Patient-centered communication is a fundamental component of effective clinical practice and plays a critical role in promoting health behavior change and improving clinical outcomes [1-5]. Physicians frequently engage in patient education during routine consultations, particularly when managing chronic diseases such as diabetes, hypertension, and cardiovascular conditions that require sustained lifestyle modification and self-management [1]. Evidence suggests that structured patient education interventions can improve clinical outcomes across a wide range of conditions, including cardiovascular disease, diabetes, respiratory disorders, and mental health conditions [1,2]. Effective patient education is typically supported by communication approaches that emphasize patient engagement, individualized counseling, and shared decision-making [6,7].

Among the various communication strategies used to support behavioral change, motivational interviewing (MI) has emerged as one of the most widely studied and evidence-based approaches [8]. MI is a collaborative, patient-centered counseling method developed by Miller and Rollnick [8] that aims to strengthen individuals’ motivation and commitment to change by exploring and resolving ambivalence [9]. The approach emphasizes empathy, collaboration, and respect for patient autonomy while guiding patients toward identifying their own motivations for change. Over the past 3 decades, MI has been applied across a wide range of health care settings and clinical conditions [9,10].

A growing body of evidence demonstrates that MI can effectively support improvements in health behaviors and clinical outcomes [9-15]. Systematic reviews and meta-analyses have shown that MI interventions are associated with increased physical activity, smoking cessation, weight reduction, improved glycemic control, and reductions in alcohol consumption and other health-risk behaviors [11-14]. MI has also been successfully implemented in primary care settings, where physicians frequently counsel patients on lifestyle modification and chronic disease management [15-17]. However, despite its demonstrated effectiveness, studies indicate that motivational and patient-centered communication techniques remain underused in routine clinical practice, partly due to insufficient training among health care professionals [16,17].

Recognizing the importance of behavior-change communication, medical education programs have increasingly explored ways to incorporate MI training into undergraduate curricula [1]. Previous studies have shown that MI can be successfully taught to medical students and other health professional trainees using a variety of instructional strategies, including workshops, role-play exercises, coaching, and supervised practice [18,19]. These educational interventions have been associated with improvements in students’ communication skills, confidence, and readiness to support patient behavioral change [20-22]. In addition, training in MI may help students develop transferable clinical communication skills such as reflective listening, open-ended questioning, and affirmation, which are valuable across many areas of clinical practice [6,23].

Despite these promising findings, several challenges remain in integrating MI training into medical curricula. Existing educational programs vary widely in duration, teaching methods, and assessment approaches, and there is no widely accepted standard model for MI education in undergraduate medical training [1,18,19,24-26]. In many programs, MI instruction is limited to short workshops without sufficient opportunities for reinforcement, practice, or longitudinal integration. As a result, the sustained application of MI skills in clinical practice remains inconsistent [10,24,25].

Multifaceted or combined educational methods comprising face-to-face instruction with web-based learning modules have been proposed as a promising strategy for improving MI training [14,27]. Such approaches allow learners to acquire foundational knowledge through flexible online learning while using in-person sessions for interactive practice and feedback. Emerging evidence suggests that combined educational methods can enhance learner engagement, knowledge retention, and skill development compared with traditional teaching methods alone [18,19,28]. However, relatively few studies have examined the effectiveness of combined MI training models among undergraduate medical students, particularly in Asian and low- and middle-income educational contexts [18,19,26].

Although MI training has been studied in medical education, relatively little research has examined how combined educational approaches comprising in-person workshops with web-based modules can be implemented within undergraduate medical curricula in resource-constrained educational settings. This study therefore evaluated the implementation of a combined learning approach for introducing MI to final-year medical students in Thailand and explored students’ learning experiences and reported application of MI during clinical training.

Our medical school, located in northeastern Thailand, enrolls approximately 310 students annually. The 6-year undergraduate medical curriculum consists of a premedical phase, a preclinical phase, and a clinical phase, totaling 259 academic credits [29,30]. The first year focuses on premedical education (38.5 credits), while the second and third years emphasize preclinical sciences (76.5 credits). Clinical education occurs during years 4 to 6 and comprises 96 credits during years 4 and 5, followed by 48 credits during the final-year clinical rotations [30].

