- BASED PATIENT - CENTERED INTERVIEWING METHOD ON PHYSICIAN KNOWLEDGE, PHYSICIAN SELF - EFFICACY, AND PATIENT SATISFACTION VIA A NEWLY DEVELOPED PATIENT - CENTERED CODING SCHEME By Katelyn Anne Grayson - Sneed A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Communication - Doctor of Philosophy 2015 A BSTRACT - BASED PATIENT - CENTERED INTERVIEWING METHOD ON PHYSICIAN KNOWLEDGE, PHYSICIAN SELF - EFFICACY, AND PATIENT SATISFACTION VIA A NEWLY DEVELOPED PATIENT - CENTERED CODING SCHEME By Katelyn Anne Grayson - Sneed There is a movement in healthcare to train medical workers in patient - centered care due to many - centered interviewing method (Fortin, Dwamena, Frankel, & Smith, 2012) is a behaviorally - defined, evidence - based method that has shown to be easily learned and associated with positive outcomes such as increased patient satisfaction . H owever, this method was lacking in a systematic, standardized way of rating adopters of the method to discover wh ich patient - c entered skills prescribed by the method led to positive outcomes. Therefore, this research effort involved develop ing a coding scheme comprising - steps. This research provided evidence construct validity, and inter - results of the coding scheme w ere then tested to determine whether training in patient - centered interviewing le d to provider knowledge, provider self - efficacy, or patient satisfaction . Providers who received training in patient - centered interviewing use d significantly more patient - centered skills than did untrained providers. Similarly, an increase i n patient - centered skill use le d to provider self - efficacy. The patient - centered coding scheme developed here will provide institutions with an instrument that combines descriptive and evaluative elements of provider patient - centered behaviors and will allow for a standardized way of evaluating those who adopt the method. iii This dissertation is dedicated to my parents and to my husband. I would not be who I am today without the love and guidance that my mom and dad have continually provided to me. I thank God every single day for my parents, who taught me that hard work, pe rseverance, and an occasional tear will allow me to achieve all of my dreams. And of course to my husband, Sam. You make me laugh even when things are not funny, and things have not been very funny during our time in Michigan. Thank you so much for that , an d for always believing in me. I love the three of you beyond words, thank you for continually being my biggest fans. XO! iv ACKNOWLEDGEMENTS There are many people who have guided me along my path and who have helped me to achieve my dreams. I am so fortunate to have suc h amazing people in my life because without them, this would not have been possible. uck out!! Greg, Josh, Pat, Rain, Shannon, and Soo, my journey here at Michigan State was absolutely inc redible because of each of you . I love that competition was never an issue between us and instead we chose to help each other become the best that we each could be. All of you brought something unique to my time at Michigan State, and I will forever be g rateful for my time spent with you . E ven more amazing to me is that we are walking away from this experience with lifelong friends. I mean it, I love all of you so much! To my East Lansing BFF, Shannon Cruz. You made being in Michigan fun, from our Thu imosa Sundays , you somehow made getting a doctorate fun. More importantly, you taught me SO much. You are brilliant, and being able to learn from you enhanced my experience and my degree far more than I think you know. Our s tatistic dates, although not as fun as our beer dates, were incredibly insightful and made my work and my understanding of statistics so much stronger statistics it is a rare gift . Your students for the rest of your life will be the luckiest of students Dr. Jon Hess, five years ago when I was sitting in your office going over a class paper, you suggested that I pursue my PhD. The thought of going on for my doctorate had truly never even crossed my mind. Thank you so much for believing in me and for pushing me to achieve this incredible goal, it is my proudest achievement and has been one of the best experiences of v my all you have done for me, your help and what yo u have taught me is in valuable . To my fantastic committee: Drs. Amanda Holmstrom, Francesca Dwamena, and Maria Lapinski. I have learned so much from all of you, and am a far better scholar because of your comments and insight. Thank you so much for pushing me, because of eac h of you and your dedication to my work I am really proud of what I have accomplished. I truly picked the best committee, and I have learned far more than I ever dreamed. Dr. Robert Smith, there will never be enough words to thank you for all that you have done for me. Not just for funding me and providing me with the opportunity of my lifetime, but for introducing me to the provider - patient relationship in a way that I never would have been able to find on my own, and for teaching me all of the wonder ful things there are to know about patient - centered care. I came to Michigan State with a general sense that I wanted to study interperso nal communication in the health care context, and I am leaving Michigan State with a strong passion for patient - centere d care and the many other things that you have taught me about the provider - become such an incredible friend to me during my time here, and I am infinitely better for having kn own you. I will always be grateful for what you have provided me with, and I will always b e happy to have you as my mentor and friend . Thank you so much! live Not many professors/advisors let their students come over to discuss paper ideas, get hel p with homework, vi have lunch, and of COURSE, hang with the best doggies! Thank you for always helping me through what I did not understand, and being patient with me as I tried to keep up. Your influence on my work and thinking is unmatched. I am going to miss our weekly dates, but I know our friendship will last forever. That makes me so happy! Ashtray, the bestest listening and helping me through the toughest and darkest of days. Your fri endship is invaluable (#thebigC), because that meant that during the last three years you always understood when I was busy, and always found time to talk when I was n ot. It is so wonderful to have a friend who knows me so well, cheers me on, and helps me celebrate in a proper fashion (champs anyone?) I will be grateful until the end of time that you decided not to get off the school bus in third grade, because that d ay prov best friend . I will forever be grateful for your friendship. I love you lots and lots. Gram, at a very young age you started teaching me things and fostering my love for You even taught me that a person can be their own grandpa. Music helped me so much during my time at Michigan State. It was an escape for me when everything else was so challenging that I thought I should give up. There were many days that music was my only solace , and I owe the calm, relaxed feeling that it brings me to you and all of your musical teachings. ix You have been an incredible influence in my life, and that influence helped get me to where I am today. I am so, so lucky to have you for my grandma, because you are the best that there is. always needed you. I love you so much, Grandma. Grandpa Grayson, your memory inspired me to follow in your footsteps and become the first Dr. Grayson in the family since you. Although I will never be able to fill your big shoes, I hope that my borrowing your title makes you smile and I hope you know that so much of my drive has come from y ou. We all miss you very much and wish you were here. I am grateful for the time we got with you and Grandma while you were still with us! To m y brothers, Jer and An, how lucky I am to get to be the sister to the two of you. Jerry, I have looked up to you since the moment I was born, and still do. You work so hard and provide so much for you and Katelyn, it makes me so proud of you. Having a cool older brother that everyone admired helped me to strive in my own life to be as good and as kind as you ha ve always been. Thank you for being a wonderful big brother, for making me laugh, and for being He did a sit down in a stand u p! absolutely incredible you are and will always be . I love you so much. Dad, thank you so much for instilling in me that hard work pa ys off. Your consistent hard work to provide for our family was always inspiring, and you are the person in my life that I look up to the most. Making you proud is always an ultimate goal of my aspirations, and it is because of this that I am motivated t o do great things with my life. I hope to achieve as much as you have during my lifetime, and I hope to be as selfless and giving as you. Your selflessness ix allowed all of your children to attend college debt free, which meant that I got the start I neede d to make it into my graduate studies. Also, thank you for all of the beer you have bought us during my doctoral program, those beers and chats on the patio (where I did all of the chatting) were s ome of my only escapes from the difficulty of the last thr ee years. I will forever be grateful, and will always love you so much for being the best dad. Mom, you have always been my biggest fan and I consider myself the luckiest girl alive because of that. You always help me strive to be the best that I can b e, and you stand by with the most incredible amount of support that I have ever seen or known. You are the reason I push myself to continue achieving in my life , and you are the reason that at the end of the day, I believe in myself. I have always believ ed in myself because you always have, and that is honestly the only reason I have gotten as far as I have. Thank you for letting me call you and cry (every week). Thank you for just listening. Thank you for all of the times you provided me with invaluab that pride makes me feel so much pride for myself. Thank you for giving up on many of your own dreams - at - home mom, and for ultimately providing the most loving home and upbringing imaginable. Your willingness to giv e up those dreams provided your children with the ability to do and become anything they wanted, and I am positive that none of us would have achieved what we did without you and your support. Most of all, thank you so much for being my BFF and for loving me as much as you do. I would not be who I am without you, and my life would not be nearly as fun without you in it. Someday, I hope to be ix even half the mom that you are to me. You are, and always will be, my hero and my best friend . I love you very, very much, girlfriend ! Finally, and most importantly, to the man of my dreams, my confidant, my own personal to m y ecause there is no thank you large enough for what you have done for me. Not just for loving me (thank you, so much, for that!), but mostly for supporting me, being my rock, and lettin g me achieve all of my dreams. When I told you that I wante d to move to Michigan to pursue my PhD, you did not look overly thrilled. But you came with me, did not complain (too much), and achieved one of your own dreams and made the most of these last three years (Yay, Esquire!). I mean it when I say that this w ould have never happened without you. You are in every way my strength, and through the countless tears and upsets, you held me and