Motivational Interviewing in Palliative Care

The investigator will use a 2-arm randomized wait-list control design with up to 30 palliative care clinicians (15 in each arm). Clinicians in the intervention arm will be taught Motivational Interviewing (MI) via a coaching model in which a didactic session is followed by feedback through review of clinicians' audio-recorded encounters. Clinicians in both arms will audio record 4 encounters with patients with advanced illness and their family caregivers. The patients/caregivers will be provided with a 1-page information sheet about the study and will sign a HIPAA B form which will allow the study team to record a palliative care encounter and allow the research assistant to administer a short survey immediately within 1-2 days following a palliative care encounter to assess the effect of integrating MI techniques on perceived empathy and satisfaction with the encounter. The investigators will also assess clinician satisfaction with the encounter. Clinician burnout will be assessed at the time of study enrollment and following completion of all study encounter recordings. Clinicians randomized to the wait-list control arm will receive MI coaching only after they have recorded 4 study encounters. The wait-list control study design was selected to give all participating clinicians access to motivational interviewing coaching.

Intervention: The investigator is comparing standard palliative care communication skills enhanced by Motivational Interviewing coaching to standard palliative care. Given that palliative care is currently the gold standard for clinician communication in the setting of serious and advanced illness, if Motivational Interviewing coaching improves encounters for palliative care clinicians, it is even more likely to do so for other clinicians who care for people with advanced illness. The investigator has adopted a "coaching" model that includes both didactic and individual feedback. The coaching approach maps to Social Cognitive Theory in that its purpose is to build skills and improve self-efficacy or confidence to use the techniques. Participating palliative care clinicians randomized to the intervention arm will receive Motivational Interviewing coaching immediately. Those randomized to the wait-list control arm will receive Motivational Interviewing coaching after the study encounters and data collection have been completed. The intervention consists of several components: 1) 1-hour face-to-face (in person or via Skype) didactic session in which a Motivational Interviewing coach explains tenets of Motivational Interviewing and specifics, particularly addressing ambivalence and reluctance. This session will be recorded for future broader dissemination; 2) 1-hour individual session via Skype, including individualized goal-setting; 3) Clinician audio records 2 encounters, which are transcribed. The Motivational Interviewing coach then codes the encounters and meets with the clinician via Skype for 30 minutes to give feedback and coaching; 4) Clinician audio records 2 additional encounters and again receives individualized feedback and coaching. At the end of the interactive Motivational Interviewing didactic, each clinician who is randomized to the intervention arm will set an individual goal for which Motivational Interviewing technique he/she wants to try.

Each clinician will then audio record 2 palliative care encounters; audio recordings will be transcribed. The Motivational Interviewing coach will listen to the recordings and code the transcriptions paying attention to the clinician's stated goal. The coach will conduct 1:1 Skype calls to review audio-recorded encounters and provide individualized feedback and coaching. During the feedback sessions, the coach will provide positive feedback on the Motivational Interviewing techniques used, paying most attention to the technique the clinician set as his/her individual target technique. The coach will also offer feedback on parts of the encounter when Motivational Interviewing could have been applied. At the end of the session, the coach will ask the clinician to set another individual goal for which Motivational Interviewing technique they want to try and repeat the process of having them audio record 2 additional palliative care encounters and providing individualized feedback and coaching. After each clinician has finished the intervention, the investigators will obtain extensive process data from clinicians to learn what went well about the coaching and what can be improved to plan for future refinement and study. To plan for future scalability, the investigators will simultaneously be developing a coaching manual that will be used to train others to serve as Motivational Interviewing coaches.

Wait List Control: Clinicians who are randomized to the wait-list control arm will audio record 4 palliative care encounters, which will be transcribed, and have an individual coaching and feedback session in which the Motivational Interviewing coach will review their audio-recorded encounters following completion of study data collection.