The learning outcomes of the curriculum are categorized into 3 domains: fundamental knowledge, professional competency, and professionalism. Communication skills are included as a core competency under the professionalism domain. Communication training is integrated throughout both preclinical and clinical courses; however, structured training specifically focused on behavior-change communication techniques has not been mandatory in the curriculum.

Before the 2024 academic year, some students may have been exposed to MI informally during clinical rotations in psychiatry. Beginning in the 2024 academic year, MI training was formally introduced as a compulsory component of the final-year curriculum within the Ambulatory Care in Primary Care Setting course, where this study was conducted.

Final-year medical students participating in this course have already completed core clinical rotations and are actively involved in outpatient care under faculty supervision. During these rotations, students conduct patient interviews, participate in clinical decision-making, and provide counseling for chronic disease management. This clinical environment provides opportunities for students to apply behavior-change communication techniques such as MI during real patient encounters.

The educational intervention was designed to introduce foundational principles of MI and to provide opportunities for students to apply MI concepts in clinical contexts. The intervention combined a face-to-face interactive workshop with a structured web-based learning module and brief MI guides, allowing students to acquire theoretical knowledge and practice communication strategies relevant to behavior-change counseling in primary care.

A 2-hour interactive workshop on MI was provided. The students attended the workshop in small rotation groups (25‐28 students per group; 6 rotations throughout the academic year). The workshop facilitators (IT and PN) are faculty members in family medicine and medical education with experience in behavioral counseling in primary care. They have completed formal MI training programs and are continuing professional development activities related to MI.

The workshop content included an overview of health-behavior change theory, the principles and spirit of MI, and the 4 core MI processes (engaging, focusing, evoking, and planning). Students were introduced to the use of key MI communication strategies, including open-ended questions, affirmations, reflective listening, and summaries.

Interactive learning activities were incorporated to support skill development. These included case-based discussions, role-play exercises, and guided demonstrations of brief MI techniques. Students practiced applying MI strategies to simulated clinical scenarios commonly encountered in primary care, particularly in counseling patients with chronic conditions such as diabetes and hypertension.

In addition to the workshop, students were provided access to a structured web-based MI learning module designed to reinforce key concepts and support self-directed learning. The module contained approximately 3 hours of learning material and included short lessons covering MI principles, stages of change, and practical applications in patient consultations.

The online course incorporated interactive elements such as quizzes, self-reflection exercises, and case-based learning activities to encourage active engagement. The web-based curriculum was developed following established principles for effective online education [32]. The web-based module was provided as supplementary learning material to reinforce the workshop content. Students could voluntarily access and complete the course at their own pace through the medical school’s learning management system.

Completion of the web-based module was defined according to the platform’s predefined criteria, which required students to complete all lessons and associated activities in the online course.

A brief MI guide was provided as a downloadable resource within the web-based course and distributed during the workshop. The guide summarized key MI communication principles and included practical examples of open-ended questions, reflective statements, and strategies for exploring patients’ motivation for behavior change. It also provided practical prompts to help students incorporate MI-informed communication into routine outpatient consultations. The guide served as a quick reference tool during clinical training rather than a comprehensive MI training manual. The resource was adapted from the “A Taste of MI” exercise included in the MI foundational training developed by Miller, Rollnick, and Moyers [33] and has been described in our previous publication [27].

The learning objectives of the intervention were to (1) introduce students to the principles and spirit of MI; (2) familiarize students with the four MI processes—engaging, focusing, evoking, and planning—and with fundamental MI communication skills, including open-ended questions, affirmations, reflective listening, and summaries; and (3) support the initial application of MI-informed communication strategies, including brief MI techniques, during clinical encounters.

Given the limited duration of the training, the program was designed to provide introductory exposure to MI concepts and basic communication strategies rather than to develop full MI proficiency.

