Evidence-based guidelines for teaching patient-centered interviewing.

In a rare study of effectiveness of an interviewing method, we previously reported a randomized controlled trial demonstrating that training in a step-by-step patient-centered interviewing method improved residents' knowledge, attitudes, and skills and had a consistently positive effect on trained residents' patients. For those who wish to use this evidence-based patient-centered method as a template for their own teaching, we describe here for the first time our training program--and propose that the training can be adapted for students, physicians, nurse practitioners, physician assistants, and other new learners as well. Training was skills-oriented and experiential, fostered positive attitudes towards patient-centered interviewing, and used a learner-centered approach which paid special attention to the teacher-resident relationship and to the resident's self-awareness. Skills training was guided by a newly identified patient-centered interviewing method that described the step-by-step use of specific behaviors.

Enhancing smoking cessation rates in primary care.

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) guidelines on smoking cessation recommend that primary care physicians provide both brief advice against smoking and follow-up care for all smokers. Surveys show that although physicians understand the importance of smoking cessation, the actual implementation of these guidelines is limited. The main objective of our study was to evaluate the comparative effectiveness of 2 different approaches to smoking cessation counseling: practice-based and community-based. METHODS: Both smoking cessation approaches consisted of 1 recruitment session and 6 computer-assisted counseling sessions. In the practice-based approach, counseling was provided by office nurses and telephone counselors; in the community-based approach, the counseling was given by telephone counselors only. Four practices in 3 mid-Michigan communities participated, including 120 physicians and 487 patients who were smokers. The physicians were trained to provide brief advice for smoking cessation consistent with the AHCPR guidelines; the nurses and telephone counselors were trained in relapse prevention, computer skills, and individual case management. Sixty-two percent of the participants obtained free nicotine replacement therapy. RESULTS: At 6 months, quit rates (7-day smoke-free status) were 35% in the practice-based group and 36% in the community-based group. Participants who completed at least 4 sessions showed higher quit rates than those who did not. CONCLUSIONS: Nurses in primary care practices and counselors can be trained to deliver effective relapse-prevention counseling during office visits and by telephone. Our study showed an increase in the reported rates of smoking cessation by using these counseling methods.

The influence of recovery status and education on addiction counselors' approach to treatment.

The goal of this study is to examine the influence of education and recovery status on substance abuse treatment counselors' approach to patients. Three hundred forty-four drug abuse and alcoholism treatment counselors were questioned about treatment goals. A subgroup of 197 were also questioned about treatment practices. The influences of education and recovery status on the choice of treatment goals and treatment practices were examined through structural modeling procedures. Level of education influenced neither treatment goals nor techniques. Being in recovery, however, was associated with more varied treatment techniques and a broader range of treatment goals. The other variable related to treatment goals and practices was treatment modality. Working in residential programs was linked to a wider range of treatment goals and treatment practices. Implications of these findings for counselor training and the movement to professionalize substance abuse treatment are discussed.

Exploratory and confirmatory factor analyses of the Brief Symptom Inventory among substance abusers.

The Brief Symptom Inventory (BSI) is a multidimensional measure of psychological and somatic distress that is used to obtain detailed symptom profiles. The BSI has been questioned regarding its ability to differentiate among its proposed nine dimensions, and the factor structure underlying the BSI has not been confirmed with substance abusers. Exploratory factor analyses were completed on substance abusers (ntotal = 453; nwomen = 121; nmen = 332); nine factors were not identified. Five models were then submitted to confirmatory factor analyses using an independent sample of substance abusers (ntotal = 456; nwomen = 127; nmen = 329). A one-factor model (i.e., global psychological distress) best represented the data. Implications for using the BSI in research and counseling are discussed.

Substance abuse treatment staff: recovery status and approaches to treatment.