convinced me that I am smart and that I can do this. Sometimes I do not know how YOU did it. What I do know is that I am truly the luckiest woman in the universe, because I honestly got the best husband alive . Thank you so much for being my best friend and for loving me. You are the very best part of me, my truly better half. I am forever thankful that I chose to wear my x TABLE OF CONTENTS LIST OF TABLES xii LIST OF FIGURES xiii INTRODUCTION 1 CHAPTER 1 : LITERATURE REVIEW 3 Patient - Centered Care 3 Background 3 Importance 6 Health Outcomes 10 Patient - Centered Interviewing : A Review 12 - Centered Interview 16 Step One 18 Step Two 19 Step Three 20 Step Four 21 Step Five 26 Provider and Patient Outcomes: Knowledge, Self - Efficacy, and Satisfaction 29 CHAPTER 2 : METHOD S 35 Participants 35 Procedure 35 Training 35 Data Collection 37 The Development of the Patient - Centered Coding Scheme 38 Assessing the Validity of the Developed Coding Scheme 41 Content Validity 42 Construct Validity 43 Criterion Validity 45 Training and Reliability 46 Instrumentation 48 Patient - Centered Training 48 Patient - Centered Skills 48 Patient - Centered Knowledge 49 Self - Efficacy 49 xi Patient Satisfaction with Communication 50 Measurement Analysis 51 CHAPTER 3 : RESULTS 53 CHAPTER 4 : DISCUSSION 56 Overview of Findings and Practical Implications 56 Directions for Future Research 64 Limitations 67 CHAPTER 5 : CONCLUSIONS 69 APPENDICES 70 Appendix A Four Habits Coding Scheme 71 Appendix B Four Habits Coding Scheme Extended 72 Appendix C - Centered Interviewing Method 75 Appendix D The Seven Descriptors of Symptoms 76 Appendix E Total Videotapes Data Chart 77 Appendix F Christina Smith Instructions for Provider 78 Appendix G Data Gathering Instructions to Standardized Patient 79 Appendix H Knowledge Questionnaire 8 1 Appendix I Simple Coding Sheet 87 Appendix J Pati ent - Centered Interviewing Codeb ook 88 Appendix K Patient - Centered Definitions, Glossary, and Emotion Guide 121 Appen dix L Tables 126 Appendix M Figures 140 REFERENCES 145 xii LIST OF TABLES Table 1 Pathway for the End of the Interview 126 Table 2 Resident Training Level by Grant Year 127 Table 3 Demographic Information Resident Questionnaire 128 Table 4 Efficacy Questionnaire 129 Table 5 Interview Satisfaction Questionnaire 130 Table 6 Communication Assessment Tool 131 Table 7 Patient - Centered Interview Coding Scheme 132 Table 8 Confirmatory Factor Analysis for the Patient - Centered Interviewing Self - Efficacy Variable Including Factor Loadings, Means, and Standard Deviations 133 Table 9 Confirmatory Factor Analysis for the Data Gathering and Relationship Building (Smith) Case Patient Satisfaction Items Including Factor Loadings, Means, Standard Deviations, and Scale Reliabilities 134 Table 10 Secord Order Unidimensio nal Factor Analysis for the ISQ Including Factor Loadings, Means, and Standard Deviations 135 Table 11 Descriptive Statistics of all Patient - Centered Outcome Variables by Condition 136 Table 12 Correlations among All Variables 137 Table 13 Correlations among the Separate Patient - Centered Skills and Patient Satisfaction Ratings 138 Table 14 Descriptive Statistics of Patient - Centered Variables by Condition 139 xiii LIST OF FIGURES Figure 1 Integrated Medical Interviewing 140 Figure 2 Patient - Centered Core Skills 141 Figure 3 A Proposed Patient - Centered Path Model to Test 142 Figure 4 Path Model of the PC Training Process 143 Figure 5 Updated Path Model of the PC Training Process 144 1 INTRODUCTION T here is a current movement toward training medical workers in patient - centered (PC) care (Roter, Stashefsky - Margalit, & Rudd, 2001; Smith et al., 1998) due to the many positive outcomes associated with exhibiting PC characteristics (Epstein, Fiscella, Lesser, & Stange, 2010) . PC Quality Chasm preferences, needs, and values, and ensur (Bloom, 2002, p. 6) . More specifically, there are three core values associated with a PC the patient t he opportunity to take part in their care and provide input, and (3) enhancing the understanding and the relationship between the provider and patient (McWhinney, 1995) . Due to the many positive outcomes associated with this particular type of care, such as patient satisfaction, patient adherence, and cost effectiveness (Stewart et al., 2014) , PC care has received increased attention recently and is considered a vital component of high - quality health care organizations (Greene, Tuzzio, & Cherkin, 2012) . T raining people in patient - centeredness is therefore critical; and part of successful training is assessing whether medical workers are using the style correctly if at all, and whether their use of the style is producing desired outcomes. Such assessments are crucial for potential growth in medicine. PC interviewing is an effective method for teaching PC provider - patient communication that ultimately results in enhanced patient care (Smith, 2002) . Currently, two behaviorally - defined, evidence - based methods of interviewing, (Fortin, Dwamena, Frankel, & Smith, 2012; Frankel & Stein, 2001) . R esearch indicates that training in either method results in learning of the PC skills (Fossli Jensen et al., 2 20 11; Smith et al., 1998) (Fortin et al., 2012) as its use leads to more satisfied patients compar ed to untrained providers (Smith et al., 1998) , shows clinical improvement of patients with medically unexplained symptoms (Smith et al., 2006) , and help s treating patients with somatization (Smith et al., 2009) . the only method available associated with positive patient health outcomes 1 . Although past research has demonstrated these fi ndings, it was lacking a systematic method for rating model which has five steps with 21 sub - steps. This will allow trained raters the ability to code provider - patie nt interactions for specific instances of patient - centeredness prescribed by the method. It will provide a standardized way of comparing those trained and untrained in the method and how that relates to patient and physician outcome data, such as patient satisfaction, provider self - efficacy, and provider knowledge. Additionally, the coding scheme will allow for standardized comparisons of medical professionals before and after training. This will show in a precise way what people learned from training, a nd more importantly, what they use in practice with patients after the training period and how this relates to important health outcomes. As such, a review of PC care, the history of its development, and its significance in medicine will be offered . Next, an examination of the two evidence - based methods currently available in medicine will be conducted, followed by a thorough review of the method of methods and a nalyses for developing and t esting the coding scheme are offered and results of the impact of PC training, shown via the developed PC coding scheme, on provider knowledge, provider self - efficacy, and patient satisfaction will be discussed. S uggestions for using the coding scheme in the future will be presented. 1 3 CHAPTER 1: LITERATURE REVIEW Patient - Centered Care Background. PC care has recently been described by the Institute of Medicine as one of the six aims of high quality health care (Bloom, 2002) , but the ideals associated with PC medicine date back to the ancient Greek schools of Cos (Crookshank, 1926) , indicating that several of these principles have been present for thousands of years. Client - centered therapy (Rogers, 1965) , also known as pers on - centered therapy, was developed in the 1940s and 1950s by Carl Rogers and was foundational in developing many PC ideals into practice. A therapist - centered therapy has three conditions to establish with their client: (1) empat hy, (2) unconditional positive regard allows the therapist to help the client correct maladaptive behaviors ("Client - Centered Therapy," 2009) cal interview context, and PC care was more thoroughly developed. A s PC ideals have been traced far back into history it seems that the development of the (2000) conceptual framework and review of the emp irical literature shows the many inconsistencies involved in defining and measuring patient - centeredness. In fact, Mead and Bower (2000) - utility may care, and developed five dimensions that encompass the varying definitions and aspects of PC (2000) work has been regard (de Boer, Delnoij, & Rademakers, 2013) , as the researchers were able to amalgamate over 30 years of PC conceptualizations into five distinct dimensions that will be reviewed here, as these dimensions 4 provide the most encompassing definition of what it truly means to be PC. The dimensions are: (Mead & Bower, 2000) . Due to the complexities involved in treating human patients, the biopsychosocial p erspective dimension to patient - centeredness encourages viewing patients as a combination of their unique biological, psychological, and social characteristics. The biopsych osocial principles were synthesized by Engel (1977) , and the adoption of this model was encouraged over the the social context in which he lives, and the complem entary system decided by society to deal 132). Engel (1977) noted that the biopsychosocial model would need to include the psychosocial aspects without sac rificing the advantages that the biomedical model brought to medicine. Patient - centeredness depends on this philosophy, as Stewart et al. (1995) explain that PC care requires that the doctor not just focus on the biomedical problems of the patient, but to also be involved in the full range of difficulties that patients bring with them. The biopsychosocial concept influenced the development of PC care, and is therefore a key dimension of what it means to be PC (Mead & Bower, 2000) . The dimension stresses that understanding the biopsychosocial perspective is not enough to be PC, as patient - centeredness also requires that the provider must (Mead & Bower, 2000) . Smith and Hoppe (19 91) issues involved in treating the 5 (Smith & Hoppe, 1991) . This dimension of PC care is concerned attempting to understand their patients as unique individuals in unique settings (Bower, 1998) . how they interpret their illness and the significance the illness has in their lives is vital to a PC appr oach (Mead & Bower, 2000) . The third dimension, sharing power and responsibility, envisions an egalitarian relationship between doctor and patient as opposed to the typical asymmetrical relationship traditionally experienced in medicine where the control a nd authority belong to the doctor alone (Mead & Bower, 2000) . PC care stipulates that mutual participation in the medical interview is important, as shared power and responsibility allows the patient to be involved in the decision making process (Mead & B ower, 2000) . This active participation on the part of the patient leads to increased respect and rights to full information regarding their treatment (Mead & Bower, 2000) , which in turn enables patients to gain responsibility regarding their health (Grol, de Maeseneer, Whitfield, & Mokkink, 1990) . Mead and Bower (2000) indicate that it is uncertain point here is that PC medicine promotes the idea of greater patie nt involvement in care. A therapeutic alliance is the fourth fundamental requirement of PC medicine, where the relationship between the provider and patient is seen as quite important (Mead & Bower, 2000) . The therapeutic alliance is not only important fo r a medical diagnosis and for being