The interactive workshop was a required component of the Ambulatory Care course, and therefore, all enrolled students attended the workshop session. In contrast, the web-based MI learning module was provided as a supplementary self-directed learning resource, allowing students to access and complete the lessons voluntarily at their own pace through the learning management system.

A before-and-after design was applied to assess students’ knowledge before and after participation in the MI training. Students completed the pretest questionnaire before participating in the MI workshop. The baseline questionnaire included demographic characteristics (age and sex) as well as information about students’ prior exposure to MI and other communication strategies used in patient counseling. Additional items assessed whether students had previously received training related to MI and their experiences with behavior-change communication during clinical rotations. These baseline variables were collected to characterize this study’s population and to provide contextual information regarding students’ prior familiarity with MI and communication skills before participating in the educational intervention. The posttest questionnaire was administered immediately after completion of the workshop to assess immediate changes in knowledge and confidence following the instructional session. The web-based module was provided as supplementary learning material that students could access voluntarily after the workshop to reinforce MI concepts during their clinical training. The instruments were developed by the research team (IT and RM) based on the relevant literature [14] and reviewed by experts in medical education and general practice to ensure content validity. Three independent reviewers assessed each item for clarity, relevance, and necessity. The questionnaires included multiple-choice, yes or no, open-ended, and Likert-scale questions evaluating knowledge, attitudes, and self-reported application toward MI.

Knowledge scores were calculated by summing the number of correct responses to the multiple-choice questions, generating a total knowledge score for each participant in both the pre- and posttests.

For attitudinal measures, the postintervention questionnaire included items assessing students’ self-reported confidence in applying MI during patient consultations. Confidence was assessed across the 4 MI processes—engaging, focusing, evoking, and planning. Participants rated their confidence using a 5-point Likert scale ranging from 1 (not at all confident) to 5 (very confident). Students also reported the extent to which they applied MI during clinical encounters using a 5-point Likert scale ranging from 1 (used the least) to 5 (used the most). The questionnaire items were developed based on the MI framework described by Miller and Rollnick and were reviewed by experts in medical education and general practice to ensure content validity. After piloting with 28 students, minor revisions were made. Internal consistency reliability was assessed for the Likert-scale items measuring confidence related to MI, yielding a Cronbach α coefficient of 0.93. The survey instrument used in this study is available from the corresponding author upon reasonable request.

Semistructured interviews were conducted with students who had completed both the pre- and posttests. The semistructured interview guide was developed by the research team based on this study’s objectives, findings from the quantitative phase, and relevant literature on MI education and communication skills training in medical education. The interview questions explored several key domains, including students’ experiences applying MI in clinical encounters, which MI processes or techniques they used most frequently, perceived changes in their communication style following the training, challenges encountered when attempting to apply MI during patient consultations, perceived benefits of MI for patient communication, and students’ perspectives on the most appropriate timing and methods for teaching MI in the medical curriculum. All interview participants were drawn from the same cohort of final-year medical students who participated in the quantitative component of this study.

Students were informed about the qualitative component after completing the MI training and posttest questionnaire and were invited to participate in voluntary interviews. Students who expressed interest were contacted by the research team and scheduled for an interview.

A total of 12 students were selected using purposive sampling to ensure representation from different periods of course participation during the academic year. Specifically, students were selected from early, middle, and late course rotations in order to capture a range of experiences with learning and applying MI during clinical training.

The sample size was guided by the principle of thematic sufficiency commonly used in qualitative research exploring participant experiences. During analysis, the research team observed that key themes began to recur across interviews, suggesting that sufficient depth of information had been obtained for the purposes of this exploratory qualitative component.

Interviews were conducted in May 2025 via Google Meet and lasted approximately 15‐20 minutes. The relatively brief duration reflected scheduling constraints during students’ clinical rotations; however, the semistructured format enabled focused discussion of key topics related to students’ experiences with learning and applying MI. All interviews were audio-recorded with participants’ consent, transcribed verbatim, and returned to participants for verification to ensure transcription accuracy.

