Improving physicians' HIV risk-assessment skills using announced and unannounced standardized patients.

OBJECTIVE: To evaluate feasibility and to validate a rating scale for two educational programs that use standardized patient-instructors (SPIs) in the office setting to improve physicians' HIV risk communication skills. DESIGN: Pilot randomized trial of announced and unannounced SPIs. PARTICIPANTS/SETTINGS: Twenty four primary care physicians in the Rochester, NY, area. MEASUREMENTS: The Rochester HIV Interview Rating Scale (RHIRS), HIV test ordering, physician satisfaction questionnaire. RESULTS: Physicians found the intervention useful, and predicted a positive effect on their future HIV-related communication. HIV test ordering and RHIRS scores increased similarly in both intervention groups. Announced SPI visits were more convenient and preferred by physicians. Cost for each SPI visit was $75. CONCLUSIONS: A brief office-based intervention using SPIs was feasible, well-accepted, convenient, and inexpensive. Announced SPIs were preferred to unannounced SPIs. Pilot results suggesting improvement in HIV-related communication should be confirmed in a larger randomized trial.

Use of stage of change (SOC) to develop an STD/HIV behavioral intervention: phase 1. A system to classify SOC for STD/HIV sexual risk behaviors--development and reliability in an STD clinic.

This paper reports on the initial phase in the development, program implementation, and inter-rater reliability of an application of Stage of Change (SOC) behavioral theory for use in STD/HIV risk reduction. SOC was adapted to assess readiness for sexual behavior change in an urban STD clinic in Rochester, New York. A standardized staging grid and protocol were developed and implemented as part of HIV pre- and post-test counseling. A "client instructor" methodology was used to assess standardization and staff inter-rater reliability. Percent agreement for stage assessment for target behaviors was calculated. The Rochester STD/HIV Behavioral Counseling (RoSHBeC) Staging Grid and Protocol was used to train staff and this staging system was implemented in the STD clinic. After training, staff identified the correct behavioral target and stage 90% of the time. Inter-rater agreement for SOC classification was greater than 70%. Our experience demonstrates that it is possible to develop, implement, and sustain an integrated provider-delivered STD/HIV behavioral intervention in a busy urban STD Clinic. This staging system has the potential for use in other settings and for other health-related behaviors.

Genetic testing for breast-ovarian cancer susceptibility: a regional trial.

To evaluate receptivity to testing for a genetic susceptibility to breast-ovarian cancer, information is needed on the response when the offer is open to all qualifying women in a given region. To qualify in this trial, a woman who had not had breast or ovarian cancer had to have at least two first-degree relatives or one first- and one second-degree relative with breast and/or ovarian cancer, whereas a woman who had had breast or ovarian cancer had to have at least one first-degree relative with breast or ovarian cancer and a first- or second-degree relative without cancer willing to be tested. Of 140 women qualifying and interested enough to return questionnaires requesting baseline information, 111 were referred by their physician and 29 were identified from a regional tumor registry. Of these 140, 112 came for pretest education and 98 of these chose to be tested. Thus, the acceptance rate was 70% for all those returning baseline questionnaires, but 88% for those interested enough to come for pretest education. The most common reasons for accepting testing were to take extra precautions if a mutation were found (42.9%) and to determine if offspring were at risk (24.5%). The most common reasons for declining were anxiety and absence of specific interventions. Factors predicting who chose testing were years of education (p < 0.005) and family closeness (p < 0.02). Fourteen deleterious BRCA1 or BRCA2 mutations were found in 13 of the 87 families actually tested. If the criteria for testing had been three or more affected family members rather than two or more, the number of families tested would have been reduced by 46%, but the number of families found to have a deleterious mutation would have been reduced by only 9%.

Cystic fibrosis carrier population screening: a review.

Population screening for cystic fibrosis (CF) carriers, now possible because of the cloning of the CFTR gene, merits evaluation because CF is common, serious, and without satisfactory treatment, and because prenatal diagnosis is available. Clinical trials of CF population carrier screening are reviewed. These trials have involved pregnant women, adults of both sexes of reproductive age, or adolescents. Schools, the usual setting for screening programs for adolescents, provide an excellent opportunity for a formal educational component and for comprehensive coverage of the population, but compared to a health-care setting, may entail subtle coercion and may compromise confidentiality. In the case of adults, many say they prefer screening before conception but do not see a physician for evaluation before conception and providers find screening more readily accomplished in the setting of a prenatal visit. Two large U.S. studies of prenatal screening with quite different subject populations and health-care settings encountered few of the adverse outcomes originally predicted for CF carrier population screening.

Carrier screening for cystic fibrosis: test acceptance and one year follow-up.

