Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention
Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention
Anthony Jerant 1 2
Richard L. Kravitz
Daniel Tancredi 1 5
Debora A. Paterniti 0 1 4
Lynn Baker-Nauman 1
Chloe Villarreal 1
Andrew Hudnut 3
Peter Franks 1 2
0 Department of Internal Medicine, Division of General Medicine, University of California Davis School of Medicine , Sacramento, CA , USA
1 Center for Healthcare Policy and Research, University of California Davis School of Medicine , Sacramento, CA , USA
2 Department of Family and Community Medicine, University of California Davis School of Medicine , Sacramento, CA , USA
3 Sutter Medical Foundation , Sacramento, CA , USA
4 Department of Sociology, Sonoma State University , Rohnert Park, CA , USA
5 Department of Pediatrics, University of California Davis School of Medicine , Sacramento, CA , USA
BACKGROUND: Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors. OBJECTIVE: To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT). DESIGN: Randomized controlled trial. PARTICIPANTS: Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California. INTERVENTIONS: Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min. MAIN MEASURES: The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption). KEY RESULTS: Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant betweenarm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.12.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores. CONCLUSIONS: Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS.GOV IDENTIFIER: NCT01618552
continuing professional development; health behavior; patient engagement; physician behavior; primary care; J Gen Intern Med 31(7); 716-22 DOI; 10; 1007/s11606-016-3644-z © Society of General Internal Medicine 2016
ehaviors such as following a prudent diet, exercising
regularly, and adhering to medications can improve
chronic illness outcomes, yet patients struggle with these
behaviors, in part due to low motivation.1 While research
indicates primary care providers can be trained to enhance
patients’ behavioral motivation,2–5 evidence-based methods
such as motivational interviewing are broad in scope, difficult
to learn, and lengthy to apply.6–14 As a result, the approaches
are not widely employed in practice, where primary care
providers must address multiple issues in office visits, seldom
limited to behavioral change.15–17 There is an urgent need for
effective, focused, time-efficient interviewing approaches that
busy practitioners can routinely employ to motivate healthy
One promising approach is training primary care providers
to enhance patient self-efficacy, or confidence in their ability to
complete the tasks leading to a behavioral goal.19 Theory and
research indicate that self-efficacy influences myriad
behaviors and can be strengthened by interventions, improving
health outcomes.19–29 We had previously developed a brief
intervention for training resident primary care physicians
(PCPs) to use self-efficacy-enhancing interviewing techniques
(SEE IT).30 The intervention was grounded in self-efficacy
theory, and informed by prior interventions shown to bolster
self-efficacy and improve health behaviors and outcomes.
Standardized patient instructors (SPIs) delivered the training
in outpatient visits, scheduled during usual office hours,
juxtaposed with real patient visits. In a randomized controlled
trial (RCT), residents receiving the intervention increased their
use of SEE IT and had favorable responses to training.30
Whether these findings extend to practicing PCPs, who
might be less amenable to learning new interviewing
techniques, remained unclear. We addressed this issue in the current
RCT, examining the impact of the SPI-delivered intervention
on practicing PCPs’ use of SEE IT and soliciting their
responses to the training. SPI delivery maximizes the salience
and impact of training by allowing providers to immediately
practice and assimilate new skills in their daily work
environment. Also, we anticipated busy practicing PCPs would
appreciate training using SPIs, because it entails no time
commitment outside of usual work hours.15 Beyond the success of
our prior RCT of SEE IT targeted to resident PCPs,30 other
SPI-delivered interventions have improved surgeons’
informed consent skills31 and PCPs’ skills in assessing human
immunodeficiency virus risk32 and addressing patient requests
for low-value testing.33
We hypothesized that, compared with practicing PCPs
receiving an attention control intervention, those receiving
SPIdelivered SEE IT training would: (
) demonstrate greater use
of SEE IT during three post-intervention evaluation
standardized patient visits; (
) perceive greater value in their training;
) indicate similarly low hassle in participating.
We conducted the trial activities from January 2013 through
December 2014. We obtained ethics approval from the
University of California Davis (UCD) and Sutter Health
institutional review boards.