The semistructured interview guide used in this study is available from the corresponding author upon reasonable request.

Table 1 shows demographic data of the participating final-year medical students. None of the participants had prior MI training or course completion within the past 3 years. Table 2 shows student participation in components of the MI training program. All 130 final-year medical students attended the required 2-hour MI workshop as part of the Ambulatory Care course. The web-based MI learning module was offered as a voluntary supplementary learning resource. Learning-management system analytics showed that 100 (76.9%) students accessed or enrolled in the online module. Among those who accessed the module, 51 (51%) students completed all required lessons and activities according to the platform’s completion criteria. Across students who accessed the module, the mean number of lessons completed was 9 of 19 lessons, indicating varying levels of engagement with the online content. Participants’ enrollment time in the course ranged from 0 to 481 minutes, with a mean of 71.98 (SD 92.49). The number of completed lessons by participants ranged from 0 to 19 lessons, with a mean of 9.19 (SD 8.87). These findings indicate variable engagement with the web-based module, reflecting the self-directed nature of the online component.

Most final-year medical students expressed strong needs and expectations regarding MI. Before completing the MI workshops, the majority wanted to strengthen their skills in choosing words carefully, applying stages of change, motivating patients, and enhancing communication for health-behavioral change (Table 3). Their learning expectations were consistently high, with mean scores near 4 on a 5-point scale, particularly for MI skills, knowledge, and helping patients control their diseases through MI (Table 4). Regarding specific behavioral areas, students prioritized skills related to oral medication adherence, diet and nutrition, doctor appointment adherence, and injection drug administration (Table 5). Overall, the data highlight the strong motivation among students to develop practical MI communication and counseling competencies that directly support patient self-management and lifestyle modification.

After attending the MI workshop, 126 of 130 (96.9%) final-year medical students reported attempting to apply elements of MI during patient encounters within the preceding 2 weeks. Most participants (n=120, 92.3%) indicated that the combination of a 2-hour workshop and web-based learning was sufficient for applying MI in clinical practice. Students perceived MI as a useful communication approach for supporting health-behavioral change (mean 4.47 of 5, SD 0.67).

After completing the MI workshop, the final-year medical students who applied MI techniques in real clinical settings predominantly used MI to support patients in improving their diet, physical activity, and medication adherence (Table 6), particularly among those with diabetes, hypertension, and dyslipidemia (Table 7). Students reported applying elements of MI during patient encounters and demonstrated moderate to high confidence in applying MI across all 4 MI processes (Table 8). The highest confidence score was observed for engaging (mean 3.73, SD 0.78), followed by focusing (mean 3.65, SD 0.74), planning (mean 3.52, SD 0.87), and evoking (mean 3.38, SD 0.90). These findings suggest that students felt relatively comfortable initiating and structuring MI conversations but reported slightly lower confidence in more advanced MI processes such as evoking change talk.

A total of 130 final-year medical students participated in the MI workshop. Of these, 126 (96.9%) students completed the pretest questionnaire, and 120 (87.5%) students completed the posttest questionnaire. Students who did not complete the posttest were primarily absent during the postintervention data collection session or did not submit the questionnaire. Paired analyses were conducted using data from the 120 students who completed both the pre- and posttest. The proportion of missing data for the paired analysis was therefore small and unlikely to substantially affect the results. A paired-sample t test was conducted to examine differences in knowledge scores before and after participation in the MI training. There was a statistically significant difference in the knowledge test scores from time 1 (mean 8.87, SD 2.69) to time 2 (mean 15.04, SD 2.99), t₁₁₉=−18.45, P<.001 (2-tailed). The mean increase in knowledge test score was −6.18 (SD 3.66), 95% CI −6.84 to −5.51. The eta-squared statistic indicated a large effect size (eta-squared=0.74).

