Primary Care Resident Training for Obesity, Nutrition, and Physical Activity Counseling: A Mixed-Methods Study.

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency programs are preparing physicians to counsel about obesity, nutrition, and physical activity (ONPA) and to examine program members' perspectives regarding the place of ONPA counseling in the curriculum, and its relevance in primary care training. Using mixed methods, we collected and analyzed data on 25 family medicine, internal medicine, and obstetrics/gynecology residency programs across Ohio. Programs averaged 2.8 hours of ONPA-related didactics per year. Ten programs (42%) taught techniques for health behavior counseling. Having any ONPA-related didactics was associated with greater counseling knowledge (p = .01) among residents but poorer attitudes (p < .001) and poorer perceived professional norms (p = .004) toward ONPA counseling. Findings from interview data highlighted similar perceived barriers to ONPA counseling across all three specialties but variation in perception of responsibility to provide ONPA counseling. While widespread expectations that primary care physicians counsel their overweight and obese patients prevail, few residency programs provide training to support such counseling.

A participatory model of the paradox of primary care.

PURPOSE: The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care. METHODS: In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity. RESULTS: In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters. CONCLUSION: This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health.

A randomized trial to evaluate primary care clinician training to use the Teachable Moment Communication Process for smoking cessation counseling.

OBJECTIVE: To implement and evaluate the impact of a Teachable Moment Communication Process (TMCP) training intervention on clinicians' smoking cessation counseling behaviors in practice. METHOD: Using a group randomized trial, 31 community-based, primary care clinicians in Northeast Ohio received either TMCP training or an attention control (2010-2012). TMCP training consisted of two, three-hour sessions involving didactic instruction, skill practice with standardized patients, and coaching. Clinician performance of TMCP elements was assessed by coding audio-recordings of routine visits with smokers at baseline and post-intervention (n=806). RESULTS: Baseline performance of all TMCP elements was similar in the two groups. After the intervention, TMCP-trained clinicians were more often observed advising patients to quit while linking smoking to the patient's concern (58% vs. 44%, p=0.01), expressing optimism (36% vs. 3%, p<0.001), expressing partnership (40% vs. 12%, p=0.003) and eliciting the patient's readiness to quit (84% vs. 65%, p=0.006) than clinicians in the comparison group. TMCP-trained clinician responses were also better aligned with patients' expressed readiness to quit smoking than comparison group clinicians (p<0.001). CONCLUSION: The intervention significantly changed the content of clinicians' smoking cessation communication in ways consistent with the TMCP model for health behavior change.

The Role of Oncology Nurses in Discussing Clinical Trials.

PURPOSE/OBJECTIVES: To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions.
. RESEARCH APPROACH: A qualitative study designed to elicit narratives from oncology nurses. 
. SETTING: Community- and academic-based oncology clinics throughout the United States.
. PARTICIPANTS: 33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. 
. METHODOLOGIC APPROACH: In-depth interviews were conducted and analyzed using a immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients.
. FINDINGS: Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions.
. INTERPRETATION: These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. 
. IMPLICATIONS FOR NURSING: Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling.

BACKGROUND: Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity. OBJECTIVE: To assess the degree to which residents training in adult primary care programs are prepared to provide obesity, nutrition, and physical activity (ONPA) counseling. METHODS: Senior residents (postgraduate year [PGY]-3 and PGY-4) from 25 Ohio family medicine, internal medicine, and obstetrics and gynecology programs were surveyed regarding their knowledge about obesity risks and effective counseling, as well as their attitudes, self-efficacy, and perceived professional norms toward ONPA counseling. We examined summary scores, and used regression analyses to assess associations with resident demographics and training program characteristics. RESULTS: A total of 219 residents participated (62% response rate). Mean ONPA counseling knowledge score was 50.8 (± 15.6) on a 0 to 100 scale. Specialty was associated with counseling self-efficacy (P < .001) and perceived norms (P = .002). Residents who reported having engaged in an elective rotation emphasizing ONPA counseling had significantly higher self-efficacy and more positive attitudes and professional norms scores. CONCLUSIONS: Our findings suggest that primary care residents' knowledge of ONPA assessment and management strategies has room for improvement. Attitudes, self-efficacy, and perceived norms also are low and vary by training program characteristics. A deeper understanding of curricula associated with improved performance in these domains could inform interventions to enhance residents' ONPA counseling skills and prevent chronic disease.