Using Blackboard Discussion Board in a Health Care Communication Course

1. Using Blackboard Discussion Board in a Health Care Communication Course Teresa Cheng Julie Crosson Suzy Sarfaty Thomas Barber

2. Health Care Communications Course • Course begun in 2010 • Series of workshops on advanced physician patient communications skills in the Ambulatory Medicine Clerkship for 3rd and 4th year medical students • Led by internal medicine attending physicians, each with more than 15 years of clinical experience

3. Health Behavior Change • Common part of most medical encounters in ambulatory medicine • Motivational interviewing (MI) has been developed as one way of encouraging behavioral change • MI activates patients’ own motivation for change and adherence to treatment • Medical students usually taught to counsel with advice giving • Often difficult to appreciate the challenges of behavior change, especially in the context of difficult socioeconomic situations

4. Teaching Motivational Interviewing • Pre work posted on Blackboard • Review Motivational Interviewing (MI) concepts • Demo MI with a volunteer student “patient” • Small group sessions with role play practice • Each student will pick a behavior change from their own lives to discuss and work through • Assign health behavior change and posts on Blackboard Discussion Board

7. Role Play • Patient: You will be playing yourself, visiting your primary care provider. • Provider: Overall your patient is pretty healthy and you have a little extra time today to discuss lifestyle changes. You ask about and discuss any change the patient wants to work on. The patient will decide to take on some change or component of the change for the following week and you agree to meet again next week to see how it went.

8. Motivational Interviewing Summary • R: Resist the Righting Reflex • U: Understand You Patient’s Motivations • L: Listen to Your Patient • E: Empower Your Patient • Reflective Listening • Asking open ended questions • Affirming • Summarizing

9. Behavior Change Assignment • Pick a behavior change to try for this week (either the one you worked on in your small group or one of the others on the list) • Please post two reflections of your experiences on your behavior change on Blackboard 8. Ideally, this would be before the weekend. • Read, respond and reflect on two posts from your small group. • Next week, before session, we will briefly discuss your experiences.

11. Post-Eating habits • To be honest, I have not made much progress in terms of the behavior change I chose to adopt after Wednesday’s MI session. After reflecting on some of the things discussed during my motivational interview, I realized that I probably wasn’t completely honest about the extent to which I actually believe my poor eating habits over the past few years have had an impact on my health. I know that , in theory, not eating enough fruits, vegetables and whole grains, etc does have an impact on my underlying health. However, as I think my metabolism is still pretty good, I feel like I have managed to avoid putting on excessive weight which is the most concrete evidence, in my mind, of poor eating and insufficient exercise. Thus I feel like I have managed to stay distanced from the impact of unhealthy eating. I know, however, that as one ages and one’s metabolism slows, that weight is harder to avoid if you’re not eating well. • A second aspect that I have realized over this past week is that if I don’t schedule time to make healthy eating happen, it won’t happen. For instance, during my MI session, we explored the fact that if I can get to the grocery store, I will buy healthy food and during that following week or so, I will eat healthy. The problem arises when I am unable to make time to get to the grocery store and thus end up eating at local cafes or skipping meals (which I know can often be just as detrimental as not eating healthy). • Overall, I feel confident that as long as I begin to make healthy grocery shopping a part of my weekly schedule (no matter what comes up), I will be able to make improvements in the quality of my diet. In terms of resolving the first point, I am at a bit of a loss in terms of changing my mentality about the effect my unhealthy eating is having on my underlying health. Suggestions are welcome!

12. Response – Eating Habits • I totally understand how you feel about not seeing any bad effects of eating unhealthy foods. I think that is probably very similar to how patients with Diabetes of hypertension feel when we tell them that they have a chronic disease that puts them at risk for heart attack and strokes. They often say, "But I feel just fine." It's hard to really make something like good eating habits a priority when the consequences seem so distant and unreal. • I have to admit that I struggle with the same problem and it did not really get any better during third year. That being said, one thing I did was to allow myself to spend the extra money on healthy foods when I had to eat out. It is virtually guaranteed that you will feel zapped of energy during third year and I told myself that eating fried, greasy foods may satisfy my hunger, but they wouldn't give me the energy I needed to be motivated to work and learn for 14 hours a day. Also, eating 3 meals a day from the fried food line in the cafeteria for 8 weeks of surgery will definitely cure you of your craving for unhealthy food! • It's definitely a mind game, and like we talked about in class, maybe it really does only take 21 days to make a habit. But it is definitely a difficult 21 days.

