Training chiropractic students in weight management counseling using standardized patients

The World Health Organization states that obesity is 1 of the 5 leading global risks for mortality. It is the third-leading risk in higher-income countries like the United States, behind only tobacco use and hypertension.¹  As of 2014, approximately 37% of US adults were obese.²  In fact, as tobacco use has been decreasing and is now at an all-time low, obesity has risen to its current all-time high, and it has not decreased despite national attention to the issue.²  The US Preventive Services Task Force (USPSTF) currently recommends screening all adults for obesity. The USPSTF also recommends that clinicians offer obese patients intensive, multicomponent behavioral interventions or refer them for such programs.³ 

In keeping with this USPSTF recommendation, like other first-contact health professions, doctors of chiropractic (DCs) contribute to the health of the public not only by treating conditions but also by assisting patients in disease prevention and health promotion.^4,5  In fact, this is incorporated into national accreditation standards for DCs by the Council on Chiropractic Education (CCE).⁴  Appropriate screening and interventions for all major health behavior risks have also been recommended as “best practices” for chiropractic care in general populations⁶  and special populations like children⁷  and older adults.⁸ 

The CCE standards for health promotion and wellness have been incorporated into all accredited chiropractic colleges, and a body of research is beginning to accumulate both on the content of specific wellness-related course work and on evaluations of such courses.^5,9–17  Furthermore, the National Board of Chiropractic Examiners, which designs and administers the licensure examinations that are a prerequisite to practice chiropractic in the United States, has included specific health promotion topics in its Part II examination (available at http://mynbce.org/prepare/part-ii/part-ii-test-plan). These include “exercise and healthy diet for obesity,” “behavior theories and lifestyle change,” and “wellness counseling.” However, despite this and expert recommendations on including weight management counseling in chiropractic practice, there appears to be a gap between training and practice.^6,16  This is particularly important to address because obesity has been found to be a factor in poorer outcomes of low back pain and other musculoskeletal conditions, which DCs very commonly treat.^18,19 

A qualitative study of chiropractic clinicians identified 2 barriers to discussing weight management with patients: weight management was viewed as a sensitive topic that might offend patients, and DCs perceived weight management as a low priority since they did not associate it with patients' musculoskeletal complaints—apparently not being aware of the connection between obesity and such complaints.^18–20  At this time, there is a gap in the evidence on the status of training DCs in weight management counseling, with no articles found describing any systematic approach to such training. This may be because the CCE standards do not specifically require it, although it has been recommended to be added.^4,5  It is likely that such training is not being provided, judging by the fact that, in 1 study of 2 chiropractic teaching clinics, chiropractic students provided advice on weight management to only 7% of overweight or obese patients.¹⁶ 

In the early 1960s, standardized patients (SPs) were created by Dr. Howard Borrows.²¹  An SP is an individual trained to portray the role of patient, family member, or others to allow students to practice history-taking skills, communication skills, physical exam skills, and other exercises.²²  During the encounter with a student, the SP responds to specific questions by the student and in some cases undergoes specific examination procedures. Each encounter is designed to teach or assess skills appropriate to the student's level of learning. An SP is trained to provide constructive written and verbal feedback from the patient perspective to enrich the learning experience of health professions students. SP encounters have been found to be effective in increasing students' clinical skills.²³ 

The purpose of this study was to contribute to the growing body of evidence on this topic by describing and assessing a classroom and experiential activity that trained chiropractic students to counsel patients on weight management using SPs.

This was a descriptive study using mixed methods to assess behavioral theory application and acceptability of a simulated patient encounter on weight management for chiropractic students. The Texas Chiropractic College institutional review board determined that the study is exempt. All records were deidentified before the analysis so that no names or other identifiers were associated with the data.