We identified 124 carriers among 4,879 patients of prenatal care providers in the Rochester region. Six factors were identified that together permitted a correct classification regarding test acceptance for 77.5% of all subjects. For those pregnant, the most influential of these factors was a more accepting attitude toward abortion. As an indication for abortion, cystic fibrosis (CF) ranked between mild and moderate mental retardation. Of the 124 carrier women identified, we obtained 1-year follow-up information on 100. Mean score for CF knowledge at 1 year (77.4 +/- 13.2%), although significantly lower than immediately after counseling (84 +/- 12.4%), was still significantly higher than after detection but before counseling (51.1% +/- 20.7%). Anxiety about having a child with CF significantly declined from 25.8 +/- 8.0 SD immediately after counseling to 18.9 +/- 7.8 at 1 year (Spielberger State Anxiety Scale). Although 15 carriers regretted having been tested, 83% believed that they benefited from testing, 83% would make the same decision to be tested over again, and 79% would recommend testing to a friend. We conclude that, for most women, CF carrier screening accomplished its purpose: most carriers detected came for counseling, had their partners tested, and, if their partners were also carriers, had prenatal diagnosis. The major undesirable outcomes were that many women testing negative did not understand that a negative result did not exclude being a carrier and that three women found to be carriers did not have their partners tested because of anxiety or the unacceptability of pregnancy termination and therefore may not have carefully considered their decision to be tested. Both of these undesirable outcomes could have been avoided by greater attention to pretest patient education by the primary care provider.

Cystic fibrosis carrier population screening in the primary care setting.

To determine the receptivity of prenatal care providers and their patients to carrier testing for cystic fibrosis (CF), we offered free carrier screening, followed by genetic counseling of carriers, to all prenatal care providers in Rochester, NY, for all their female patients of reproductive age, pregnant or not. Of 124 prenatal care providers, only 37 elected to participate, but many of these offered screening only to pregnant women. The acceptance rate among pregnant women was approximately 57%. The most common reasons for accepting screening were to obtain reassurance (50.7%) and to avoid having a child with CF (27.8 %). The most common reasons for declining screening were not intending to terminate a pregnancy for CF (32.4%) and believing that the chance of having a CF child was very low (32.2%). Compared with decliners, acceptors were more likely to have no children, regarded having a child with CF as more serious, believed themselves more susceptible to having such a child, knew more about CF, would be more likely to terminate a pregnancy if the fetus were shown to have CF, and more strongly supported offering CF screening to women of reproductive age. Of 4,879 women on whom results were obtained, 124 were found to be carriers. Of these 124 carriers, the partners of 106 were tested. Of the five at-risk couples, four requested prenatal diagnosis and one requested neonatal diagnosis. No woman found to be a carrier whose partner tested negative requested prenatal diagnosis. Except for the imperfect knowledge of those testing negative, none of the adverse outcomes predicted for CF carrier testing in the general population were observed in this study.

Women's receptivity to testing for a genetic susceptibility to breast cancer.

Four hundred eighty-four patients undergoing mammography and 498 patients visiting their obstetrician-gynecologist were asked whether they would take a breast cancer 1 (BRCA1) test to detect a genetic susceptibility to breast cancer. More than 90% in both groups said they would take the test. Women were more likely to accept if they were regularly having breast examinations by a physician, believed that mammography effectively detects early breast cancer, and believed that early breast cancer is curable. If shown to have inherited a susceptibility, many reported that they would be very anxious, would want the test repeated, would examine their breasts more often than monthly, and would want mammography more often than yearly. Many also reported that they would recommend testing to relatives.

Cystic fibrosis carrier screening: knowledge and attitudes of prenatal care providers.

We are conducting a trial of population carrier screening for cystic fibrosis (CF), targeting pregnant and nonpregnant patients of prenatal care providers. We first enlisted providers by presenting a description of the trial to the obstetrical staffs of the five Rochester, New York, hospitals having delivery services. Of the 124 prenatal care providers (111 obstetricians and 13 family practitioners) with delivery privileges at the five hospitals, only 81 (65%) attended one of our presentations. Providers who attended lacked knowledge about CF screening and counseling and expressed divergent attitudes about prenatal diagnosis for carrier women having test-negative partners. Of the 79 providers completing an attitude questionnaire, 68 (86%) were willing to offer carrier screening to all their patients if educational materials, testing, and counseling were all provided without charge. After visiting participating physicians' offices to orient their staff, we reached two additional conclusions. First, in considering whether to offer CF carrier screening to their patients, prenatal care providers are less concerned about imperfect test sensitivity, false reassurance of those testing negative, or discrimination against those testing positive than about time required to answer patients' questions if they screen and about legal liability if they do not. Second, some providers are more resistant to offering screening to nonpregnant patients than to pregnant patients, not because they believe that the timing is less appropriate, but because nonpregnant patients do not routinely receive an advance mailing, have phlebotomy, or return for follow-up. Our experience raises concerns about the willingness and capability of prenatal care providers to translate advances in molecular medicine into prenatal screening services.