PC, but it has been suggested that the relationship itself has therapeutic benefits (Mead & Bower, 2000) . In order to produce a therapeutic change in patients, Rogers (1961) proposed that congruence, empathy, and uncond 6 status as a result of positive emotional responses. This aspect of patient - cent eredness is distinctly different from biomedical medicine, but it has shown to have positive biomedical outcomes. Thus, the inclusion of a therapeutic alliance is essential to PC care. Finally, the qualities into consideration, and goes against the notion that doctors are interchangeable; i.e. the stance that if a doctor is well - trained, it should not matter which doctor a patient meets at the clinic (Mead & Bower, 2000) . The doctor is a distinct pa interview through this lens creates a more important, integrative role for the doctor. The sensitivity and insight into the reaction of both the doctor and patient have the potential for therapeutic outcom es for both parties, showing the importance of the doctor themselves being a significant part of the relationship (Mead & Bower, 2000) . Thus, the assembly of these five distinct dimensions synthesizes the vast literature on patient - centeredness, and the c urrent research adopts an understanding of PC care in the terms created by these dimensions. PC care is defined here as an approach to medicine which encompasses five distinct dimensions of patient - PC care in medicine follows. Importance. PC approaches to care are increasingly being incorporated into the training of healthcare professionals and are supported by both consumers and clinicians (Dwamena et al., 2012) , indicating that this approach is important to both. There are three main outco mes that the literature provides for a PC approach to care that indicat e the importance of PC care. Each of the 7 three outcomes will be reviewed here: (1) increased patient satisfaction, (2) patient adherence, and (3) cost effectiveness (Stewart et al., 20 14) . Patient satisfaction care (Linder - Pelz, 1982) , is one positive outcome associated with PC care. People interested in PC care should be interested in patient satisfaction, because patient satisfaction has been positively associated with: (1) increased patient adherence to therapy (O'Brien, Petrie, & Raeburn, 1992; Sherbourne, Hays, Ordway, DiMatteo, & Kravitz, 1992) , (2) a lower tendency of patients suing for malpractice (Hickson e t al., 1994) , (3) greater patient adherence to medical treatments (Weingarten et al., 1995) (Ware & Davis, 1983) , and (5) increased patient recall (Falvo & Tippy, 1988) . These favorable patient satisfaction out comes, although not all directly related to health, are all positive and ultimately interested in patient satisfaction with PC communication (PSPCC), which is u nderstood as the - (Grayson - Sneed, 2014) . The remainder of this paper will focus on PSPCC when referring to patient satisfaction (i.e. no other forms of patient satisfaction outside of the provider - patient interaction will be reviewed). PC care has been shown to result in PSPCC. Krupat et al. (2000) found that physicians ex hibiting a PC approach to medicine garnered higher patient satisfaction than doctors who did not exhibit the approach. Similarly, Fossum and Arborelius (2004) analyzed orthopedic physicians to see what characteristics were associated with patient satisfac tion, as most research on PC care is focused on general practitioners. This research found that when the patient was 8 involved in the consultation, and when the physician and patient were able to arrive at shared understanding, the patient was more satisfi ed; therefore, the researchers concluded that ultimately increase their patient satisfaction (Fossum & Arborelius, 2004) . Zyzanski, Stange, Langa, and Flocke (1 998) found that patients of high - volume physicians were less satisfied as they reported less attention to their responses, less follow - up on their problems, and inadequate explanations, lending support to the belief that PC care results in higher satisfact ion. Finally, (1999) literature review revealed that when patients are dissatisfied and have complaints about their doctors, it is usually due to communication problems rather than technical competency issues, showing the link between a P C approach to medicine and increased patient satisfaction. Patient adherence , or the degree to which patient behavior coincides with health or medical advice (McDonald, Garg, & Haynes, 2002) , has also been positively associated with PC care. Patient adhe rence is desirable, as a meta - analysis looking at patient adherence and medical treatment outcomes found that patient adherence to medical regimens is linked to more positive outcomes than is non - adherence; specifically, the meta - analysis included effects from more than 19,000 patients in 63 studies, and approximately 26% more patients experienced a favorable medical outcome by adhering than not adhering (DiMatteo, Giordani, Lepper, & Croghan, 2002) . Additionally, a comprehensive review on patient adherenc e to treatment produced three implications for adherence: (1) non - adherence imposes increased financial burdens in health care, (2) adhering to treatment, lifestyle change, or advice is the key connection between process and outcome in medicine, and (3) ig noring levels of adherence can have a negative effect on the 9 conclusions drawn in clinical research, such as in drug trials (Vermeire, Hearnshaw, Van Royen, & Denekens, 2001) . Thus, patient adherence is viewed as a positive aspect of medicine. Research s hows that PC care results in greater patient adherence. Robinson, Callister, (2008) research found that PC communication encouraged adherence and volvement in their care and individualization of patient care enable patient responsibility and ultimately (1999) review of patient adherence research found four themes between patient - doctor communica tion and adherence which illustrate the link between PC care and patient adherence. One theme found that patients who were well educated by their doctor with clear, precise instructions were more likely to adhere. A second theme found that shared expecta tions between the doctor and patient resulted in adherence, which may have resulted from negotiations to reach shared expectation. Third, patient participation in the tanding, and encouragement all increase patient adherence (Stewart et al., 1999) . Each of the four themes (1999) review show the strong connection between PC care and patient adherence. Finally, Zolnierek and DiMatteo (2009) con ducted a meta - analysis on 106 correlational studies that related communication variables to the outcome of patient adherence and found that patient non - adherence was 19% higher when the doctor was a poor communicator. This meta - analysis indicated that whe n a practitioner is a good communicator, patient adherence is 2.16 times greater (Zolnierek & DiMatteo, 2009) . A third important outcome of PC care is the reduction of healthcare costs . Schneider and Guralnik (1990) looked at future healthcare costs, and found that healthcare costs will escalate enormously due to the growth of the oldest age groups, meaning that without changes in the 10 health of the older population in the United States, healthcare costs will increase vastly. With healthcare costs already high and research showing a growing trend in costs, reducing health care costs is imperative. Lower healthcare costs have been associated with physicians using a PC approach to care. Specifically, physicians using PC communication had fewer expenditures for diagnostic tests, as well as less total standardized expenditures (Epstein et al., 2005) . Although PC care will not fix the enormous health care costs in this country, it can attenuate the problem by reducing some costs in health care, while also enh ancing the experience for patients. Overall, PC care leading to satisfied patients, patient adherence, and lower healthcare costs provides some justification for adopting this approach. However, the ultimate goal of healthcare is to achieve better patien t health outcomes. Identifying positive health outcomes associated with a PC approach is therefore critical and is discussed next . Health O utcomes. PC care has been linked to better patient health outcomes. Since the overarching goal of medicine is to produce enhanced health outcomes for patients, PC care is especially important in this regard. Research has found the following health outcomes associat ed with a PC approach to care: a reduction of concern in patients, better self - reported health, and many instances of improved physiological status (Stewart et al., 2014) . Each of these will be detailed here. Stewart et al. (2000) conducted a study where first time visit adult patients with an episode of illness were either seen by a doctor displaying PC characteristics or a doctor performing biomedical care. A goal of their research was to discover if, after 2 months, patients receiving PC care would rec over from their illness more frequently than patients receiving biomedical care, and also if they would recover from the concern regarding that symptom. This research found that a PC approach to care was associated with improved health status, including 11 l ess discomfort and less concern , meaning better mental health (Stewart et al., 2000) . With mental health illness on the rise in the United States (Whitaker, 2010) , reducing medical concern in patients, and in turn bettering their mental health is a positi ve PC health outcome for patients. A PC approach to care was also found to result in better self - reported health from patients. Stewart et al. (2000) - centeredness and th eir health, and found that patients who perceived their doctor to be more PC also viewed their health more positively (Stewart et al., 2000) . In another study, Stewart et al. (2007) conducted a randomized controlled trial (RCT) 2 comparing doctors, inclu ding family physicians, surgeons, and oncologists, who received typical education (2 hours of PC education) to an intervention group (6 hours of more detailed PC education) (Stewart et al., 2007) (2000) findings were that patients of doc tors from the intervention group reported feeling significantly better than patients whose doctors were from the control condition. Finally, and most importantly, physiological health status outcomes associated with PC care are crucial to the importance placed on adopting a PC approach to care. There have been numerous studies that have shown enhanced health status outcomes for patients as a result of PC care, including: better cancer outcomes (Andersen et al., 2008; Kissane & Li, 2008; Spiegel, 2 Randomized controlled trials have been considered the gold standard in medicine for conducting clinical research (Abel & Koch, 1999; Feinstein, 1984) . Moher et al. (1995) explained that the design, conduct, and published report of RCTs should be of high quality, which leads to better treatment effect estimates, accurate estimates of the efficacy of treatments, and wider treatment accep tance within healthcare. It is important that high quality research be based in RCTs, as Cook, Guyatt, Laupacis, and Sackett (1992) indicate that RCTs are the most reliable method offered to assess the efficacy of treatment. Begg et al. (1996) suggest th at although RCTs can have the most powerful and immediate impacts on patient care, the readers of published reports should be provided with additional information allowing for informed judgments regarding the internal and external validity of the study, su ch as the design, conduct, analysis, and generalizability of the research. 