The counseling intervention was the culmination of several lecture-discussion classroom sessions that were sequenced into the course. (1) The first session introduced students to health behavior theory, with an emphasis on the transtheoretical model of Prochaska and DiClemente, also known as the “stages of change.”²⁴  (2) Next in the sequence was a session on health promotion counseling, emphasizing use of motivational interviewing applied to patients in different stages of change. This was reinforced by an assignment in which students watched public domain videos illustrating doctors and counselors using these techniques with patients with various health behavior issues. (3) Next was a lecture-discussion on the epidemiology of obesity in the United States and a presentation of a broad overview of counseling patients on weight management, using the 5 A's combined with the transtheoretical model and motivational interviewing. The 5 A's are a widely used method for organizing a health promotion counseling intervention:²⁵ 

1. Ask about weight concerns, diet, and physical activity.

2. Assess risk factors and readiness to change.

3. Advise on necessary behavior change.

4. Assist patient to develop an action plan.

5. Arrange follow-up.

This lecture also provided background on reasonable goals for diet, physical activity, and weight loss. (4) Finally, at the class meeting immediately prior to the SP encounter, students were provided with a protocol to follow during the counseling session. This protocol was a streamlined and simplified version of the more general discussion of weight management counseling previously given. It also introduced students to the patient information handouts to be used in the encounter. These were obtained from Move, an open-access Veterans Administration program for helping people manage their weight, diet, physical activity, and stress (https://www.move.va.gov). Students could use any of the handouts they considered most appropriate for the patient but were instructed that they must use at least 1. The handouts were as follows:

1. For dealing with pain that might prevent physical activity: “Coping with Pain”

2. For getting ready to start a weight management program: “Getting Ready to Lose Some Weight?”

3. Getting started on improving their diet: “How Do I Get Started With Changing My Eating Habits?”

4. Getting started with increasing their physical activity: “Walk”

Although students were not given a script to follow, the training session suggested ways to elicit and convey the necessary information from patients in an empathic and positive manner. The instructor reviewed counseling techniques they had already learned, particularly open-ended questioning, reflective listening, positive reframing, summarization, and formation of SMART goals (Specific, Measurable, Action oriented, Realistic and Time lined). They were cautioned that obesity and weight management are sensitive topics with many patients and that most if not all obese patients are aware that their weight is a health risk but that changing one's diet and lifestyle is very difficult. Therefore, they were reminded that it is important to help patients identify small, doable goals to increase their self-efficacy and success. They were instructed to make a connection between the patient's weight and her back and joint pain, providing a patient-centered entrée into the discussion.

The students were given a brief case history of the patient prior to the encounter, and it was also available to them when they met with the patient. The patient was a 45-year-old woman with a body mass index of 32, waist circumference 40 inches, and blood pressure 135/90 and who was nondiabetic. She was not taking any medications. She was an established patient with a chief complaint of chronic mechanical low back pain with no radiation. She had very recently had an exacerbation that was not responding as well as usual to chiropractic care, which had consisted of high-velocity, low-amplitude spinal manipulation and soft tissue work. The doctor had not yet discussed weight management, so this encounter represented the first time that he or she introduced the topic.

The SPs were given additional history to provide if the students asked them but not to volunteer it. They were told that they worked as a greeter at Walmart so were on their feet all day, that they ate a lot of fast food because they did not have time to cook, that they craved sweets and drank a lot of soda for the caffeine, and that they did not do any type of regular exercise. They were aware that they were carrying too much weight but were not aware that it might be affecting their back pain.

Students had 15 minutes for the encounter. In the 2016 class, they had a follow-up session allowing 10 minutes with the patient. Feedback from the students and SPs indicated that they did not find this session to be productive. Furthermore, students spent an average of only 7 minutes with the SP in the follow-up session. In order to conserve time and resources, the follow-up session was eliminated from the program in 2017, so only the initial encounter is analyzed in this study.

The encounters were assessed in 2 ways: (1) The SPs answered a brief questionnaire about the students' performance. It was a modified version of 1 used in a previous study.¹⁷  The questions were dichotomous (yes or no) and covered the key components of the counseling intervention. SPs could also write comments along with their “yes” or “no” responses, although it was not required. They also gave feedback in person to each student immediately after the session. (2) The students answered a questionnaire about the intervention, also based on 1 used in the previous study cited above.¹⁷  This questionnaire allowed students to express their opinion on how helpful the activity was for their learning process and future practice. Students responded to each statement on the questionnaire using a 5-point Likert scale of “strongly agree,” “agree,” “no opinion,” “disagree,” and “strongly disagree.”