A total of 12 final-year medical students voluntarily participated in the semistructured interviews, representing 3 groups categorized by their enrollment period in the MI course: students who completed the course at the beginning of the 2024 academic year (May to August 2024), coded as group A; those who completed it in the middle of the academic year (September to December 2024), coded as group B; and those who completed it at the end of the academic year (January to April 2025), coded as group C. To maintain participant confidentiality while distinguishing individual responses, each quotation is identified using a code consisting of a letter and a number. The letter (A, B, or C) represents the interview group based on the period of course participation, and the number represents the individual participant within that group.

The qualitative analysis identified several themes related to students’ experiences learning and applying MI during clinical training, including experiences using MI in clinical encounters, changes in communication style, barriers to implementation, perceived advantages and benefits of MI, development of confidence, and students’ perspectives on MI education.

According to the semistructured interviews (Table 9), the final-year medical students reported applying MI primarily in brief forms during patient encounters, particularly with patients managing chronic conditions such as diabetes, hypertension, dyslipidemia, and gout. They identified engaging as the most frequently used and comfortable skill, whereas evoking and planning were used less often due to time limitations and lower confidence. After completing the MI course, the students observed noticeable improvements in their communication, becoming more empathetic, reflective, and patient-centered. They perceived MI as a valuable approach that enhanced patient motivation, strengthened doctor-patient relationships, and promoted ethical and collaborative care. Nonetheless, challenges such as heavy workloads, time constraints, and communication barriers with some patients were reported. Most students expressed increased confidence in using MI and preferred learning it during their fifth year, when clinical exposure allowed sufficient opportunity for practice before the externship year. They also emphasized that effective MI instruction should integrate lectures with practical components, such as role-play, video demonstrations, and feedback sessions, ideally delivered through blended or flipped classroom models, to reinforce both theoretical and applied communication skills.

This mixed methods evaluation examined a combined MI training program for final-year medical students. Quantitative findings showed higher MI knowledge scores and greater self-reported confidence after participation in the training program. In addition, most students reported applying elements of MI during clinical encounters, primarily in brief interactions related to counseling patients with chronic diseases.

Qualitative findings provided further insight into students’ learning experiences. Participants described increased awareness of patient-centered communication strategies, including reflective listening, open-ended questioning, and affirmations. However, students also reported challenges in applying more advanced MI processes, such as evoking and planning, due to time constraints, clinical workload, and limited opportunities for repeated practice. Together, these findings suggest that the combined learning approach was associated with improvements in knowledge and perceived communication confidence, while also highlighting practical challenges in implementing MI during routine clinical encounters.

It is important to note that these findings reflect self-reported learning outcomes and perceptions of MI use, rather than objectively measured MI competency or verified patient behavior change.

Our findings are broadly consistent with previous studies suggesting that brief MI training can increase learners’ knowledge and confidence in behavior-change communication [18,19,35,36]. Similar to prior research, students in this study reported feeling most comfortable using the early MI processes of engaging and focusing, while evoking and planning were more difficult to apply without extended practice or supervision. Previous research has also suggested that blended learning approaches combining online instruction with interactive teaching may enhance learner engagement and flexibility in medical education [28].

However, it is important to note that many studies evaluating MI education rely primarily on self-reported outcomes, and evidence regarding objective skill acquisition remains limited. Therefore, while this study contributes additional evidence from a Thai undergraduate medical education context, further research using objective assessment tools and controlled study designs is needed to better evaluate the effectiveness of MI training programs for undergraduate medical students.

Consistent with qualitative findings, students perceived limited consultation time as a barrier to applying MI. These perceptions are consistent with previous reports from trainees who are newly learning MI techniques and may require additional time to formulate reflective responses and guide behavior-change conversations [27]. However, evidence from the broader MI literature suggests that when clinicians become more proficient in MI, the approach can be incorporated efficiently into routine clinical consultations without substantially increasing encounter time [9,37]. Some studies have even reported that effective MI communication may improve the efficiency of patient interactions by helping clinicians focus more quickly on patients’ motivations and priorities for behavior change [9,38]. Therefore, the time-related challenges reported by students in the present study may reflect their early stage of learning rather than an inherent limitation of MI itself. As students gain more experience and practice integrating MI skills into clinical encounters, the perceived time burden may decrease.