Study Setting, Sample Recruitment, and Randomization
We recruited family physicians and general internists from 12
primary care offices in the Sacramento, California area, drawn
from the UCD Primary Care Network and Sutter Medical
Group. All of the practices were fully focused on providing
patient care; none were academic (e.g., residency training)
sites. The physicians were solicited for participation via
presentations at practice meetings, with follow-up e-mails and
phone calls. A research assistant obtained informed consent
for participation using a standard consent form. Sutter
physicians received $325 for participating. UCD physicians could
not receive direct monetary compensation, so we transferred
$325 to the primary care network for each UCD physician,
which then credited each with an equivalent amount of relative
value units (RVUs).
The PCPs were randomly assigned to receive either SEE IT
training or an attention control intervention. Recruitment
personnel achieved randomization by using a custom-created
computer program that implemented randomization in blocks,
with random variation in block size (2, 4, 6, or 8).34
Recruitment personnel and SPIs were aware of the PCPs’
random study group allocation. All other personnel
(investigators, biostatistician, trainers of the SPIs and evaluation
standardized patients, study visit audio-recording coders) were
blinded to the PCP study arm.
Experimental Intervention. The experimental intervention
provided training on the use of nine self-efficacy-enhancing
interviewing techniques (SEE IT), presented in a logical
sequence (Fig. 1). The techniques were drawn from self-efficacy
theory, other relevant behavioral theories, direct observation of
primary care, and research-proven approaches to enhancing
self-efficacy and promoting healthy behaviors.19–29
Standardized patient instructors (SPIs) delivered the training
over three outpatient visits, scheduled during the PCPs’
regular office hours. We notified study PCPs in advance of SPI
visits. We employed pre-notification because PCPs tend to
have less favorable views of unannounced SPI visits.32 The
SPIs audio-recorded all experimental intervention visits using
pocket digital recorders.
The experimental training visits were timed to last 20 min.
In the first 7 min, the SPI portrayed a patient with co-existing
depression and diabetes who was struggling with medication
adherence and other behaviors known to help control these
conditions. Each of the three SPI visits featured a completely
different fictional patient and scenario. Each actor was trained
to portray only one patient/scenario. Across the three SPI
visits, case presentation sequence varied non-randomly among
PCPs. Random case sequencing was not feasible due to
scheduling constraints. SEE IT steps 1–3 were presented in the first
SPI visit, steps 4–6 in the second visit, and steps 7–9 in the
A pocket digital timer alarm prompted the SPI to come out
of patient role at 7 min, introduce themselves, briefly review
the purpose of the remaining 13 min of the visit, address
questions, and then deliver the training. The SPIs employed
standard scripts implemented on flip cards, and provided each
physician with a copy of the SEE IT diagram (Fig. 1), referring
to it periodically for orientation and clarification. For each
targeted interviewing technique, the SPIs employed the
following approach: first, state the technique; if PCP used the
technique during the patient portion of the visit, note and
reinforce its use; if PCP did not use the technique, gently point
this out, identify where it might have been used in the
foregoing encounter, and demonstrate how to use it; briefly resume
patient role and allow the PCP to practice the technique; solicit
and answer questions before moving to the next technique.
Videos simulating the three experimental SPI training visits
(drawing on audio recordings from the trial) are available at:
http://bit.ly/1HuSNgN (visit 1); http://bit.ly/1K7EX7K (visit
2); and http://bit.ly/1M613ai (visit 3).
Attention Control. SPIs delivered the attention control
intervention in a single visit. Similar to the experimental
SPI visits, the SPI initially portrayed a patient with
depression and diabetes struggling with self-care, then
came out of role at 7 min to deliver the intervention,
audio-recording the visit with a pocket digital device.
However, the control intervention was an 8-min video
summarizing new medications for type 2 diabetes, viewed on a
laptop.35 The video contained no material on self-efficacy,
health behavior, or patient interviewing, and the SPI did not
discuss these issues. The SPI also provided the PCP with a
printed copy of the journal article from which the video
content was drawn.36
Post-intervention Standardized Patient Visits. All study PCPs
received three pre-announced evaluation standardized patient
visits 1–3 months post-intervention. Each visit again featured
a different Bpatient^ struggling with medication adherence and
other depression- and diabetes-related health behaviors, with
non-random variation (due to office scheduling constraints) in
case sequence among physicians. Unlike the SPIs, evaluation
standardized patients stayed in patient role throughout. PCPs
in both study groups were notified in advance of the visits,
since providers tend to prefer pre-announced standardized
patient visits,32 and because we sought simply to determine
whether the PCP had learned how to use the targeted
interviewing skills. Standardized patients audio-recorded
evaluation visits using pocket digital recorders.