Recovery status is an important characteristic of staff members working within substance abuse treatment. Recovering and nonrecovering staff members were contrasted previously, however there is a third group: Individuals who are not recovering themselves but are part of families with recovering or addicted members. The purpose of the present study is to compare background, roles within program and approaches to treatment of these three groups. Six hundred and thirty-four staff members of fifty-one treatment programs completed questionnaires. Five hundred and seventy-five completed an item indicating their recovery status. Forty-four percent identified themselves as nonrecovering, 30 percent as recovering, and 26 percent as nonrecovering but part of families with an addicted or recovering member. Nonrecovering staff with addicted or recovering family members differed from the other two groups on gender, more of them were female, but were similar to nonrecovering staff in their approach to treatment but fell between recovering and nonrecovering staff on measures of roles within programs and background. Recovering counselors reported to pursue a wider range of treatment goals and to use more varied treatment techniques than nonrecovering counselors. The implication of these findings for training and licensure of paraprofessionals in the field of substance abuse treatment is discussed.

The effectiveness of intensive training for residents in interviewing. A randomized, controlled study.

BACKGROUND: Interviewing and the physician-patient relationship are crucial elements of medical care, but residencies provide little formal instruction in these areas. OBJECTIVE: To determine the effects of a training program in interviewing on 1) residents' attitudes toward and skills in interviewing and 2) patients' physical and psychosocial well-being and satisfaction with care. DESIGN: Randomized, controlled study. SETTING: Two university-based primary care residencies. PARTICIPANTS: 63 primary care residents in postgraduate year 1. INTERVENTION: A 1-month, full-time rotation in interviewing and related psychosocial topics. MEASUREMENTS: Residents and their patients were assessed before and after the 1-month rotation. Questionnaires were used to assess residents' commitment to interviewing and psychosocial medicine, estimate of the importance of such care, and confidence in their ability to provide such care. Knowledge of interviewing and psychosocial medicine was assessed with a multiple-choice test. Audiotaped interviews with real patients and videotaped interviews with simulated patients were rated for specific interviewing behaviors. Patients' anxiety, depression, and social dysfunction; role limitations; somatic symptom status; and levels of satisfaction with medical visits were assessed by questionnaires and telephone interviews. RESULTS: Trained residents were superior to untrained residents in knowledge (difference in adjusted post-test mean scores, 15.7% [95% CI, 11% to 20%]); attitudes, such as confidence in psychological sensitivity (difference, 0.61 points on a 7-point scale [CI, 0.32 to 0.91 points]); somatization management (difference, 0.99 points [CI, 0.64 to 1.35 points]); interviewing of real patients (difference, 1.39 points on an 11-point scale [CI, 0.32 to 2.45 points]); and interviewing (data gathering) of simulated patients (difference, 2.67 points [CI, 1.77 to 3.56 points]). Mean differences between the study groups were consistently in the appropriate direction for patient satisfaction and patient well-being, but effect sizes were too small to be considered meaningful. CONCLUSION: An intensive 1-month training rotation in interviewing improved residents' knowledge about, attitudes toward, and skills in interviewing.

A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study.

PURPOSE: To use a controlled, randomized design to assess the effect on patient satisfaction of an intensive psychosocial training program for residents. METHOD: Twenty-six first-year residents, in two internal medicine and family practice community-based programs affiliated with the Michigan State University College of Human Medicine, were randomly assigned during 1991 and 1992 to a control group or a one-month intensive training program. Experiential teaching focused on many psychosocial skills required in primary care. A 29-item questionnaire administered before and after the residents' training evaluated their patients' satisfaction regarding patient disclosure, physician empathy, confidence in physician, general satisfaction, and comparison of the physician with other physicians. Analyses of covariance with groups and gender as factors and pre-training patient satisfaction scores as the covariate evaluated the effect of the training. RESULTS: The patients of the trained residents expressed more confidence in their physicians (p = .01) and more general satisfaction (p = .02) than did the patients of controls. The effect of training on patient satisfaction with patient disclosure (p < .01) and physician empathy (p < .05) was greater for female than for male residents. CONCLUSION: The intensive psychosocial training program for residents improved their patients' satisfaction.

Improving residents' confidence in using psychosocial skills.

