retraumatizing children and/or caregivers.

TOW #44: Transition to adult care

R3s will soon be making their own big transitions into jobs and fellowships! Likewise, our adolescent/young adult patients will soon experience notable transitions as they graduate and move on to new adventures. Transitions for some of our patients with special health care needs require additional support, which we will review in this week’s topic. Big thanks to Dr. Peter Asante for his contributions to his topic!

Materials for this week:

Take Home Points:

  1. Why is transition of care important? Every year, about 500,000 adolescents transition from pediatric to adult care. For children with special healthcare needs, this is the highest risk time for health complications and poor outcomes. Some studies have shown that continued care at pediatric medical centers (after age 21) can lead to higher risk of mortality. Transition involves both assuming self-management of medical care (when appropriate for the patient’s abilities) and transfer of medical summary/ documentation.
  2. When should transition process start? 2011 joint guidelines on transitions of care recommend the following schedule as a general guide:
    • Age 12-13: Start discussing the transition process with teens and parents. Provide a copy of office Transition Policy. (To me this is REALLY early for primary care, so I am more likely to wait to mid- to late teens, depending on the pt)
    • Age 14-15: Jointly develop a Transition Plan with youth and parents. During this time, providers should create a safe space within clinic visits for teens to start practicing self-management skills.
    • Age 16-17: Review and update Transition Plan, and prepare for adult care.
    • By age 18, youth understand and have experienced an adult model of care. Before actually transitioning, the teen and family can visit adult medicine practices, meet new providers, and decide who will be the best fit for their needs. Some may not be ready until closer to age 21.
  3. What are the key elements of transition? Six Core Elements of Transition have been described, include establishing a policy, tracking progress, administering transition readiness assessments, planning for adult care, transferring, and integrating into an adult practice. Using these elements helps start the conversation with families early and provide a standardized process.
  4. What resources are there to help with this process? GotTransition.org provides customizable forms on their website, which can be used to create many of the important documents needed in transition. For medically complex adolescent patients who see multiple specialist providers for their care, this process will probably be more complicated, so it is encouraged that you start this process early! Locally, the UW Medicine Transitions Clinic can be a valuable resource for 18-24 year old patients with complex medical needs, as well as the Center for Children with Special Needs which supports families with adolescent care transitions.

TOW #39: Adolescent sexuality

One of the joys of general pediatrics is the opportunity to see children across the lifespan. After some recent infant-focused TOW’s, it’s time to shift gears to adolescents and review an important topic to them: sexuality! We have the privilege to help teens and their parents navigate through an incredibly important (albeit challenging) phase in life. So, here are some materials to get us comfortable with the sex talks.

Materials for this week:

Key take-away points on adolescent sexuality:

  1. Importance of discussing conditional confidentiality: When meeting with adolescents, we need to review why we are having these conversations and that our discussions are confidential except for situations of abuse or self-harm (when we are mandated reporters). Some helpful wording: “I need to ask you some personal questions that I ask all of my patients so that I can the best take care of your health. When we talk our conversation is confidential. This means that what we talk about is between you and me, and I won’t tell other people, such as your parents, unless you want them to know. One exception to this is if I am concerned someone has abused or hurt you. Another exception is if I am concerned you are at risk of hurting yourself or someone else.” It’s also good to specify that patients do not have to answer any question that they don’t want to answer.
  2. How to broach the subject of sexuality/sexual orientation: we want to normalize the conversation as much as possible and put our patients at ease. “Many teens your age have romantic interests and develop attraction to other people. Have you been attracted to anyone? Do you find yourself attracted to guys, girls, both?” This can be followed by more specific questions about sexual activity. Remember, sexual attractions can be evolving throughout adolescence so you should continue to ask as this may not be a fixed preference.
  3. Asking about sexuality activity: Some prefer to start by asking what questions the teen may have: “What questions do you have about sex that you’ve never really had the chance to ask?” Others prefer to start by asking directly about types of sexual activity. Dr. Shafii reminds us we will not find out unless we ask, and we have to ask direct questions to find out about different behaviors and STI risks. “There are different ways people have sex like oral, vaginal, and anal sex. Have you ever had any of these types of sex?” and “Now or in the past have you had sex with males, females, or both?”
  4. Screen for unwanted sexual activity: As mandated reporters, we need to ask about a history of sexual abuse with a question like: “Has anyone touched you in a way you didn’t want to be touched?” “Have you ever felt forced or pressured into having sex with anyone?”
  5. Counsel on contraception: Discussing contraception and pregnancy prevention is so important for us to do: in one US study, 46% of males and 33% of females did not receive formal education about contraception before their sexual debuts. Contraception should be discussed with both males and females regardless of whether they have started having sex. Helpful wording includes “What are you doing to protect yourself from pregnancy?” or “What are you doing to protect yourself from sexually transmitted infections?”