12 2012) , i mproved diabetic control (Hojat et al., 2011) , shorter and less complicated postoperative courses (de Groot et al., 1997; Egbert, Battit, Welch, & Bartlett, 1964; Kiecolt - Glaser, Page, Marucha, MacCallum, & Glaser, 1998) , better perinatal outcomes (Shear, Gipe, Mattheis, & Levy, 1983) , and better blood pressure (Kaplan, Greenfield, & Ware, 1989) , providing clinical outcome support for the use of a PC approach. Although these findings of the importance of PC care and the health outcomes associated with it are critical for medicine and have moved the field in a positive direction, there is more work needed. Specifically, PC care has been taught in an array of different ways and has not been measured systematically with an objective rating procedure, requiri ng caution in interpreting the positive results previously found. The next step in this research is to scheme developed systematically in a standardized way. Th is will advance the work previously done on PC care by allowing researchers to see specifically which skills providers are using, and of those skills, which produce more positive outcomes in both the providers and patients. Patient - Centered Interviewi ng: A Review The first step in creating a systematic way to perform PC care is to develop a well - defined, specific, repeatable interview (Smith, Fortin, Dwamena, & Frankel, 2013) ; otherwise an extremely variable PC interview may result (Headly, 2007) . Th us, it is important that behaviorally - defined PC skills be collapsed into specific, definable segments that are sequenced and prioritized so that people adopting the method can both easily learn the method and know what to say to patients (Cegala & Lenzmei er Broz, 2002; Headly, 2007; Stewart, Brown, & Weston, 1989) . Behaviorally - defined means that actual behaviors are specified, and defined behaviors can be observed for their presence or absence. Once a behavior can be defined, it 13 becomes the basis of com petency based education, which is an approach to education that addresses accountability for education outcomes, specifically aligning workforce needs, occupational expectations, and assessments of educational program competence (Anema & McCoy, 2010) . Com petency - based medical education (CBME) has gained increased attention in recent years by health profession educators, as CBME is organized around specific competencies, or predefined abilities of medical professionals, that serve as outcomes of curriculum (Frank et al., 2010) . Competency - based medical education has six steps required for planning criteria: (1) identify the required abilities of the program, (2) define the required competencies and the corresponding components, (3) define milestones along t he program path, (4) decide education activities and instructional methods, (5) decide on assessment and measurement tools, and (6) design the outcomes of the program (Frank et al., 2010) . Since many programs now consider PC care to be a core competency, having a behaviorally - defined PC interview is important, as it is one way to move towards and achieve CBME. Frank et al. (2010) suggest that CBME has the potential to transform existing medical education, as it has the possibility of enhancing the way in which physicians are prepared for practice. Thus, a review of behaviorally - defined PC interviews follows. Smith, Dwamena, Grover, Coffey, and Frankel (2010) conducted a review of the literature looking for RCT intervention studies that examined behavi orally - defined, PC methods. - articles 13 were behaviorally - defined interventions (Smith et al., 2010) . The researchers broke the functions of a PC method into two model types: (1) data - gathering and emotion - handling and (2) informing and motivating patients. These two model types are two of the three fundamental functions of the interview (Cole & Bird, 2014) , but the data - gathering and emotion - handling 14 model type ( model 1) is the inherently PC aspect of the interview, as this portion of the interview contains explicit PC behaviors and skills, whereas the informing and motivating interview integrates PC skills with the clinician - centered skills needed to accomplish t he goal of informing and motivating a patient to alter negative health practices. Three out of the 13 interventions were generalizable, evidence - based methods focused on model type 2, informing and motivating (Smith et al ., 2006) included both of these model types (i.e. data gathering/emotion handing and informing/motivating patients) , and no study focused only on model type one (Smith et al., 2010) (2010) review, the Four Habits Model (Frankel & Stein, 2001) also provided evidence for its efficacy (Fossli Jensen et al., 2011) , and focuses on the first model type, data - gathering and emotion - handling. Since the first model type is the inherently PC function of the interview and is the crux of this research, the Four Habits Model will briefly be reviewed here in order to ascertain the difference between The Four Habits Model is a medical interviewing model for providers , which focuses on four habits, or organized ways of acting or thinking during the medical interview . It includes and (4) i (Frankel & Stein, 2001, p. 79) , see Appendix A . The habits are designed to be conducted in order, as they logically lead the doctor through the medical encounter in an effective way (Frankel & Stein, 2001) . Each habit is a crucial PC step assisting people adopting this model in their ability to conduct a PC interview . The first habit, invest in the beginning, appointment with the patient (Frankel & Stein, 2001) . The secon d 15 (Frankel & Stein, 2001) . The third habit, demonstrate empathy, includes being open to p as nonverbally showing empathy (Frankel & Stein, 2001) . The fourth habit, invest in the end, suggests that the provider deliver diagnostic information a nd education, include the patient in the decision making process, and end the visit (Frankel & Stein, 2001) . The Four Habits Model attempts to enhance the provider - patient relationship by creating a mutually satisfying experience for the provider and pati ent (Frankel & Stein, 2001) . In order to test this model, a crossover RCT was utilized where all doctors would receive the intervention (i.e. a two day training course on the Four Habits Model), and doctors would serve as their own controls (Fossli Jens en et al., 2011) . A coding scheme developed specifically to measure the Four Habits Model (Krupat, Frankel, Stein, & Irish, 2006) was then used in Fossli (2011) crossover RCT, and inter - rater reliability was established on each of the four habits by having four trained raters rate groups of 20 videos until raters reached an acceptable inter - r > 0.70), see Appendix B. This research found significant mean score differences before and after the two day Four Habits Model training, where people trained achieved significantly higher scores than those who were untrained (Fossli Jensen et al., 2011) . This RCT provided evidence for the utility of the Four Habits Model by showing that the model is quickly learned and can be repeated in practice, making this particular model the only other evidence - based PC model in medicine. Although the Four Habits Model has produced findings regarding its efficacy, the model is not specific, as it provides very general suggestions for c onducting a PC interview. Prior research has shown that the method is easily learned (i.e. providers using the method scored 16 higher on their developed coding scheme than did untrained providers), but no patient outcomes have been assessed. So although th is PC model can be learned, it is less certain what results associated with positive outcomes for patients (Smith et al., 2009; Smith et al., 2006) , so further wor described in detail. - Centered Interview book The P s S tory: Integrated P atient - D octor I nterviewing (Smith, 1996) , the method was updated in the second edition, Patient - Centered Interviewing: An Evidence - based Method (Smith, 2002) , and is in its current, third edition which was updated to reflect new findings on PC medicine (Fortin et al., 2012) . This behaviorally - defined, replicable interviewing method was enhanced and updated under the direction of the original author (Smith, 1996) with newly added coauthors (Fortin et al., 2012) and was based on literature review, empirical evidence (Smith et al., 2006; Smith et al., 1998; Smith et al., 2000) , consultations with experts on PC care, and personal experiences with medical care (Fortin et al., 2012) . The result is a 5 step, 21 - substep method that has shown thro ugh research to be an efficient and replicable method (Smith et al., 1998; Smith et al., 2000) . This method has been used in several research studies, all showing the importance of adopting a PC approach to care. grated interviewing, where the doctor starts the interview with PC interviewing skills, which are the foundational, core skills needed to open the interview successfully in a PC manner. The doctor then moves into the middle of the interview where clinicia n - centered interviewing predominates, and ends the interview with PC 17 (Fortin et al., 2012) , see Figure 1 . Research by Cole and Bird (2013) presents the medical interview as a series of core tasks that are addressed through three functions: (1) building the r collaborating for management. Each of the functions of the medical interview are assessed in model (which is the focus of t his research), and the third function that focuses on shared decision (Fortin et al., 2012) . PC interviewing skills are skills the doctor uses to encourage the patient to express what is most important to them, fo of personal concerns, feelings, and emotions (Fortin et al., 2012) . Clinician - centered interviewing skills are skills that allow the clinician to take charge of the interaction, allowing t identifying a disease, and predominantly avoids nonmedical data (Fortin et al., 2012) . During the clinician - centered portion of the interview, some PC skills may be used to help facilitate (Fortin et al., 2012) . Interviews begin with a PC approach, psychosocial information. The clinician - centered port ion that comprises the middle of the interview is largely closed - ended, symptom information, with some psychosocial data that is of a more routine type than the data collected at the beginning (Fortin et al., 2012) . The doctor then synthesizes these data into a biospsychosocial patient description. Each of the specific steps of 18 Smit , will be reviewed here followed by a brief description of the middle (clinician - centered) and ending (patient - centered) of the interview. Step One. The first step in the interview is setting the stage for the interview, which should take between 30 - 60 seconds (Fortin et al., 2012) . The six sub - steps or skills of step one ensure a PC atmosphere and include: (1) welcoming the patient, (2) us removing all barriers to communication, and (6) putting patient at ease and ensuring comfort (Fortin et al., 2012) . These skills can be adjusted appropriately for follow - up visits or with long - term patients with whom the doctor is already familiar. These skills work together to ensure an appropriate