SPI and Standardized Patient Training. Seven individuals
were trained as SPIs, while nine additional individuals were
trained to make evaluation standardized patient visits. Both
genders and a range of ages, races, and ethnicities were
represented in the SPI and standardized patient pools. All
had prior amateur and/or professional acting experience, and
many had worked as standardized patients (but not as SPIs).
The training processes were developed and implemented by a
physician assistant with over 30 years of SPI and standardized
patient training experience, and were maintained by two
The trainers conducted monthly fidelity audits of about
10 % of the SPI and evaluation standardized patient visit
recordings, using a standardized checklist (options for all
items: excellent; acceptable but with room for improvement;
or not acceptable). With regard to SPI and SP patient role
portrayal (31 visits audited), fidelity was as follows: stayed in
character, 31 (100 %) excellent; realistically disclosed
selfcare issues, 25 (81 %) excellent, 5 (16 %) acceptable, 1 (3 %)
not acceptable; and conveyed appropriate depression level, 25
(81 %) excellent, 6 (19 %) acceptable. For SPI presentation of
interviewing techniques (N = 27 technique presentations [9
visits audited × 3 techniques presented in each], fidelity ratings
were 22 (81.5 %) excellent and 5 (18.5 %) acceptable. Trainers
provided corrective feedback to actors based on the audits
PCP Use of SEE IT. The patient role portion of the first
experimental group SPI visit and of the sole SPI visit in the
control group represented the baseline (pre-intervention)
interaction (henceforth Bvisit 1^). The three evaluation
standardized patient visits were the post-intervention interactions
(henceforth Bvisits 2, 3, and 4^). Three trained coders, blinded
to physician study group, listened individually to each
recording and applied the Doctors’ Observable Use of
Self-EfficacyEnhancing Interviewing Techniques (DO U SEE IT) measure,
a count of ten behaviors, employed in our prior
residentfocused RCT.30 Six of the ten DO U SEE IT items
corresponded to SEE IT steps 1–4, 8, and 9 in Figure 1; three items
corresponded to the three Bsub-behaviors^ of SEE IT step 6
(blue circles in Fig. 1); and a final item assessed both steps 5
and 7, given their overlap. All ten items employed a yes/no
response scale (PCP demonstrated/did not demonstrate
behavior), with one point assigned for each Byes^ response (score
range 0–10). We maintained coder blinding by removing
PCP–patient introductions from recordings and, for visits 2–
4, by truncating the recordings just before the SPIs left the
patient role. The mean chance-corrected agreement (kappa)
among the three coders for each item was 0.60 (range 0.11–
0.83, all P < 0.01). Subsequently, one of the coders,
predesignated as master coder, reconciled any between-coder
discrepancies via group re-review and discussion of
recordings until consensus was reached. The consensus DO U SEE
IT scores were employed in the current analyses. Cronbach’s
alpha (α) for the measure was 0.94.
PCP Responses to Intervention. Following their participation,
PCPs completed an 11-item measure of their responses to
study intervention and trial participation (Online Appendix).
All items employed five-point Likert response scales. We
conducted an exploratory factor analysis of this newly
developed measure, which indicated two factors. Seven items
formed a Value scale (mean score 4.03, standard deviation
[SD] 0.80, higher scores = higher Value; α = 0.96). Items in
this scale concerned training quality, helpfulness,
understandability, practice relevance, feasibility of application, plans for
future use, and anticipated impact on patient care. Two
items—personal hassle and disruption of patient flow—formed a
Hassle scale (mean 2.17, SD 0.87, higher scores = higher
Hassle; α = 0.73). The two remaining items, SPI case realism
and PCP willingness to participate in future similar studies, did
not load with other items, so we examined them individually.
We also collected information regarding PCP age, gender,
race/ethnicity, and specialty.