TOW #27: Motivational interviewing

Motivational interviewing seems deceptively simple in concept, and is decidedly more complicated to implement effectively in practice. The UW first year medical students just got their first intro to MI this week (it’s great we are starting exposure earlier now, to build time for lifelong practice!). MI is especially helpful for behaviors related to all of those new year’s resolutions including healthy eating, physical activity, screen time, and substance use. This week happens to be National Obesity Awareness week, and the week after next is National Drug and Alcohol Facts Week (for teens to learn science-based facts about drug use), so timely for us to review tools that can help us promote related health behaviors.

Materials for this week

Take-home points:

  1. What are the key principles of MI? Why does it work? Behavior change is challenging for all of us, and we are usually ambivalent about change (and don’t like to be told what to do!). MI is founded on helping people do their own convincing for change by using techniques to highlight “change talk”- statements from the patient that argue in favor of making a change. Key elements in this approach include: 1) collaboration, with patient-centered communication approaches fundamental to implementing MI; 2) guiding style to elicit from our patients the changes they want to make; and 3) respect for patient autonomy: we all live our own lives and can’t make changes for each other so we encourage and support (some caveats here for adolescent behaviors that may be more immediately life-threatening/illegal).
  2. What are the key strategies of MI? There are several techniques shown to be effective. We demonstrate curiosity and collaboration through open-ended questions, and use these strategically to elicit change talk. Reflections allow us to demonstrate empathic listening and highlight discrepancies between desired values/ outcomes and current behaviors. We can use 1-10 scale “rulers” to ask about the level of importance and confidence of making changes, to bring out more about why a change is important, and how certain people feel they might be able to make it. These scales can be especially useful with adolescents and their concrete thinking-it can be helpful to get them to elaborate their one-word answers! Before giving advice, we want to first ask what people already know. Then, we can use “ask-tell-ask” to ask permission, then give short concrete advice/information that might be helpful, and then ask what they think of that, or how that might relate to them. Seeking permission before offering advice helps people to be more open to hearing it. You may simply say, “do you mind if I give you some advice?” or “would you be interested in hearing what has worked for some of my patients in the past?”
  3. How do we know what to apply when? It’s helpful to remember that we all go through different stages of being ready for change. This has been described in the Transtheoretical Model for Change (TTM), otherwise known as the Stages of Change. This model describes five distinct stages, and we can tailor our counseling and discussions to meet people where they are-using ask-tell-ask and respecting autonomy when people are pre-contemplative. We can use more eliciting with open-ended questions and Rulers to help people who are more ready to make changes. The 5 stages are:
    • Pre-contemplation: the person has not considered making any change
    • Contemplation: the person has considered change, but that is all
    • Preparation: the person is making a plan of how to change
    • Action: the person is in the early stages of carrying out a plan for change
    • Maintenance: the person has made a change and is making it stick
  4. How has motivational interviewing been used in pediatrics? MI has been shown to be helpful in decreasing weight, as in the BMI2 (Brief Motivational Interviewing to reduce Body Mass Index) by Resnicow et al. which showed decreased BMI percentiles at 2-year follow-up in overweight and obese 2- to 8-year-old patients whose families received an MI intervention versus usual care. MI has been applied successfully in adolescent care to address cigarette smoking, alcohol and marijuana use, chronic disease management, and safety behaviors.