Data were extracted from LearningSpace (CAE Healthcare, Montreal), an audiovisual and center management platform designed to capture clinical and learning events for review, debrief, and assessment. No names were associated with the data at any time; students and SPs were identified in the databases only by code numbers. Numerical data were downloaded from the Learning Space site and double key entered (for verification) into an SPSS (version 24) database. Time spent in the encounter was automatically recorded in Learning Space and was also entered into the SPSS database. It was then assessed by trimester and year in order to determine whether we could combine the groups, using an independent samples t test for normally distributed data or the Mann-Whitney U test for data that were not normally distributed. If they did not differ significantly (p > .05), then the groups could be combined. Descriptive statistics were computed for each question. Comments made by students and SPs were copied and pasted verbatim from Learning Space into a Word table for content analysis. The principal investigator (CH) organized them into themes, which were then viewed by the other investigators and revised until agreement on the themes was reached.

A total of 102 students took part in the activity. For the fall term in 2016, there were 63 students (trimester 5 = 33, trimester 7 = 30). In the spring term of 2017, there were 39 students (trimester 5 = 15, trimester 7 = 24). As shown in Table 1, for the 2016 class, the average time spent in the encounter was 11.05 minutes, and for 2017 it was 10.6 minutes, a difference of .45 minutes, which was not statistically significantly different (since the data were normally distributed, p = .200 using a t test). Thus, we combined the 2 classes in the analysis. As shown in Table 2, the difference between trimesters 5 and 7 was .94 minutes, which was statistically significantly different (p = .011). Thus, we did not combine trimesters in the results but display them separately along with the total.

Table 3 summarizes the SPs' assessment of the students' performance in the encounter by trimester and totaled. Students' performance was uniformly high, with over 90% “yes” responses to all questions except “Gave me printed information material” (79% for trimester 5) and “Discussed the printed material with me” (75% for trimester 5). Table 4 displays representative comments from the SPs on the students' performance on several key issues. Most of the comments were positive. The only key issue that had more criticisms than positive comments was the issue of connecting weight management with the patient's chief complaint.

As shown in Table 5, a large majority of the students found the activity useful. In particular, 97% thought the activity would be useful to their future practice, and 97% felt it had increased their confidence in providing weight management counseling. Only a minority (24%) thought that they should have had more time with the patient. Almost all the students (98 of 102) made a comment on the activity. There were 4 themes identified: (1) the activity was fine as it was and needed no improvement (n = 49, 50.0%), (2) more practice or demonstrations prior to the activity would have been helpful (n = 20, 20.2%), (3) more in-depth encounter or complex case would be preferable (n = 18, 18.4%; 16 of the 18 were in trimester 7), and (4) more time was needed (n = 11; 11.2%). Table 6 gives representative examples of comments under each theme.

This study demonstrated several teachable moments for chiropractic students on communication and consultation skills when addressing a comorbidity. Traditionally in chiropractic education, students are not exposed to SPs or clinical encounters that involve communication skills to assess health behavioral change. The advantage of exposing our students early in preclinical education allows them to engage in self-reflection and correct any communication deficiencies prior to clinical education. We suggest that clinical faculty also be educated on theories and applications of behavioral change to assess and provide feedback on health communication skills with chiropractic interns. Clinical faculty also need to model health communication skills to the chiropractic interns with patients with a variety of comorbidities. We also suggest that when assessing communication skills, a formative assessment can reduce student examination anxiety and allow the students to focus on the encounter knowing that a summative grade is not tied to encounter performance. The formative assessment of this study could account for the positive responses from the students on the experience. Learning to apply theories in clinical practice to improve health outcomes is a skill that can be enhanced using SPs for immediate feedback to the learner. Future training of chiropractic students would benefit by the application and assessment of health behavioral communication.

The SP assessments may have been biased since students were assessed by only 1 SP. However, SPs did have extensive training in assessing health professions students, so we believe that overall their assessments were useful and reflected the students' performance adequately. Another limitation was the relatively small sample size and the inclusion of only 1 college, which precludes generalization. However, our results were quite similar to the study done on tobacco cessation counseling at another chiropractic college,¹⁷  which supports our finding that this type of activity is a positive learning experience valued by the students.

The authors thank Sheryl Walters for her assistance with this study.

This work was funded internally. The authors have no conflicts of interest to declare relevant to this work.