A major strength of this study lies in its mixed methods design, which allows integration of quantitative findings with qualitative insights to provide a broader understanding of students’ learning experiences. The inclusion of an entire cohort of final-year medical students reduced the selection bias and enhanced representativeness. The use of validated instruments and expert review increased internal validity.

Several limitations should be considered when interpreting the findings of this study. First, this study used a single-group before-and-after design without a control group, which prevents causal attribution of observed changes to the educational intervention. Improvements in knowledge or confidence may also reflect concurrent clinical learning experiences, maturation effects, or testing effects during the academic year.

Second, several outcomes, including students’ reported application of MI in clinical encounters, were based on self-reported measures, which may be subject to recall bias or social desirability bias. These measures, therefore, reflect students’ perceptions rather than objectively verified MI competence. In addition, the qualitative interviews were relatively brief (approximately 15‐20 minutes) due to scheduling constraints during students’ clinical rotations, which may have limited the depth of exploration of participants’ experiences.

Third, the duration of the intervention was relatively brief (approximately 5 hours of combined learning), which may be sufficient for introducing foundational MI concepts but is unlikely to support mastery of more advanced MI skills without continued practice, feedback, and supervision [10,39].

The relatively low completion rate of the web-based module may also reflect challenges related to implementation fidelity, as not all students were fully engaged with the online component of the intervention. However, the web-based course was designed as a supplementary resource to support students who wished to review or reinforce knowledge delivered during the onsite sessions. Participation in the web-based module was optional, and therefore variations in uptake among students were expected. As this study was not originally designed to compare outcomes between students who completed the web-based module and those who did not, subgroup analyses were not conducted. Future studies may explore whether different levels of engagement with online learning components influence educational outcomes.

Finally, this study was conducted at a single medical school, and therefore, the findings may not be generalizable to other educational settings or health care systems.

The findings of this study offer practical implications for undergraduate medical education. A combined learning structure that integrates a short workshop with a self-paced web-based module may provide a flexible approach for introducing MI concepts within a busy curriculum, although engagement with the online component varied among students. The web-based component provides flexibility, while the in-person workshop facilitates experiential learning and peer interaction.

Students’ preference for learning MI during the fifth year supports the alignment of MI training with clinical exposure to maximize relevance and skill transfer. A spiral curriculum, introducing MI principles during preclinical years and reinforcing practical skills during clinical rotations, could further strengthen integration.

Addressing barriers such as workload and limited practice time will require institutional support, including formative feedback, supervision, and longitudinal reinforcement. Embedding MI within broader communication skills training and assessment frameworks may enhance sustainability.

Future research should incorporate objective measures of MI competency, such as validated behavioral coding systems or structured communication assessments, to more accurately evaluate skill acquisition. Longitudinal studies are also needed to examine the retention of MI skills and their potential impact on patient outcomes over time. In addition, multicenter and cross-cultural research in low- and middle-income countries would help determine how combined MI educational approaches can be adapted to different health care systems and educational environments.

Overall, the findings suggest that the intervention was feasible within an undergraduate medical curriculum and was associated with higher knowledge scores and increased perceived confidence among participating students, while qualitative findings illustrated how students perceived and attempted to apply MI principles during clinical training.

In summary, this study evaluated a combined educational approach comprising a brief workshop and a web-based learning module to introduce MI to final-year medical students. The findings suggest that the training was associated with improvements in students’ MI knowledge and self-reported confidence in behavior-change communication. Students also reported applying elements of MI during clinical encounters, particularly when counseling patients with chronic diseases.

While these findings indicate that combined MI education is a feasible approach for introducing communication skills within undergraduate medical curricula, the results should be interpreted cautiously due to the absence of a control group and the reliance on self-reported outcomes. Further research using controlled study designs, objective assessment tools, and longitudinal follow-up is needed to better evaluate the impact of MI training on clinical competency and patient outcomes.