setting for the interview, put both parties at ease, and create or reaffirm the pa (Fortin et al., 2012) . The first sub - step, welcome the patient handshake is not possible, when culturally appropriate. Using positive nonverbal skills is also a vital part of this step that will enhance the relationship between the provider and patient, and also helps to make the patient feel like a priority (Fortin et al., 2012) . The second sub - step, using the , suggests starting with a formal term of address (e.g. Mr., Miss., Ms., Mrs.) and to be addressed (Makoul, Krupat, & Chang , 2007) . After the formal greeting, it is appropriate to ask the patient how they prefer to be addressed (Fortin et al., 2012) . The third sub - step, introduce yourself and specify your role , recommends that the doctor introduce themselves with matching id entity terms to avoid suggesting power differentials or unequal relationship status 19 (Fortin et al., 2012) . The provider should also specify their role so that the patient is aware of the credentials of the provider (e.g. nurse practitioner). Sub - steps four, five, and six are all designed to put the patient at ease and create a positive atmosphere for conducting the interview. Specifically, sub - step four, ensure patient readiness and privacy , is designed to make sure the timing is appropriate and convenient for the patient, particularly in the hospital setting. For instance, if a patient has severe nausea, severe pain, family visiting, need for medication, etc., the interview may need to be postponed (Fortin et al., 2012) . Similarly, monitori ng for nonphysical, potentially interfering problems such as lost keys or a recently received disturbing phone call may require a brief delay to the interview. lso or shutting the door (Fortin et al., 2012) . The fifth sub - step, remove barriers to communication, involves asking permission to turn off noisy air condi tion er s or televisions, speaking loud enough so that the patient can hear well, sitting down so as to be eye level with the patient, and only using computers intermittently to avoid disrupting the flow of communication (Fortin et al., 2012) . Finally, sub - step six, ensure comfort and put patient at ease , is accomplished by making sure the patient is comfortable where they are sitting and with the exam room itself (e.g. too bright of lights, uncomfortable chair or examination table, etc.). If the patient se ems uneasy about starting the interview, asking friendly questions to begin can help the patient to feel comfortable and at ease with the provider (Fortin et al., 2012) . Step Two. cern and setting the agenda, which is done through the next four sub - steps (Fortin et al., 2012) . The seventh sub - step, indicate time available, is a simple step that has the provider tell the patient 20 how much time is available for the interview (Fortin e t al., 2012) . This orients the patient and allows them the ability to gauge what and how much they want to say (White, Levinson, & Roter, 1994) . Sub - step eight, forecast what you would like to have happen in the interview , is designed to let the patient know what the doctor needs to accomplish during the visit, such as performing a physical exam or asking many routine questions. Sub - step nine, obtain a list of all issues the patient wants to discuss , allows the patient the opportunity to list out all of the issues they want to cover in that visit. When done correctly at the beginning, this sub - step helps to minimize the chance that the patient will raise an important concern at the end of the interview when time has run out (White et al., 1994) . The fin al sub - step in step two, summarize and finalize the agenda , is typically a summary of the items that the patient would like to address in the visit. In this sub - step, the provider needs to prioritize the issues if too many are raised for the allotted time , to make sure that important issues are covered, and to understand the chief concern of the patient, always beginning with that particular concern (Fortin et al., 2012) . Step Three. The third step of the interview, begin the interview with non - focusing skills that help the patient to express her/himself , includes three sub - steps that help the provider to use PC skills to elicit the history of present illness (HPI) and focus on the chief concern. Focusing and non - focusing skills are open - ended skills pro viders can use to encourage their patien ts to express freely what is on their mind (Fortin et al., 2012) . Focusing skills (e.g. echo, request, summarizing; see below) are used to help patients develop their narrative and to invite the patient to talk more about topics already mentioned (Fortin et al., 2012) . Non - focusing skills (e.g. silence, nonverbal encouragement, neutral utterances; see below) are used throughout the interview to encourage the patient to talk freely, but are critical at the beginning of the interview 21 as the patient provides information regarding their history; non - focusing skills are useful as long as the patient provides a nonrepetitive, coherent history (Fortin et al., 2012) . The 11th sub - step requires the provider to open the HPI with an open - ended beginning (Fortin et al., 2012, p. 40) . Sub - step 12, use non - focusing open - ended skills , involves the use of silence, nonverbal gestures (e.g. attentive beha vior, eye contact, hand gestures), and neutral utterances (e.g. uh - huh, mmm) that encourage the patient to continue talking. It is suggested that the provider continue using the non - focusing open - ended skills until the patient has finished telling their c hief concern story, as the provider is receiving information that will ultimately help learn (Fortin et al., 2012) . The next sub - step of step three, obtain additional data from nonverbal sources , requires that the provider look for nonverbal cues (e.g. arms folded across chest), physical characteristics (e.g. jaundice), autonomic changes (e.g. sweating at outset of interview), accoutrements or accessories (e.g. thick eyeglasses) , environment (e.g. greeting cards in hospital setting), and self (e.g. being aware of own emotional reactions to patients) for additional information about the patient, as well as being mentally active and thinking about what the information means (Fortin et al., 2012) . Step Four. use focusing skills to learn 3 things: physical story, personal story, and emotional story , involves the three different types of stories, or medical narratives, included in the intervie w. According to Charon (2006) , in order for doctors to effectively treat and care for their patients with trustworthiness, humility, and respect, they must be able to understand to some extent what their patients go through. A current trend in medicine i 22 (Charon, 2006, p. 4) . Charon (2006) argues that in order for doctors to gr ow in their scientific expertise, they need to listen to their patients, to understand the ordeals of illness, to honor the meanings of that they can act on medical narratives: physical story, personal story, and emotional story (Fortin et al., 2012) . The th them, and does not include personal or emotional aspects. The personal story is the personal, non - emotional psychosocial story regarding the context in which the physical disease problem occurs, but does not directly discuss the physical illness. The emotional story is the emotional component of the expressed feelings that the patient conveys to their provider during their medical interview. These three medical narr components of the biopsychosocial model (Engel, 1981) people adopting the method to facilitate their patients in discussing each story of their medical narrative. People using the method learn to facilitate their patient in addressing these stories through a variety of skills discussed in step four: focusing open - ended skills, direct emotion - seeking skills, indirect emotion - seeking skills, and respondin g to feelings and emotions using the skills of naming, understanding, respecting, and support (Fortin et al., 2012) . The first sub - step of step four, elicit symptom story , encourages the provider to aid the patient in describing their symptom or physical story by using three different focusing open - encouraging the patient to continue talking about something particular the patient has already 23 mentioned (e.g. if the patient has disclosed that they have strong pain in their left knee, the doctor cou the patient to elaborate about the pain). This ski ll allows providers to obtain more information about issues discussed by the patient, without being closed - ended or doctor - centered (Fortin et al., 2012) . The second focusing skill that can be e provider uses this skill to encourage the patient to continue discussing the current topic (Fortin et al., 2012) . The third focusing, open - ended skill is called summarizing, which occurs when the provider summarizes several things that the patient has j ust disclosed and ends with silence, enticing the patient to provi der accurately understands the patient, but also encourages the patient to continue telling their physical story. The next sub - step of step four, elicit personal context , helps the provider to obtain information concerning the broader personal/psychosocia (Fortin et al., 2012) . Although developing this story relates less to symptoms and may be less important in terms of diagnosing disease, it is information can arise in this step (Fortin et al., 2012) . This sub - step is accomplished by using the same focusing, open - ended skills previously mentioned (i.e. echo, request, summa ry), but does so by using the focusing skills strategically to move the patient from their physical story to their personal story (Fortin et al., 2012) . The provider can do so by echoing a word to help move 24 Each of these focusing, open - ended skills can be used repeatedly by the provider important direction for that particular story (Fortin et al., 2012) . Sub - st ep 16, elicit emotional context , is designed to help the provider obtain the emotional story. There are two types of emotion - seeking skills involved in this step: direct and indirect. The direct emotion - seeking skill involves directly asking the patient how they are feeling or how they are dealing with the problem emotionally (Fortin et al., 2012) . The indirect emotion - seeking skills include four types: (1) Inquiring about impact, which asks how the problem has affected the life of the patient, the patie strating understanding through self - disclosures, which disclose help time (e.g. "Is there anything going on in your life right now that could have triggered this?"; Fortin et al., 2012) . The use of direct and indirect emotion - seeki ng skills will aid in eliciting an emotion from the patient. Once the patient has expressed an emotion, the provider can use additional focusing, open - ended skills to gain a better understanding of the emotion and what may have caused it (Fortin et al., 2 012) . The next sub - step in step four, respond to feelings and emotions , involves four empathy skills that should be used once the provider has obtained an emotion from the patient and once 25 the provider thoroughly understands the emotion and how the patien t came to that emotion (Fortin et al., 2012) . The four skills make up the mnemonic NURS: naming, understanding, respecting, and supporting. These empathy skills can be used together or separately