Teaching risk-factor counseling skills: a comparison of two instructional methods.

The effectiveness of a class-wide lecture coupled with small group discussions was compared to the outcome of clinical instruction provided by patient instructors (PIs) who were specially trained to teach behavioral counseling skills for health promotion and lifestyle risk-factor modification. PIs are nonprofessionals trained to simulate a medical encounter in order to evaluate clinical competency and provide individual feedback. Each PI enacted the role of an ambulatory patient at high risk for coronary artery disease because of the presence of multiple risk factors. Two groups of medical students were studied using the entire second-year class in two consecutive academic years. In group 1 (n = 92), students received a lecture on risk-factor modification and attended a small group discussion. In group 2 (n = 91), students performed the PI exercise as their primary source of risk-factor counseling instruction. Six months after receiving the initial instruction (at time 2), all students completed the clinical exercise with the PI, who objectively rated each student's counseling skills using the University of Rochester Risk Factor Interview Scale (URRFIS). Differences between groups 1 and 2 at time 2 were significant for total URRFIS and all subscale scores, indicating that students who had received PI training as their form of instruction performed the risk-factor counseling more skillfully. For students in group 2, within-student performance from time 1 to time 2 also was significantly improved. This study demonstrates that instruction in risk-factor counseling for medical students who are early in their formal medical training may be taught more effectively by PIs; the learning appears durable when measured six months after instruction.

Patient priorities for behavioral change: selecting from multiple coronary disease risk factors.

When a physician advises a patient to modify unhealthy behaviors, the physician may be tempted to prescribe a target for change by selecting the single "risk factor" that poses the greatest threat to health. The present study was conducted to determine how frequently a statistical approach to health risk appraisal would conflict with a patient's priorities for lifestyle change, even when the patient was fully informed of the rationale for the advice. Coronary artery disease (CAD) risk factor assessment was performed using the American Heart Association's RISKO scale, a validated health risk appraisal instrument. Two hundred forty-one patients were seen in an ambulatory clinic that specialized in heart disease prevention. Risk of CAD was estimated based on age, sex, smoking status, blood pressure, body weight, and serum cholesterol. Using RISKO, patients were told which single risk factor posed the greatest threat to health; patients then selected a personal priority for risk factor intervention. The overall rate of agreement between the patients' priorities and RISKO targets was 63%. If weight loss is considered a nonpharmacologic "target" for controlling hypertension, then the agreement rate rises to 70%. Disagreement was observed even though patients were fully informed of the relative importance of all possible risk factor choices. Since risk factor intervention efforts are less successful unless the target of the intervention is negotiated with the patient, these data should be of clinical importance in devising plans for behavioral change interventions by practitioners.

Does physician uncertainty affect patient satisfaction?

Physicians may choose one of several strategies when initially uncertain about making a specific therapeutic recommendation. The authors investigated how patients' satisfaction is affected by disclosure of uncertainty and its attempted resolution during a clinical encounter. Three hundred and four patients awaiting appointments at a university hospital's ambulatory medical clinic were randomized to view one of five videotapes (VTs) of a patient seeking advice about antimicrobial prophylaxis for a heart murmur. In VT-1 and VT-2, the physician disclosed no uncertainty and prescribed therapy. In VT-3, VT-4, and VT-5, the physician openly conveyed uncertainty but then: (VT-3) prescribed antibiotics without resolving his uncertainty; (VT-4) consulted a reference book with the patient present, then prescribed; or (VT-5) checked a computer with the patient present, then prescribed. Patients rated their satisfaction with the physician on a standardized questionnaire. Differences in satisfaction between the five VTs were significant (p = 0.001), with the highest ratings found for VT-1 and VT-2, where no uncertainty was disclosed. The lowest ratings in satisfaction were found when the physician expressed but then ignored uncertainty (VT-3) or examined a textbook (VT-4). Global satisfaction was inversely and significantly correlated (r = -0.47) with the patients' perception of uncertainty in the physician. The manner in which clinical uncertainty is disclosed to patients and then resolved by the physician appears to affect patients' satisfaction.

Hospitalization as an opportunity to improve hypertension recognition and control.