OBJECTIVE: To evaluate an intensive training program's effects on residents' confidence in their ability in, anticipation of positive outcomes from, and personal commitment to psychosocial behaviors. DESIGN: Controlled randomized study. SETTING: A university- and community-based primary care residency training program. PARTICIPANTS: 26 first-year residents in internal medicine and family practice. INTERVENTION: The residents were randomly assigned to a control group or to one-month intensive training centered on psychosocial skills needed in primary care. MEASUREMENTS: Questionnaires measuring knowledge of psychosocial medicine, and self-confidence in, anticipation of positive outcomes from, and personal commitment to five skill areas: psychological sensitivity, emotional sensitivity, management of somatization, and directive and nondirective facilitation of patient communication. RESULTS: The trained residents expressed higher self-confidence in all five areas of psychosocial skill (p < 0.03 for all tests), anticipated more positive outcomes for emotional sensitivity (p = 0.05), managing somatization (p = 0.03), and nondirectively facilitating patient communication (p = 0.02), and were more strongly committed to being emotionally sensitive (p = 0.055) and managing somatization (p = 0.056), compared with the untrained residents. The trained residents also evidenced more knowledge of psychosocial medicine than did the untrained residents (p < 0.001). CONCLUSIONS: Intensive psychosocial training improves residents' self-confidence in their ability regarding key psychosocial behaviors and increases their knowledge of psychosocial medicine. Training also increases anticipation of positive outcomes from and personal commitment to some, but not all, psychosocial skills.

The longitudinal stability of the Addiction Severity Index.

The Addiction Severity Index (ASI) is a structured interview widely used by substance abuse clinicians and researchers for client screening, determining treatment needs, and assessing treatment outcomes. Previous researchers have evaluated inter-rater agreement, test-retest reliability, and concurrent validity. The present report describes the stability of ASI scores in longitudinal work. In the context of an ongoing treatment outcome evaluation study involving seven assessors, inter-rater agreement, inter-rater reliability, as well as intra- and inter-rater accuracy were assessed repeatedly during a 2-year period. The results show the scores derived from the ASI to be stable across assessors and over time. The relationship between stable scores and resources required for training are discussed.

Program factors influencing client satisfaction in alcohol treatment.

There is little documentation about how the union of self-help and professional treatment services influences client treatment satisfaction. This study examines the relationship of treatment characteristics indicative of program size, staffing patterns, Alcoholics Anonymous (AA) influence, and staff recovery status to client satisfaction. Thirty-six public substance abuse treatment programs participated in this study. At outpatient programs, satisfaction was related to program size, and the number of paraprofessional and medical staff; satisfaction was unrelated to AA influence on treatment. For residential clients, AA influence on treatment and AA beliefs held by staff were consistently related to satisfaction; factors related to program size and staffing patterns were independent of satisfaction. The results question the appropriateness of self-help interventions in all settings, and emphasize contextual differences in outpatient and residential programs.

A work-site weight management program to reinforce behavior.

This pilot weight management project addresses the efficacy of reinforcing dietary behavior change versus weight loss. This 6-month program served professional and support staff participating in the work-site wellness program at a midwestern university. Behavior-contingent program data were compared with data from the previous model where contracts were made for weight loss. In the behavior-contingent program, dropout rate and satisfaction with the program compared favorably with the old model weight loss-contingent program. Contract adherence was 93% compared with 74% in the weight loss-contingent program. Actual pounds of weight lost were lower in the behavior-contingent program, however, long-term weight management must still be studied with this population.

Issues related to participation in worksite health promotion: a preliminary study.

PURPOSE: The purpose of this study was to identify characteristics associated with participation in worksite-based health promotion activities. DESIGN: Follow-up interviews were used to identify demographic, attitudinal, and behavioral differences among three employee groups. Reasons employees chose not to participate in health promotion activities were also explored. SETTING: All respondents were employed at a large midwestern university and were eligible to participate in free onsite health fairs and health promotion programs. SUBJECTS: A stratified random sample of 89 nonparticipants, health fair participants, and behavior change program participants was interviewed. MEASURES: The interview was comprised of questions related to demographic information, personal health habits, physical activity, perceived health status, perceived self-efficacy, worksite norms, health promoting lifestyle factors, and knowledge about health promotion activities. RESULTS: ANOVA and chi-squared comparisons revealed few group differences. Graduate students and employees with advanced degrees were most likely to take part in health fairs. Behavior change program participants were older, clerical-technical staff members, and women. Faculty members were least likely to participate. A lack of time was the most often cited reason for nonparticipation. CONCLUSIONS: The study was retrospective and the analyses limited due to low statistical power. The results suggest that different groups of employees are attracted to different types of health promotion activities.

