Though effective, prior interventions for enhancing patient self-efficacy have been focused directly on patients, have often been condition-specific14–18,19,21,22
and have been removed from physician-patient office visits.14,17,18,20–23
. We found a brief, office-based, SP instructor-delivered intervention led to significant improvements in family medicine and internal medicine residents’ use of SEE IT during SP encounters. Of note, the difference became apparent after one training visit, and persisted without attenuation through two post-intervention visits conducted within a month of completing the intervention, only one of which involved patient conditions encountered by residents during a training case. These observations suggest that resident use of SEE IT may generalize to patient health behavior concerns beyond those encountered during training visits.
While our case scenarios reflected common presentations of prevalent physical and mental health conditions in primary care, studies more optimally designed to assess physicians’ use of SEE IT across patient concerns are required to further explore this issue. Prior studies indicate that physician interviewing behaviors demonstrated during SP encounters correlate with their use during real patient encounters,40
and with patient ratings of physician interviewing behaviors.41
Future studies should evaluate physician use of SEE IT during actual patient visits over longer periods of time and explore the impact of SEE IT training on patient self-efficacy, health behaviors, and outcomes.
Self-efficacy is a key mediator of patient behaviors across a wide array of health conditions and settings,42
and self-efficacy enhancement can lead to improved health outcomes.14–23
If SEE IT training is shown to facilitate patient health behavior change and improve patient outcomes, its potential to improve health care could be considerable. First, however, it would need to be disseminated from research into practice. To do so, training centers could be strategically placed to supply SP instructors to practices in various regions.
Self-efficacy also tends to be lowest in those most vulnerable to adverse health outcomes, such as minorities44
and people with depression,45
yet preliminary evidence suggests such individuals may derive the greatest benefit from well-conceived self-efficacy enhancing interventions.23,46
Thus, training physicians to employ SEE IT also holds promise as a “downstream” approach to reducing health-care disparities.47
Encouragingly, participating residents were not highly selected; 73% of eligible family medicine residents and 44% of eligible internal medicine residents enrolled. However, the Cronbach’s alpha among DO SEE IT items was moderate (0.61), suggesting that individual residents were consistent in their use of SEE IT (i.e., substantial, moderate, or minimal use). Additional work is needed to optimize resident response to SEE IT training.
The SP instructors presented SEE IT sequentially. Since the teaching lasted only 15 min, and residents had little familiarity with the material, techniques toward the bottom of Figure received less attention. Exploratory analyses confirmed that most changes in experimental group resident use of SEE IT relative to controls occurred for Techniques 1 through 6 (details available upon request). Providing the SEE IT training over three to four visits might remedy this problem. However, studies are be required to examine how increasing the number of SEE IT training visits may affect resource requirements, clinical effectiveness, and dissemination potential.
Our RCT had additional limitations. The experimental group had more senior year residents and greater baseline use of SEE IT than controls; however, the analyses adjusted for these differences. The teaching portion of both training visits was twice as long in the experimental as control group, so observed differences in post-intervention SEE IT may reflect attention differences. Also, while the post-intervention SP visits were not pre-announced, participating residents discovered they were seeing an SP after logging into the electronic medical record. Thus, we have shown residents were able to apply SEE IT under “prompted” circumstances (unannounced but detected SPs). However, prior SP intervention studies suggest little impact on outcomes whether SPs are detected or not.48
Finally, studies will be needed to address whether the intervention will work in practicing physicians. A similar SP instructor intervention has been shown to improve practicing physicians’ human immunodeficiency virus risk assessment interviewing skills.30
We conclude that SP instructors can train residents to apply SEE IT during office visits with SPs portraying individuals with common primary care problems and health behavior change concerns. The effect was apparent after a single SP instructor training visit and persisted without attenuation through two additional evaluation SP visits. Studies are warranted to determine the effects of SEE IT on practicing physicians, and on actual patients, including their health behaviors and outcomes. However, our findings suggest that training primary care physicians to use SEE IT—generic techniques that can be applied to facilitate essentially any health behavior change—has potential for wide dissemination and clinical impact.