To our knowledge, this is the first published systematic review that focuses on curricula designed to enhance trainee performance in addressing behavioral change to improve population health. This review identified multiple small, single-institution studies with varying degrees of effect on learner and patient outcomes. Most studies reported learner satisfaction or knowledge rather than performance outcomes. Despite these shortcomings in the literature, our review points to successful curricular strategies grounded in behavior-change frameworks, learning theory, and the mobilization of clinical systems to augment behavior-change interventions.
Among interventions that used a theoretical framework, the Transtheoretical Model of Change was most commonly employed. When theory informs curriculum design, the lessons learned may be more generalizable.44
The Transtheoretical Model promotes motivational interviewing, which encourages providers to maintain a patient-centered focus, show empathy, and explore ambivalence to counteract patients’ resistance to change.45
Although motivational interviewing is a well established approach, it was developed for mental health professionals to use in treating addiction in 50-minute sessions.45
We identified multiple studies that employed a briefer version of motivational interviewing in resident continuity clinic settings with success. Although motivational interviewing can be applied to a range of behavioral and chronic illnesses,46
whether learners transfer these skills from curricula to clinical counseling interventions is unknown.
We found that most studies assessed the effects of behavior-change counseling curricula using easily measured but less robust outcomes, such as changes in attitudes, self-reported behaviors, or knowledge. For example, although one study showed a correlation between self-reported behaviors and performance with standardized patients,47
observing skills with patients would be more effective in assessing trainees’ competence.48
Refresher training would enhance ongoing application of skills and avoid decay in performance.49
We found that the highest quality studies often focused on a single behavior, particularly smoking or alcohol. Although this focus on single behaviors may be appropriate for students early on, medical trainees will need to counsel many patients with multiple simultaneous unhealthy behaviors. Many smokers exhibit additional high-risk behaviors.50
Similarly, people who abuse alcohol or drugs also commonly smoke.51
Smoking cessation among polysubstance users is associated with cessation of other substance use, a finding that reinforces the need for trainees to learn to counsel for multiple behavioral risk factors.52
Although we focused our study on medical trainees to identify components of effective curricula, our findings parallel other literature on continuing medical education interventions. The superior effect of interactive formats over didactic presentations for learning has been shown in continuing medical education,53
and in education in general.54
However, many high-quality studies show that combining interactive and didactic formats may be better than either alone at changing physicians’ practice performance.55,56
Three educational intervention components result in lasting changes in physician behavior:53
(1) demonstrating the gap between their current behavior and optimal behavior, (2) addressing gaps in knowledge and performance in the practice environment, and (3) reinforcing change over time until the new behavior is well established. Creating a learning environment to foster these components is complex, but as important as basic science content in training physicians.
Successful curricula in our study used principles of behavioral theory, which emphasizes the need for learners to practice skills with instructors providing guidance and feedback. Standardized patients, a commonly employed instructional tool, offer opportunities for targeted skills practice compared to the random opportunities that may arise in clinical encounters. In addition, learners can receive immediate coaching from standardized patients to correct errors and improve performance. Repeated cycles of practice and feedback typify deliberate practice and result in skill mastery.57
Cognitive theory emphasizes the importance of learners’ understanding and processing of information. Didactic instruction was common in many studies, including high-quality, high-level outcome studies, as part of an intervention that also included active learning strategies. Knowledge of the risks of unhealthy behaviors, the benefits of behavior change, and strategies to apply this information during patient counseling techniques equip learners to conduct counseling. In contrast, an intervention introducing report cards for adherence to practice guidelines among internal medicine residents in continuity clinic did not include didactics and failed to change residents’ behavior.58
Future curricular interventions to promote behavior-change counseling skills among medical trainees should use both behavioral and cognitive theories grounded in best educational practices. Generalizability of findings would be improved with large, multi-institutional studies that confirm the effectiveness of curricular interventions shown to be effective in smaller studies. Studies grounded in a conceptual framework with rationale for methods used to change physicians’ behaviors are needed.44,59
We found no studies on intra-professional education in providing counseling, even though health care is increasingly moving toward team-based models of care.60,61
This study has limitations. We confined our search to the peer-reviewed literature and excluded studies that did not assess effectiveness of a curricular intervention. We did not search meeting proceedings; publication bias could have limited identification of studies presented only in abstract form. However, studies with higher-level outcomes would have been more likely to proceed from abstract presentation to publication. In addition, the literature search was confined to English-language studies. Finally, we did not include studies that addressed non-physician behavioral counseling. It is possible that other strategies for achieving behavior change, such as counseling by non-physician professionals, may be more effective than physician counseling. The effectiveness of counseling for behavior change has been endorsed based on evidence for some behaviors (e.g., tobacco cessation), whereas for others (e.g., injury prevention with motor vehicle restraints) efficacy of any curricular intervention remains unproven.62