A program model to enhance adherence in work-site-based fitness programs.

We describe a program model designed to achieve high adherence, a major problem for work-site exercise/fitness programs. Our model is a 6-month program consisting of 15 1-hour program meetings, with participants exercising on their own time four times per week. Procedures employed to enhance adherence are contracting, group competition, monitoring, and social support. This program model has been applied nine times. One hundred fifty-nine university employees took part in the initial test with a dropout rate of 9% (15 persons). The average adherence rate for nondropouts was 98%, which is higher than rates usually reported in the literature. Adherence was defined as exercising four times a week.

Effects of a 6-month incentive-based exercise program on adherence and work capacity.

The purpose of the study was to evaluate the effect of behavioral management techniques on exercise adherence linked to improvements in work capacity and maximal oxygen consumption (VO2max). One hundred thirty-seven participants in six different worksites on a university campus (five experimental and one comparison site) completed 6 months of a minimally supervised, incentive-based endurance exercise program. All participants in the experimental group contracted to engage in at least four bouts of 30 min of verified aerobic exercise within a prescribed target heart rate range each week for the duration of the program. Forty dollars deposited at the beginning of the program served as a response cost that could be lost as a result of failure to fulfill the weekly contracts. Individuals in the comparison group participated in a similar 6-month program but without the contracts and response cost strategies. Weekly adherence for both groups was strictly defined as verified fulfillment of all four bouts of exercise. Adherence for the experimental group was 97% by this definition, and adherence for the comparison group was 19% (P less than 0.01). VO2max increased 2.6% (P less than 0.01), and treadmill test time increased 16% (P less than 0.01) in the experimental group after the 6-month program, with no significant changes in the comparison group. Recovery heart rates at 2 and 4 min post-exercise were significantly lower at 6 months in the experimental group but not in the comparison group. These data provide evidence that adherence to a 6-month endurance exercise program can be improved significantly through the use of well conceived behavior management strategies.(ABSTRACT TRUNCATED AT 250 WORDS)

Gender differences in depression and anxiety among alcoholics.

Recent research suggests that psychopathology, in particular depression and anxiety, differentially affects the substance abuse treatment response of men and women. This study explores the relationship between global psychopathology, depression, anxiety, and alcoholism treatment outcome. These variables were assessed in a sample of 507 (373 men; 134 women) substance abuse clients at intake and at a 6-month follow-up. With the exception of alcohol dependence, there were significant differences in the levels of alcohol problems, depression, anxiety, and global psychopathology for men and women at both intake and follow-up. For the whole sample and for men, initial levels of alcohol problems and alcohol dependence were the best predictors of alcohol problems at follow-up. For women, the initial levels of alcohol dependence and a global measure of psychological functioning were predictive of outcome at follow-up. These findings are compared with past research, and suggestions for further investigation are proposed.

Efficacy of a one-month training block in psychosocial medicine for residents: a controlled study.

