1. What grabbed me about ICMI 3?
Reflections from a friendly critical medical practitioner
investigator
Chris Butler
Head of Institute of Primary Care and Public Health
Cardiff University
Director, Wales School of Primary Care Research

3. ICMI3 Inputs
• What is the theory?
• What is it in practice?
• How do we measure it?
• How do we best train clinicians to deliver it?
• How do clients respond?
• Can it work?
• Does it work?
• What effect does training practitioners in a certain way
have on participants in a given context
• Is it worth it?
• How do we influence policy makers and practitioners?

4. A success?

5. Watkins et al
• Single centre
• “A research nurse randomised patients… The
same nurse then assigned intervention group
patients to 1 of 4 therapists using an opaque
sealed envelope..”
• Medication and medication adherence not
reported
• Cause of death not reported

6. A spectacular disaster?

7. Robling et al
• Objective To evaluate the effectiveness on
glycaemic control of a training programmein
consultation skills for paediatric diabetes
teams.
• Gave a clear, useful answer for payers of
health care
• Not to be confused with a failure of MI

8. Fidelity measurement?
• “My over-riding reaction is one of mild shock
at the state of research on MI in health care.
Researchers have lurched into trials of a really
complex interpersonal intervention and only
7/50 have bothered to assess fidelity? ”

9. Measurement, respondent burden and
risk of bias
Risk of
inclusion and
attrition bias
and
applicability
limitations
Clinician and participant respondent burden

10. ICMI3 Processes
• Strong values base
• Fantastic venue and organisation
• In- and outward looking!
• Bold, eclectic and welcoming!
• Loved the nexus between erudite, wise
psychotherapists with the researchers,
trainers and clinicians at the sharp end of
emergency care and in resource poor setting

11. ICMI3 Outputs
• Behaviour change is important!
• Showing MI can and does work, and that is
worthwhile is difficult. But we are making
progress!

14. Healthy behaviours:
The Caerphilly Collaborative Cohort Study
Non-smoking: non-smoking including ex-smokers
Body weight: BMI (weight/height²) of under 25
Diet: less than 30% of calories from fats and three or more portions of fruit and/or
vegetables a day (too few men consumed five portions).
Exercise: walk two or more miles to work each day, or cycled ten or more miles to
work each day, or regular ‘vigorous’ exercise
Alcohol intake: drinking within the guidelines, abstainers not included.
- Every item was carefully validated -
The Caerphilly Health and Social needs Study
Non-smoking, overweightetc…. .closely similar to the above
PLUS: regular aspirin taking

15. Outcome events:
During the 30 year follow-up:
Diabetes:recorded in the GP notes plus a raised fasting blood glucose
Vascular disease:a myocardial infarct or an ischemic stroke
Cancer:a registered canceror a death certified as cancer
All-cause deaths:deaths with certified cause
Dementia:clinical diagnosis by a psychogeriatrician
Every event was carefully validated against accepted clinical criteria

16. Healthy REDUCTIONS over the following 30 years
behaviours
Diabetes Vascular Cancer All-cause
in 1980
disease deaths
Non-smoking No significant 21% 29% 33%
relationship (11% to 31%) (16% to 37%) (26% to 40%)
All relationships adjusted for age and social class

17. REDUCTIONS IN:
Healthy
Lifestyles Diabetes Vascular disease Cancer All-cause deaths
None (172 men) 0 0 0 0
Any two (813 men) 16% 30% 13% 15%
Any three (436) 37% 35% 7% 30%
Four/five (112) 48% 38% 18% 35%
Significance 0.0005 0.0005 0.41. 0.0005
If all the men had been advised to take up one additional healthy behaviour…
and if only half complied…..
→ reductions of at least 12% in diabetes; 6% in vascular disease; 5% in deaths
NOTE: The 48%, 38% etc. reductions in the table are relative reductions.
The 12%, 6% etc. in the note below the table are absolute reductions.

18. Healthy behaviours and cognitive impairment:
Reductionsadjusted age and social class
Healthy (and baseline cognitive function)
lifestyle Any cognitive Dementia
Impairment (79 men)
(219 men)
No healthy behaviour 0 (0) 0 (0)
Any two 48% (48%) 47% (44%)
Any three 59% (58%) 69% (72%)
Four or five 66% (59%) 76% (68%)
Significance 0.001 (0.002) 0.003 (0.01)
Adjusted for age and social class (and NART at baseline)

19. Uptake of healthy behaviours:
Non-smoking
Low body weight 0.8% take up all 5 behaviours
Diet: 8% take up four of more
Exercise: Source: Welsh Health Survey 2008
Alcohol intake

20. Within the UK, over 95% of
NHS clinical contacts are made in general
practice and around 80% of health problems
are managed at this level. Over 300 million
general practice consultations take place in
the UK each year; these encompass health
promotion, prevention and screening as well
as acute and chronic care.

21. Debate: MI Takes more time and 2
minutes of playing the piano may not
be satisfactory and “could creep me
out”

22. Depression in primary care
• Family docs are the depression experts
• 20% of adults in some practices on SSRIs
• SSRIs effectiveness for mild depression?
• SSRIs: a sticking plaster or a lasting solution?
• ?Opportunity for MI? Recovery form depression
is all about behaviour change
• Strategies from BCC
– “Typical day”
– “Brainstorming solutions”

23. When does MI stop being MI, and
turn into good communication? Does
MI take more time?
• “Well I have examined you and my findings
suggest you don’t have a bacterial infection. Yu
have no pus on your tonsils, your nose is running,
which is more in keeping with a virus, and your
glands are not enlarged. Viruses don’t respond to
antibiotics. If I have thought this was a bacterial
infection, I would have prescribed antibiotics. But
we try to limit antibiotics these days to only those
that really will benefit, largely because of
antibiotic resistance. We want to keep the
antibiotics back so they will work when you really
need them…”

24. Can you recognise MI in this?
• “Sounds like you are taking quite a hit with this
illness“
• “So. Your thoughts about antibiotic treatment for
this illness”
• “You sound as though you are kind of hoping for
some antibiotics?”
• “Shall we together consider some of the
advantages and disadvantages of antibiotic
treatment for this condition?”
• ‘What do you think will help you most in getting
through this?”

25. The IMPAC3T study

26. Use of NPTs and communication skills
training for LRTI
 Four groups
– Usual care 68%
– CRP 39%
– Communication skills 33%
– Both 23%
Communication skills training:
 Seminar 11 key tasks e.g. exploring patients’ fears and
expectations, asking patients’ opinion on antibiotics, and outlining
the natural duration of cough in lower respiratory tract infection
 Peer review of transcripts with simulated patients

27. Exciting areas for MI
• “Personalised medicine”
• Cost effectiveness
• Uptake into policy and guidelines
• Outcome focus: clinician satisfaction, burnout,
frequency of engaging clients about behaviour
change
• Patients: satisfaction with processes of care,
“enablement”
• Individual control vs. social determinants

30. A student in my clinic a few weeks
back said ...
• “We saw this woman two weeks ago, and we
told her…”
• “….these people…”

31. Miller…
• “You have what you need. Together we will
find it.”

32. Who>what
Given that the clinician is a precious and influential
instrument (Balint= “The drug doctor” )
• The first medical ethic: do not harm!
• The second medical ethic: beneficence!
• MI will help me not harm you
• MI will help me help you
• MI will help met to be able to continue to help
you
• (State employed doctors in the Western Cape in South Africa:
76%=burnout, 30% mild to moderate depression, focus on depersonalising
patients).

33. My definition of MI: Charles Butler and Maya Rollnick