to help the patient feel that their emotion has been heard . Naming, which has also been called labeling, occurs when the provider simply repeats an emotion expressed by the patient, which signals to the patient that the provider has heard or observed the feeling and that it is okay to express the feeling (e.g. " You are upset"; Fortin et al., 2012) . Understanding, which is also called legitimating, is used to signify to the patient that their emotional reaction is reasonable (e.g. This skill is the provider does not have personal experience with the particular circumstance (Fortin et al., 2012) . The third skill, respecting, can be used (e.g. "This has been a really tough time for you!"; Fortin et al., 2012, p. 22) . The fin al component of NURS is support, or partnership, and is used to signify to the patient that the provider is ready and willing to work with the patient as a team and to form a partnership in order to help the patient (e.g. "Together, I think that you and I can get to the bottom of this and help you to feel better!"; Fortin et al., 2012) . Social support literature also recognizes these skills as foundational in connecting with others, as shown through Tighe and (2004) explores the are typically preferred by recipients (Burleson, 1 994) . A highly person centered comforting 26 those feelings, illustrates why such feelings may be experienced, and helps the other person to understand how such feelings fit into their life (Burleson et al., 2005) . The similarity between the NURS component of PC interviewing and a person centered approach as described in the nes are prescribing similar ways of connecting with others. The final sub - step of step four, expand the story, is used to elaborate on the personal and emotional stories provided from the patient. These stories are typically incomplete and need further ex planation from the patient. This is accomplished by repeatedly cycling through the focusing open - ended skills, the emotion - seeking skills, and the empathy skills, see Figure 2 . As the patient provides further information regarding their personal and emot ional stories, the provider continues to use the different types of skills to further elaborate the stories and get Once the provider feels satisfied with t he medical narrative, they move into the final step of Step Five. The final step is the transition from the PC portion of the interview to the middle, clinician - centered portion of the interview. The first sub - step here is a brief s ummary . The provider briefly summarizes what has been discussed thus far. Next, check accuracy , has the provider ask the patient if they have gotten the medical narrative correct after summarizing (Fortin et al., 2012) . This ensures that the provider di d not miss any important information throughout the expansion of the three stories. The final sub - step of the PC interview, indicate that both the content and style of inquiry will change if the patient is ready , suggests that before moving into the clini cian - centered portion of the interview, the provider should indicate that the 27 style of the interview is going to change and should make sure that the patient is ready for that to happen (Fortin et al., 2012) . At this point, the provider can move into the middle of the interview and continue in a clinician - centered fashion. The focus of this research is the PC aspect of the interview described above; however, a book (Fortin et al., 2012) will be discussed here. The middle of the interview is used to expand on the information gathered in the PC portion of the interview. The information obtained during the PC portion is likely incomplete, so the provider needs to exp and on the information gained ify other medical issues that may appear, assess the patient for risk of disease, and generally get to know the patient better (Fortin et al., 2012) . Appendix D guides the provider through the middle of the interview. A physical exam may follow the middl e of the interview, if needed. The provider then needs to end the interview, and should once again adopt a PC philosophy. There are six steps designated to ending the interview, which can be found in Table 1 . The steps include orienting the patient to the end of the interview, explaining the prognosis/diagnosis to the patient, inviting the patient to join in shared decision making, explaining the testing and treatment options to the patient, summarizing the decisions made and providing written instructi ons to the patient, and acknowledging and supporting the patient before saying goodbye (Fortin et al., 2012) . Each stage of the interview and the components of each can be found in the integrated medical interviewing diagram, found in Figure 1 . 28 PC interview has been used in a number of studies that point to the importance of (Smith et al., 1998) was an RCT designed to assess the effect of a psychosocial training program for r esidents. Specifically, residents were assigned to either a one month intensive training program where they were taught PC interviewing skills or to a control group. Residents in the intervention group scored higher on several measures, including: (1) a knowledge questionnaire designed to assess knowledge of interviewing and psychosocial medicine, (2) an attitude questionnaire designed to assess attitudes such as confidence in conducting the skills of the various interviews and provider self - efficacy , (3) somatization management, or management of patients with chronic and unexplained physical complaints (Smith et al., 1998) . The authors claim that these results show (Smith et al., 19 98) . Another RCT included 206 patients with medically unexplained symptoms, and providers of these patients were randomized to a control group or to an intervention group consisting of cognitive - behavioral, pharmacological, other treatment modalities, and method (Smith et al., 2006) . Patients of doctors in the intervention group had improvements in depression, physical disability, use of antidepressants, and use of controlled substances; similarly, patient satisfaction with their do ctor improved. Although this study does not indicate that PC care results in better patient health outcomes, it does show an association between PC care and positive health outcomes for patients receiving such care. A final study (Smith et al., 2009) rand omized patients with medically unexplained symptoms to receive usual care or an intervention treatment, where primary care physicians were trained in cognitive - behavioral, pharmacological, and PC skills. Patients of doctors in the intervention group had b etter mental functioning and had improved somatization and pain (Smith 29 et al., 2009) . Again, this was a multidimensional intervention so it does not indicate that PC skills alone result in better health outcomes for patients, but it does show an associati on between PC care and positive health outcomes. outcomes for patients provide justification for the continued use of the method. A crucial intermediate step is to evaluate t hose trained in the method as a way of discovering what skills are being enacted in practice. Equally important, however, is showing that the skills are not only utilized, but also that they lead to positive outcomes. Kirkpatrick and Kirkpatrick (2006) s uggest that in order to assess a training program, it is important to evaluate knowledge, attitudes or beliefs , skills, and outcomes of the training program. Holmboe and Hawkins (1998) support this claim, as they discuss evaluation in clinical competence and explain that competence is a broad term often used in medicine that encompasses the domains of knowledge, skills, and attitudes in evaluation. Therefore, each of these aspects of training are included in this study and are discussed below. These outc PC method. The current research aims to examine how these outcomes of training are a result of adopting the PC method through the use of a developed PC coding scheme. Provider and Patient Outcomes: Knowledge, Self - Efficacy, and Satisfaction In order to ultimately test a coding scheme created to look at particular PC skills, both the training of providers and the coding scheme itself need to be developed systematically. (Fortin et al., 2012; Smith et al., 2009; Smith et al., 2006; Smith et al., 1998) has described the method for teaching PC skills. To d ate, a standardized coding scheme has not been developed. This is an important step that will increase confidence in the method as adopters can be taught in a standardized way and the coding scheme will allow for a systematic 30 way of rating adopters to sho w what aspects of the training are most useful in PC care and which skills produce the best outcomes. The developed coding scheme will be used to assess the effectiveness of the PC training program as a way of discovering if an increase in skills results in better outcomes for both the provider and patient. According to Kirkpatrick and Kirkpatrick (2006) , there are four levels to evaluating a training program; this research will focus on levels two and four. Level one, which is evaluating the reaction o f adopters of the training, will be assessed in future research through focus groups. Level three looks at the change in job behavior that occurred due to training and and a person can be assessed performing their occupation (Kirkpatrick & Kirkpatrick, 2006) . Level three will be assessed once residents have entered their own practice in future research. Level two and level four will both be discussed in detail here. L evel two is evaluating learning, which should be done before and after the training program with both an intervention and control group, and should look at skills, knowledge, and attitudes (Kirkpatrick & Kirkpatrick, 2006) . Kirkpatrick and Kirkpatrick def participants change attitudes, improve knowledge, and/or increase skill as a result of attending (2006, p. 22) . It was also noted by the authors that some trainers claim that learning has not taken place until there is a change in behavior through an increase in skill. As such, this research hypothesizes that an increase in PC interviewing training will lead to an increase in provider PC skills, which are defined as specific PC behaviors derived from Smit interviewing method that are enacted in practice, as determined through a coding scheme developed to determine which PC skills a provider is exhibiting. H1: Training in PC interviewing will lead to an increase in provider PC skills. 