13. Second Post – eating habits • Well, it has almost been a week since the MI session and I still have not made it to the grocery store. I think I did not anticipate some of the barriers I would face when I originally discussed this issue. For example, this past week has been a busy one for me and I don't think I sufficiently explored how to approach making time for healthy grocery shopping during busier weeks. I realize also that the longer I procrastinate, the greater sense of failure I feel and the less motivated I feel to make this goal happen - it is certainly a vicious circle. Furthermore, I am realizing also the importance of a support system to effectively implementing a behavior change. • A behavior change such as this one might not need an emotional support system but perhaps a logistical one - i.e. committing to grocery shopping with a friend on a given day every week or two. I am usually more likely to carry through on something when I feel that I am accountable to someone for it. Going forward, I think I need to be more realistic about my ability to make it to the store during busier weeks and perhaps just aim to eat healthy wherever I find myself eating. • During less busy weeks, I should aim to make a grocery date with someone to ensure that I will follow through with it. I think making a zipcar reservation to get to the store will also hold me accountable and that adds financial incentive to follow through. Thanks also M.. for the reassurance that this is a challenge that a great deal of people face during their third year.

14. Discussion Board Posts • Most common posts are on healthy eating and exercise but also areas of time management, family/ friend relationships were addressed. • Student reflections on MI and challenges of behavior change are common • Student innovations on posts include attachment of pictures, links to other articles and info they have researched • Responses to posts were in the spirit of MI, more collaborative and less advice giving/ lecturing.

15. Post- Saving Money • So my behavior change was to decrease my shopping in an attempt to save money for more important things. I think I have been doing better with this. Instead of going shopping, I went to Barnes and Nobles and purchased a book off of the clearance rack to read. This enabled me to do something I enjoyed for a cheaper price and is even more time consuming so that I don't have extra time to shop. J also suggested that I read outside by the water at my apartment complex as a filler for the relaxation that shopping provided which I have not attempted yet but will try. I also made a budget to reflect how much money I have to spend on things that make me happy. All in all I am happy with my attempts but for me the key is perserverence and longevity. Anyone have any clues on that?

16. Post –Response • Congrats!!! I am so proud that you bought a book off the clearance rack!! What a smart idea! It's a purchase (your shopping fix) + a leisure way to spend time! Go you.Saving money is hard. We all need to do it. No one wants to do it. Budgeting is even harder. You feel constrained and like you have big brother on your back. Trying to save without feeling deprived is a big factor in this. I had a couple thoughts--maybe you needed this time to go cold turkey from shopping, but when and if you do start again...maybe you could set a weekly resolve to spend x less dollars. Or make a game out of it, to see how much you can get/what a steal you can get for x dollars. Another method I've adopted in times of money droughts is "desiring less". I try not to look at fashion mags etc. Ask myself is it really necessary? Ask myself why I think this will enhance my life? If it's a superficial reason (which it usually is...ie I want Billy Bob to think I'm cute) then I don't buy it. If it's something that will make me consistently happy, without getting tired of it (ie 4 months from now, I will still love wearing this shirt), then I'll buy it. I think you've been doing a great job, and you're not alone in this mula struggle, or the bigger behavior change struggle. Good luck!

17. Limitations • Unknown if sessions make a difference long term in attitudes or skills • Discussion posts require additional faculty time to organize and to provide feedback

18. Summary • Blackboard can be used in clinical medicine rotations to enhance educational experience • Drawing on students own experiences on challenges of behavior change may enhance medical student understanding and empathy • Discussion Board can be effective as a vehicle for group learning and sharing reflections

19. Thank you.Questions?