Data analyses were conducted using Stata (version 14.0;
StataCorp LP, College Station, TX, USA). To examine the
effects of the experimental intervention on PCP use of SEE IT,
we used mixed Poisson regression models, accommodating
the repeated measures on each physician. The dependent
variable in the primary analysis was the total DO U SEE IT
score in each visit from the three post-intervention evaluation
standardized patient visits (visits 2–4). The key independent
variable was the randomly assigned study group (experimental
SEE IT training versus attention control). Secondary analyses
adjusted for the baseline (visit 1) SEE IT score. Further models
examined visit-by-intervention group interaction terms (as an
alternative assessment of the interaction effect and growth of
the effect over time). We also explored whether PCP
characteristics (age, gender, race/ethnicity, specialty) or patient case
scenario were associated with the experimental intervention
effect on DO U SEE IT score and, in analyses limited to the
experimental arm, whether there was an effect of SPI (actor)
on DO U SEE IT score. To explore for possible differential
effects of SEE IT training on component interviewing
behaviors, we conducted analyses considering three sub-groupings
of the behaviors: SEE IT steps 1–3, 4–6, and 7–9,
corresponding to their presentation in SPI visits 1, 2, and 3,
respectively. We used t tests to examine PCP responses to their
randomly assigned study intervention.
Of the 102 PCPs in the participating offices, 52 (51 %)
enrolled in the RCT. Figure 2 depicts the flow of PCPs
through the trial, while Table 1 summarizes PCP
characteristics by trial arm. None of the differences in characteristics
Table 1 Characteristics of Participating Primary Care Physicians
by Study Group
Age, mean (SD)
Female, no. (%)
Race/Ethnicity category, no. (%)
Hispanic (any race)
Health system, no. (%)
University of California Davis
Specialty, no. (%)
SEE IT training
group (N = 28)a
SD standard deviation, SEE IT self-efficacy enhancing interviewing
aSPI visits could not be scheduled for one physician in each group,
leaving 50 (27 experimental, 23 control) who received their randomly
between groups were statistically significant (P ≥ 0.17 for
Effects on PCP Use of SEE IT. Fifty PCPs completed their
baseline and three post-intervention evaluation visits (Fig. 2).
Table 2 shows the unadjusted DO U SEE IT scores by study
group and visit. At baseline, study physicians used a mean 0.7
targeted behaviors per visit (median 1, range 0–2), with no
significant difference in use between trial arms.
Post-intervention, experimental arm PCPs had higher mean use of SEE IT
and a wider range of interviewing behaviors used per visit than
controls (Table 2).
Across the three post-intervention visits, experimental
group PCPs used significantly more of the targeted
behaviors than controls (mean 2.7 versus 1.0 per visit; adjusted
difference 1.7, 95 % confidence interval [CI] 1.1, 2.2;
P < 0.001). The model formulation examining the effect of
the intervention through an interaction between
experimental group and visit (including baseline visit) yielded
consistent results (interaction effect chi-square 14.1, degrees of
freedom 3, P = 0.003).
In analyses exploring moderation of the SEE IT training
effect by PCP or contextual factors, there were no significant
interactions with physician gender, age group, or
race/ethnicity, or with evaluation visit number or case scenario.
Additionally, in an analysis limited to experimental arm
PCPs, there was no significant SPI effect on the primary
outcome (F = 1.43, P = 0.25). There were also significant
effects of the experimental training on each of the three
subgroupings of interviewing behaviors (SEE IT steps 1–3, 4–6,
and 7–9). Further details of these exploratory analyses are
available from the authors.
PCP Responses to Study Training and Participation.
Compared with controls, SEE IT-trained PCPs had more
favorable Value scores (mean 1.05 points higher, 95 % CI 0.68,
1.42; P < 0.001). Both the experimental and control group
providers had low Hassle scores, high ratings of SPI case
realism, and high willingness to participate in future studies,
with no significant between-arm differences in these responses
(details available from authors).