31 Level two of Kirk patrick and Kirkpatrick (2006) evaluation training also includes (Mumford, Hester, & Robledo, 2011, p. 27) . PC knowledge can be understood as PC information stored i (2006) indication that learning has not taken place until there is a change in behavior suggests that people do not necessarily possess knowledge on a particular topic until they have enacted that behavior. (2015) work for the American Psychological Association supports this claim, as their research indicates that practicing a particular behavior or skill set allows information regarding that beh avior to stay in the short term memory long enough for it to move into long - term memory. When people first learn information it is stored for short periods in the short - term memory. Brabeck and Jeffrey (2015) suggest that practice will help increase a pe information move from short to long - term memory. This research indicates that teaching someone PC information may not be enough to advance that knowledge to the long - te rm memory; rather, teaching knowledge on PC behaviors and allowing a person time to practice those behaviors should make that information more readily available and should therefore esized that an increase participates in a given activity and the more a person becomes familiar with a particular practice, the more knowledge that person should gain and retain regarding that particular activity or practice. People can learn a method and steps of a method in training, but the knowledge 32 regarding that method and use of that method likely will not fully form and become part of that - term me mory until that skill set has been enacted in practice. H2: Patient - centered skills will lead to an incr ease in provider knowledge of patient - centered care. Level two of Kirkpatrick and Kirkpatrick (2006) training evaluation program also suggests tha t beliefs regarding a particular behavior can be assessed. Here, beliefs will be - efficacy regarding their PC abilities, which means that a - effic acy regarding their ability to enact those skills should be assessed. Providers with higher scores on a PC coding scheme (i.e. providers using more PC skills) should have higher self - efficacy in their ability to ed self - (Bandura, 2010, p. 1) . According to Bandura (1997) , students with high perceived self - efficacy work harder, persist longer, participate more readily, show enha nced interest in learning, and ultimately achieve at higher levels when compared to students with low self - efficacy. Self - efficacy may be influenced by specific outcomes of behavior, such as achievements, and also by input from the environment, such as co mparison to peers or feedback from instructors (Bandura, 1997) . Bandura (1997) suggested that people are able to gauge their self - efficacy once information is acquired regarding interpretations of their actual performance, vicarious experiences, social persuasion, and by other physiological indexes. Schunk and Frank (2009) explain that the way in which a student interprets their actual performance will provide the best information for assessing their self - efficacy, as the interpretations made in this fa shion are the r s continue by explaining that 33 - efficacy should rise; whereas an interpretation of performance as a failure should l ikely lower self - efficacy (Schunk & Frank, 2009) . Similarly, people who feel that they are efficacious in an activity are hypothesized to persist longer and work harder when difficulties are encountered than would a person who doubts their capabilities (B andura & Adams, 1977) . Ultimately, people need to believe that their actions will produce desired outcomes in order for them to have incentive to engage in such actions (Bandura, 1997) . Strecher, DeVellis, Becker, and Rosenstock (1986) reviewed health related research that looked at how skills are affected by self - efficacy, and they suggest that in order to target a behavior, the behavior should be broken down into a series of skills that can be mastered, and through encouragement of th e mastered skills, self - efficacy should increase. Particularly self - efficacy (Gilchrist & Schinke, 1983) . Therefore, a person with increased PC skill u se should lead to higher beliefs in their ability to act PC. H3: Patient - - efficacy. (2006) evaluation of training programs is the evaluation of results of the training. The evaluator must determine what final results occurred due to the attendance and participation by people in the training program (Kirkpatrick & Kirkpatrick, 2006) . A major outcome in the literature of doctors exhibiting PC cha racteristics is having highly satisfied patients. Here, the focus is PSPCC, which again is - patient interaction in terms of the hion (Grayson - Sneed, 2014) . Since patient satisfaction has shown through research to result in greater adherence to medicine 34 (O'Brien et al., 1992) , enhanced patient recall (Falvo & Tippy, 1988) , fewer malpractice lawsuits (Hickson et al., 1994) , and less (Ware & Davis, 1983) , patient satisfaction is an effective indicator for measuring the success of both hospitals and doctors (Prakash, 2010) . It has been suggested that provider - patient interaction may be the most important indicator f or determining patient satisfaction (Prakash, 2010) , as patient satisfaction increases with improved physician interpersonal skills and thus results in treatment adherence and better health outcomes (Renzi et al., 2001) fic interpersonal skills, training doctors in the enhancement of these skills by following the specific steps of the method (Fortin et al., 2012) would target the interpersonal skills taught through the PC method, it is likely that someone exhibiting these skills would engender patient satisfaction. As such, this research hypothesizes that an increase in PC skills will lead to more highly satisfied patients. 3 H4: Patient - centered ski lls will lead to an increase in patient communication satisfaction. Although previous research on PSPCC has not predicted or found that specific aspects of PC interviewing operate in different ways, one additional research question that could be posed is w hether training and use of separate PC skills leads to higher patient satisfaction in the six separate PC skills. Each stage of the interview has different, unique components, and some may be more important for the predi ction of patient satisfaction than o thers. This research question would help determine which stage(s) of the interview (i.e. which sets of the separate PC skills) are more likely to be related to patient satisfaction. RQ1: What is the relationship between the separate PC skills and satisfac tion ratings? 3 (2006) evaluation program in this research are only preliminary assessments of level four. The ultimate test of level four will require testing providers again after level three has been properly assessed (i.e. once the provider has been assessed in their own p ractice outside of this research). However, the results found here will provide an initial insight into the outcomes of training. 35 CHAPTER 2: M ETHOD S Participants The sample comprised 129 residents involved in a grant project testing PC interviewing and the impact of mental health training for residents. The majority of residents indicated that they were male ( n = 77, 60 %) and married ( n = 77, 60%). Following the guidelines of NIH, ethnicity was assessed in the following way: r esidents were primarily Asian ( n = 62, 48%), followed by Caucasian ( n = 34, 27%), African American ( n = 6, 5%), Hispanic/Latino ( n = 2, 1%), and the rest self - described as another race or ethnicity ( n = 24, 19%) 4 . Residents conducted three videotaped medical interviews with standardized patients, or (Beullens, Rethans, Goedhuys, & Buntinx, 1997, p. 58) . Over the course of three consecutive years (2012 - 2014); residents were aware that they were being videotaped, but were only told that the videotapes were being used as part of a r esearch grant. Standardized patients (n=12) were primarily Caucasian, with one African American, and ranged in age from 38 to 58. Standardized patients were paid for their participation through the Health Resources and Services Administration (HRSA) gran t. Procedure Training. At the time of posttest data collection, residents had either participated in a one - month, full - time rotation of training, or were part of the control condition 5 (i.e. no psychosocial or mental health training courses were offered to residents), see T able 2 . Some of 4 Future research may want to probe race and ethnicity more clearly. Many residents self - reported as h because they did not self - identify with one of the ethnicities provided. For example, residents in this data set from Pakistan self - an Asian ethnicity. This should be probed furthe category. 5 Pretest data was collected on each condition as well, so that each resident was assessed when they first entered the program, as well as when they were ending their residency. 36 the residents ( n = 76) were from an intervention site where training was executed during the first year of a three year residency program, with inter mittent follow up training at a specialized clinic during their second and third years, and the remaining residents were from a control site where no residents received formal psychosocial or mental health training at any point during their three years 6 ( n = 52), see Appendix E for a breakdown of the data. Residents in both locations had similar training in all other aspects, including: approximately 80 hours of work per week that included inpatient and outpatient clinics and specialty rotations, all of wh ich were disease oriented. Although random assignment to condition did not occur, there were no significant differences between the two groups during the pretest on the variables of interest: provider PC skills, provider knowledge, provider self - efficacy, and patient satisfaction. Specifics are provided at the end of the methods section. The one - month, full - time rotation for residents at the intervention site involved 60 hours of training, including PC interviewing, psychiatry lectures on mental health is sues, shadowing psychiatrists on the inpatient psychiatry unit, lectures on somatization, multicultural issues, ethics, and informing and motivating patients to change unhealthy habits. The aim of the rotation was not to transform residents into psychiatr ists, but instead was intended to train residents to be as competent with common mental health problems as they are with medical problems (Smith et al., 2014) . Five model types were addressed during training, including (1) diagnosis and doctor - patient rel ationship, (2) basic treatment principles, (3) mental health care, (4) personal awareness, and (5) team based care (see Smith et al., 2014 for complete descriptions of each). The current research is primarily focused on model 1, diagnosis and doctor - patie nt 6 Although control group residents did not receive formal psychosocial or mental health training, their core faculty are all experienced and ideal role models in all facets of training. Thus, residents in the control condition did not receive a formal one - month, full - time training rotation with follow - up training throughout their residency; however, control group residents were potentially getting psychosocial and mental health input in other ways through faculty. 37 - handling skills for establishing the doctor - patient relationship. Future research will probe models 2 - 5 in detail. Training was conducted in a linear process where r esidents progressed from one model type to the next until residents were thoroughly trained in all five types. Data Collection. Residents and standardized patients were videotaped during interviewing in three separate medical cases, including data gatherin g and relationship building, a Behavioral Healthcare Treatment Model, and informing/motivating a patient; however, this research is solely focused on the PC case, which is the data gathering and relationship building case. The Behavioral Health Treatment Model and informing/motivating a patient cases will be analyzed in future research. Throughout the entirety of the grant, residents always met with a new standardized patient, so that no resident ever met with the same standardized patient twice. Before tten instruction; see Appendix F for the data gathering and relationship building instructions. Standardized patients received both in - person training prior to data collection and written i nstructions describing in detail how to portray their particular case, for standardized patient written instructions on the data gathering and relations hip building case see Appendix G . Each medical case was allotted 15 minutes and took place in rooms des igned to simulate real examination rooms. Residents saw three standardized patients (each representing the different medical cases mentioned previously), and standardized patients never saw more than six residents per day to minimize the chance of boredom effects and participant fatigue. Video cameras were strategically placed out of the view of both the resident and standardized patient, although both were aware that they were being videotaped and that videotapes would be evaluated in some capacity. 