STUDY OBJECTIVE: To determine the efficacy of a comprehensive, one-month psychosocial training program for first-year medical residents. DESIGN: Nonrandomized, controlled study with immediate pre/post evaluation. Limited evaluation of some residents was also conducted an average of 15 months after teaching. SETTING: Community-based, primary care-oriented residency program at Michigan State University (MSU). SUBJECTS: All 28 interns from the single-track MSU residency program during 1986/87-88/89 participated in this required rotation; there was no dropout or instance of noncompliance with the study. In the follow-up study in 1989, all 13 available trainees participated. Of 20 untrained, volunteer controls, ten were second/third-year residents in the same program during 1986/87 and ten were interns from a similar MSU program in Kalamazoo, MI, during 1988/89. TEACHING INTERVENTION: An experiential, skill-oriented, and learner-centered rotation with competency-based objects focused on communication and relationship-building skills and on the diagnosis and management of psychologically disturbed medical patients. MEASUREMENTS AND MAIN RESULTS: The two subsets of the control group were combined because residents and training programs were similar and because means and standard deviations for the subsets were similar on all measures. By two-way analyses of variance (group x gender), the trainee group showed significantly greater gains (p less than 0.001) on questionnaires addressing knowledge, self-assessment, and attitudes; a mean of 15 months following training, there was no significant deterioration of attitude scores. All trainees were also able to identify previously unrecognized, potentially deleterious personal responses using a systematic rating procedure. Residents' acceptance of the program was high. CONCLUSIONS: Intensive, comprehensive psychosocial training was well accepted by residents. It improved their knowledge, self-awareness, self-assessment, and attitudes, the latter improvement persisting well beyond training.

The perceptions of program directors and clients regarding the efficacy of methadone treatment.

A statewide sample of regional coordinators, program directors, and clients associated with opiate addiction treatment programs revealed their biases and expectations regarding the efficacy of methadone as a form of treatment. Methadone and drug-free program directors held consistent beliefs about treatment except the efficacy of methadone. Prior methadone clients currently in drug-free programs were skeptical of the methadone treatment, unlike clients currently in methadone treatment. The data reveal differences of opinions across the levels of the treatment system represented in the survey. In policy decisions, the need to consider empirical evidence in addition to personal opinions is emphasized, if consensus is ever to be realized.

A comparison of problems-of-life for blacks and whites entering substance abuse treatment programs.

Blacks in the general population experience alcohol-related health problems to a greater extent than Whites, even though surveys of drinking behavior find that Blacks generally drink no more than Whites and, in fact, at younger ages Blacks actually drink less than Whites. In this study, Blacks and Whites entering randomly selected state-supported substance abuse treatment programs within a given period of time were interviewed and administered a battery of assessment instruments; results are derived from the Addiction Severity Index. A major research question was whether the higher rates of alcohol-related problems for Blacks in the general population were matched by greater severity of life-problems for Blacks in a clinical treatment population. Blacks had more severe problems than Whites in two problem areas: employment support and other drug use. Results point to socioeconomic factors as well as combined alcohol and other drug use as potential contributors to the greater alcohol-related health problems for Blacks in the general population. Comprehensive study of alcohol and other drug use norms and customs within the Black community is recommended to aid in the development of prevention and treatment strategies for alcohol-related problems among Blacks.

Residents' attitudes towards and skills in counseling: using undetected standardized patients.

OBJECTIVE: To identify the frequency and quality of certain prevention-oriented counseling skills of resident physicians and to compare these skills with the residents' attitudes towards and knowledge about primary prevention. DESIGN: Longitudinal descriptive study. PATIENTS/PARTICIPANTS: 54 PGY-1-3 internal medicine and family practice residents enrolled in three training programs affiliated with Michigan State University's College of Human Medicine. INTERVENTION: Trainees' attitudes towards and knowledge about certain prevention activities were captured by an instrument designed for this study using 127 Likert scales. Counseling skills were assessed with one of two standardized patients. Residents were unaware of the simulation, which occurred in their routinely scheduled ambulatory care setting. Audiotapes of the interactions were rated by blinded, independent raters. Residents had strong positive beliefs about the role of primary care physicians in counseling patients, high levels of knowledge about what the counseling should entail, and high self-assessment about the frequency and quality of their own counseling interventions. Skill levels, however, were at or below a level defined as minimally acceptable. CONCLUSION: Resident physicians' skill levels, as measured in this study, are inadequate to accomplish routine counseling interventions in the primary care setting. These results suggest that more reliance should be placed on direct observation of physicians, ideally in nonreactive settings, for purposes of drawing conclusions about physician performance. Further, these results have implications for the training of students and residents in the area of counseling for prevention.