In an RCT, we found that a brief intervention, delivered by
SPIs over three 20-min outpatient visits conducted during
usual office hours, increased the use of SEE IT among
practicing primary care physicians (PCPs). The SEE IT training
effect did not wane over the evaluation period (1–3 months
post-intervention), and was present in both younger and older
providers and regardless of PCP gender, race/ethnicity, or
specialty. SEE IT-trained PCPs also perceived high value in
their training (e.g., quality, relevance, anticipated clinical
impact) and little hassle in participating. These findings expand
upon the similarly encouraging findings of our prior RCT of
SPI-delivered SEE IT training, which focused exclusively on
Primary care physicians provide the bulk of care for
individuals with depression, diabetes, and other chronic
illnesses,37 and research indicates that enhancing self-efficacy
can improve health behaviors and outcomes among
chronically ill patients.19–29 Prior studies also indicate that physicians’
behaviors during standardized patient encounters correlate
with their behaviors during real patient visits.38,39 In this
context, the combined findings of our practicing
Visit 1 (baseline)
DO U SEE IT Doctors’ Observable Use of Self-Efficacy-Enhancing Interviewing Techniques, SD standard deviation, SEE IT self-efficacy-enhancing
focused and resident PCP-focused trials suggest that routinely
offering SEE IT training to PCPs, regardless of their
experience level, could have considerable clinical impact, potentially
leading to improved patient health behaviors and outcomes.
Additional studies are warranted to examine whether the
effects we observed will generalize to real patients and will
lead to improved health behaviors and outcomes.
If SPI-delivered SEE IT training is shown through further
study to have clinical impact, it will have the potential for
broad dissemination and implementation in practice, given its
brevity and delivery during usual patient care hours, and that
physicians appear to value the training and perceive little
hassle in receiving it. Also of relevance to future dissemination
and implementation potential, 51 % of the PCPs working in
the participating offices volunteered for our trial, suggesting
that the notion of SEE IT training resonates with many PCPs.
Eventually, SPI and standardized patient training centers
might be established in strategic locations throughout the
U.S., providing SPIs and standardized patients (and/or SPI
and standardized patient trainers) to practices and health
systems in various geographic regions. Such an approach might
be implemented under the aegis of medical specialty licensing
boards, as part of the growing push to achieve more
evidencebased, clinically relevant and practical maintenance of
Our trial had some limitations. The PCPs were enrolled
from 12 primary care offices drawn from two health
systems in a single, relatively small geographic region.
Whether the findings generalize to offices and PCPs
elsewhere is unclear. Because the evaluation standardized
patient visits in our trial were pre-announced, we have shown
that practicing PCPs can demonstrate the targeted
interviewing behaviors under prompted circumstances. It is
uncertain whether PCPs would use the targeted interviewing
behaviors without prompting. Nonetheless, prior SPI trials
suggest that visit behavioral outcomes are largely not
affected by whether post-intervention evaluation
standardized patients are detected.41
We conclude that primary care physicians who received
brief SPI-delivered training on the use of SEE IT during their
usual outpatient office hours subsequently increased their use
of SEE IT, and perceived the quality, utility, and anticipated
clinical impact of the training very favorably. These findings
warrant replication with real patients in other settings, and
determination of whether patients exposed to SEE IT-trained
primary care physicians will experience improved health
behaviors and outcomes.
Contributors: We are grateful to the following individuals for their
outstanding contributions: Julie Anchor, Todd Gearou, Mike Kerrigan,
Nikki Lausmann, Patris Miller, Betsy Reifsnider, and Stephen Savage,
standardized patient instructors; Michael Coleman, Bridggett Davis,
DeMarco Davis, Mark (Moe) Davis, Martin Idle, Corey Jackson, Desi
Motley, Peter Playdon, and Wanel Thomas, standardized patients;
Emily Hanes, Sanjeet Grewal, and Rimaben Cabrera, study visit audio
recording coders; Simon Dvorak and Charles Turner, PhD, who
programmed the randomization program and electronic
questionnaires; and Lizette Macias, who participated in electronic questionnaire
programming, trial recruitment and enrollment, and data collection. We
are also indebted to all of the participating primary care offices and
providers. We dedicate this paper to the memory of our friend and
colleague Janice Bishop, who made key contributions to training the
study SPIs and standardized patients.
Funders: This work was supported by grant R34MH095893 (Jerant)
from the National Institute of Mental Health, with supplemental funding
provided by the University of California Davis Department of Family
and Community Medicine. The funders had no role in the design or
conduct of the study; collection, management, analysis, or
interpretation of data; or preparation, review, or approval of the manuscript, or
decision to submit the manuscript for publication.
Corresponding Author: Anthony Jerant, MD; Department of Family
and Community Medicine, University of California Davis School of
Medicine, 4860 Y Street, Suite 2300, Sacramento, CA 95618, USA
Compliance with Ethical Standards:
Conflict of Interest: The authors declare no conflicts of interest.
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