Hospitalization may afford an excellent opportunity to maximize recognition and control of the hypertensive patient and ensure medical follow-up. We reviewed records of 536 medical or surgical patients consecutively admitted to a university hospital to assess trends in hypertension-related medical care according to guidelines established by the 1984 report of the Joint National Committee (JNC III) on Hypertension Detection, Treatment, and Control. Of 143 hospitalized patients considered hypertensive, 70% were controlled on admission, and 77% were controlled at hospital discharge. No significant differences were found in control status when medical and surgical patients were compared. Of 52 medical patients with hypertension, two lacked a documented diagnosis of hypertension at discharge compared to 16 of 94 surgical patients with hypertension (P less than 0.05). Nine of the 16 undiagnosed surgical patients were also uncontrolled at discharge. Of 43 medical or surgical patients who entered the hospital uncontrolled, 19 (44%) remained uncontrolled at discharge. Seventy percent of patients with uncontrolled hypertension entered the hospital on antihypertensive drugs, and there was no net increase in antihypertensive drug use in these patients during hospitalization. These data suggest that physicians frequently fail to capitalize on hospitalization as an opportunity to diagnose and control hypertension in some patients. Our results indicate that surgeons may be less attentive than internists to diagnosis of hypertension. In addition, hospitalization remains a setting in which medical care for hypertension could be improved.

Using patient instructors to teach behavioral counseling skills.

The authors developed an exercise to teach medical students counseling skills for promoting change in health-related behaviors using trained patient instructors (PIs) who enact the patient role, perform a standardized evaluation of the interview, and provide instructional feedback. Third-year medical students in two consecutive academic years at the University of Rochester School of Medicine and Dentistry received either feedback from a faculty member on a videotaped interview between the students and a simulated patient (SP) or direct feedback from a PI immediately following the students' interview with the PI. The students in the PI group gave higher ratings to the realism and effectiveness of the interview session than did students in the SP group. Students in both groups rated PI feedback as more helpful than videotaped review, even though they had experienced only one of these two methods. This exercise represents a new use of patient instructors that may also be applicable to teaching counseling skills in other areas of behavioral medicine.

Validation of the University of Rochester Risk Factor Interview Scale.

We report here on the reliability and validity of the University of Rochester Risk Factor Interview Scale (URRFIS). This scale was developed as an educational measure to characterize and quantify the skills required of physicians and medical students for counseling patients beginning coronary disease risk-factor modification. When used by trained "patient-instructors" to evaluate the interview skills of third-year medical students, we found the URRFIS to have high degrees of interrater reliability (r = .88) and internal consistency (alpha = .76). We also present evidence of content and construct validity. The URRFIS provides a systematic way to teach medical students a set of general counseling skills for health promotion and may increase enthusiasm for the clinical practice of risk-factor modification.

Feasibility of large-scale cholesterol screening: experience with a portable capillary-blood testing device.

We conducted a voluntary cholesterol screening in a medical/occupational setting using the Eastman Kodak Ektachem (desk top) blood analyzer. In 10 hours, five technicians performed a finger-stick puncture on 1,081 screenees, 17.7 per cent of whom were classified as moderate-to-high risk. The cost per screenee was under $3; cost per moderate-to-high risk case was under $16. Turn-around time from check-in to report of result was under one hour. This project suggests the feasibility and acceptability of large-scale cholesterol blood screening.

Recruitment using mass media strategies.

Use of mass media represents a recruitment strategy with a relatively moderate volume of initial contacts and entries, a moderate ratio of entries to initial contacts, and a relatively moderate effort level requirement for the recruitment team. In the CPPT, nine centers recruited participants directly through newspapers, radio or television or a combination. Media sources accounted overall for 4% of initial contacts, 11% of first protocol visits and 11% of entries. The media also served in an adjunctive role to other recruitment strategies. The yield from television and newspaper messages was generally better than that from radio. The flow of response varied appreciably among these types of media. Only one-fourth as many participants recruited through this strategy were excluded due to unwillingness to proceed at the first protocol visit as was observed among all sources.

Comparison of established and innovative weight-reduction treatment procedures.

A central component of a commonly used weight-loss procedure developed by Stuart (1967), which emphasizes situational engineering (SE), was compared to eating behavior control (EBC), a treatment employing reinforcement of changes in eating habits. A third treatment encouraged development of individuals' own applications of a model of self-control and attempted to provide effective feedback regarding progress toward weight-loss goals. This self-initiated treatment (SI) was designed to be less directive than many behavioral treatment packages and to be more realistic about the expectations of subjects and the actual eating habits of overweight and normalweight people. Following baseline, treatment lasted six weeks and followup lasted 16 weeks. While all treatments produced weight losses, EBC surpassed SE during treatment. SI losses during treatment did not differ from SE or EBC, but SI was the only group that lost weight throughout followup, indicating the possible utility of more subtle, less directive interventions than those that have often been associated with behavioral approaches. The results of SE question the applicability to clinical procedures of the external cue hypersensitivity theory of obesity (Schachter and Rodin, 1974), to which SE is closely related.