Medical students as health coaches

The purpose of this project was to teach students how to work effectively with patients in the area of health-behavior change. As part of the patient-doctor course, first-year medical students worked with diabetic patients who were selected by their primary physicians. In preparation for their patient interactions, students were taught basic communication concepts and the role of the relationship in improving patient outcomes, and continuity issues were addressed as students learned to collaboratively develop behavioral-change plans with their patients and then followed their patients' progress over the course of the year.

An educational research trial was conducted to compare the traditional community placement track (shadowing) with the health-coaches track. Students were randomly assigned to the two educational tracks. Health coaches were assigned in pairs to a family medicine patient with diabetes. Under supervision by the patient's medical provider, student pairs worked with the patient in an area of health-behavior change (i.e., weight loss, smoking cessation, exercise, or adherence to medication regimen). Students were required to have at least six patient contacts over the course of a year, consisting of at least three face-to-face visits and including one home visit. Didactic sessions with health coaches taught by either a behavioral consultant or health educator covered the basics of diabetes and behavior-change areas appropriate to respective patients. Students were also given reading assignments from communication and health-behavior change literature and handouts for patients. Behavior-change specialists were available as needed for consultation. In support of the health coaching process, students participated in eight small-group discussion sessions (eight students each) led by a behavioral change specialist. Small-group sessions lasted approximately 90 minutes each and contained didactic and experiential elements. Topics were: "Getting Started" (interviewing, the patient's story), "Fundamentals of a Home Visit," "Changing Behaviors" (stages of change, relapse prevention), "Home Visit Feedback" (report and reflections), "Challenging Patients to Change" (difficulties, challenging irrational ideas), "Giving Direct Guidance," "Non-verbal Skills," "Ending and Celebrating" (terminating the helping relationship). Evaluation methods included a pre- and post-physician belief scale completed by students, pre- and post-provider's evaluation of patient, and a patient-completed health behavior questionnaire. As available, patients' HbA1C levels were compared pre- and post-intervention.

As expected, initially some health coach students complained about their perceived increased workloads compared with the workloads of students in the shadowing track. Some students also expressed reservations about their abilities to be effective with their patients, but these complaints diminished as students made contact with patients. For many, this opportunity to establish continuity relationships with patients helped students begin to understand difficulties inherent in effecting health-behavior change. Some students expressed appreciation for the opportunity to discuss their increased self-awareness about communication as well as relationship difficulties and strengths during the small-group sessions. Data analysis is under way. Lessons learned from this project influenced a major first-year curriculum revision the following year, resulting in increased emphasis on basic communication skills and the use of small groups to reach a variety of curricular objectives.