38 On the same day that the interviews took place, residents had approximately 45 minutes to fill out three questionnaires on a private computer in a separate area of the facility: (1) Demographics, (2) a Knowledge Questionnaire, and (3) an Efficacy Questionnair e assessing the - efficacy with PC skills, see Table 3, Appendix H, and Table 4, respectively . Directly following each of the medical cases/encounters, standardized patients had approximately 10 minutes to fill out two patient communication satisfaction surveys regarding their communication satisfaction with the resident that had just interviewed them: (1) the 25 - item Interview Satisfaction Questionnaire ( ISQ ) measure, see Table 5 , and (2) the Communication Assessment Tool (Makoul et al., 200 7) , see Table 6 . Patient satisfaction with PC communication will be analyzed using the 25 - item ISQ in this study, as the CAT was included for validity purposes only and was analyzed in a separate analysis (see Grayson - Sneed, 2014) . Standardized patients were assured anonymity and filled out their forms privately on a computer in their examination room. The Development of the Patient - Centered Coding Scheme In order to test research hypotheses, a coding scheme was developed in this research effort to allow for a standardized way of rating people using the method , and it is d escribed here . The interview is the unit of analysis , thus only one instance of each code per interview is reported . The 33 - item coding scheme was derived from core PC skills taught in interviewing method. This coding scheme was devised to test only the first five steps with 21 sub - steps of the PC interview, as these first five steps of the interview comprise foundational skills that set the stage for the rest of the intervie w, see Appendix C . The coding scheme is built setting the agenda, 39 physical story, personal story, emotional story (including direct patient - centered skills) , indirect patient - centered skills, and general patient - centered skills. Each stage has items designed to measure that particular aspect of PC care, and are each yes/no dichotomous variables , see Ap pendix I . A more detailed code book was developed, in which each item in the coding s cheme is described in detail and includes examples to help coders understand the items and provides examples of what providers may say in c ertain instances, see Appendix J . Coders received the conceptual definitions of each stage, as provided below, as we ll as a glossary of emotional terms , which can be found in Appendix K . Setting the agenda is defined as the introduction stage at the beginning of a medical interview where the provider orients the patient by ensuring that the patient is comfortable and at ease and by obtaining a full list of issues to cover. This particular category contains three items, expressed preference, (2) provider indicates time available, a nd (3) provider obtains agenda and inquires for additional items. The physical story with them, and does not include personal or emotional aspects. This stage has two items, includin g (4) the provider starts open - endedly focusing on physical agenda item, and (5) provider addresses only physical issues volunteered by the patient. The personal story, defined as the personal, non - emotional psychosocial story regarding the context in wh ich the physical disease problem occurs, but does not directly discuss the physical illness, contains six items: (6) provider keeps the patient focused open - endedly on the personal story(ies) to elaborate them, (7) provider a ddresses only personal topics v olunteered by the patient , (8) provider e ncourages personal information open - endedly when patients do not 40 volunteer it and patient remai ns focused on the physical story, (9) provider u ses echoing to expand understanding of personal story, (10) provider u se s requests to expand understanding of personal story , and (11) provider u ses summarizing to expand understanding of personal story . The emotional story is the most detailed and contains 15 items. The emotional story is defined as focuses on the felt emotions and expressed feelings that the patient conveys to their provider during their medical interview. The emotional story is one of the most uniq ue parts of a PC provider keeps patient focused open - endedly on emotional story (ies) to elaborate them, (13) provider a ddresses only emotional topics volunteered by t he patient, (14) provider i nquires about nquires about emotions by using other emotion seeking question, (16) provider u ses echoing to expand un derstanding of emotional story, (17) p rovider u ses requests to expand understanding of emotional story, (18) provider u ses summarizing to expand understanding of emotional story , (19) provider u in response to expression of emotion, (20) provider u ses in response to expression of emotion, (21) provider u ses other understanding statements in response to expression of emotion, (22) provider u statement in response to expression of emotion, (23) provider u statement in response to expression of emotion, (24) provider u in response to expression of emotion, (25) provider u in response to expression of emotion, and (26) provider u emotion. 41 Indirect patient - centered skills are defined as tools that the physician uses to try and elicit expressions of feeling or emotion from the patient. These indirect PC skills are used to help the provider obtain an emotion from their patient when the patient has not directly discussed emotion . Direct emotion seeking skills are frequently used first hese indirect skills can also be used to help the provider obtain an emotion from their patient. Once an emotion is obtained, the emotion skills listed above can be used to help the provider explore the emotion further. This stage of the interview contai ns four items; - General patient - centered sk ills are important to the PC interview but do not fall into one of the previously defined categories. They are defined as tools that the provider uses to guide the patient through the PC portion of the interview. Three items comprise the general PC skill s, including (31) provider indicates change in direction of questioning at end of interview to disease focus, (32) provider interruptions are appropriate or nonexistent, and (33) resident determines content and direction of interview. 7 All items comprisin g e ach of these stages are derived (Fortin et al., 2012) , and are described in detail in the codebook, see Appendix J . Assessing the Validity of the Developed Coding Scheme An important step in this research was to provide evidence for the validity of the PC coding scheme, which is one way to assess whether a coding scheme is a good measure of the PC process. The validity was established in a number of ways. According to Pedhazur and 7 This item will be reverse coded. The patient should determine the content and direction of a patient - centered interview, not the provider; however, many providers do control the interview making this an important code. 42 Schmelkin (1991), a widely used method for validating a measure is a tripartite classification, including the content, construct, and criterion forms of validation , and each will be discussed here . Similarly, Riffe, Lacy, and Fico (2014) discuss establishing validity in content ana lysis quantitative research and discuss face, concurrent, predictive, and construct forms of validity; face, predictive and construct validity are applicable to the current research and will be assessed here. Content Validity . degree to which elements of an assessment instrument are relevant to and representative of the targeted construct for a particular assessment (Haynes, Richard, & Kubany, 1995, p. 238) . The importance of content validity for the purposes of valida ting a particular construct depends on the degree to which experts agree about the domain and facets of the construct and on how precisely a construct is defined (Haynes et al., 1995) . Haynes et al. (1995) note that although research involving content val idity has primarily focused on self - report questionnaires, content validity is important for assessments such as behavioral observation assessments because the results can affect clinical judgments (Haynes et al., 1995) . This makes content validity especi ally important in the current research, as the given coding scheme is a behavioral observation assessment. In order to establish content validity, or the degree to which experts agree about the domain and facets of the construct, it was important to ensur e literature review, but also with the experiences and knowledge of several PC experts (Fortin et al., 2012) who agreed on the steps and inclusion criteria for the PC method . The developed coding scheme includes all major components of the PC interviewing method, and was carefully 43 examined and approved by two leading PC interviewing expert s. This process provided evidence for the content validity of the developed PC coding scheme. Construct Validity . variables (the constructs) on the basis of observed variables (their pr up of three components: (1) logical analysis, (2) internal - structure analysis, and (3) cross - structure analysis (Pedhazur & Schmelkin, 1991, p. 52) . Riffe, Lacy, and Fico (2014) explain that constructs exist but are only obser Only the logical analysis aspect of construct validity will be discussed here. 8 The first aspect of the logical analysis is to scrutinize the definition of the construct (Pedhazur & Schmelkin, 1991) . Each of the stages, or variables, of the developed PC coding scheme and their corresponding conceptual definition were developed by car efully examining method that pertain to each of the variables included in the coding scheme devised to test PC literature was also reviewed to ensure that each of the variables not only definitions that are logically c er PC literature, see Appendix K . The second aspect of the logical analysis is the item content. Item content involves stent with that definition (Pedhazur & Schmelkin, 1991) . Each item of the coding scheme was created 8 The internal - structure analysis cannot be performed on a dichotomous me asure. A cross - structure analysis will be performed in future research. 44 be constructed based on the PC method that directly ref lect their corresponding construct and The process of assessing item content as described by Pedhazur and Schmelkin (1991) is similar to the concept of face validity, but face validity takes the process on e step further. Face ("Face Validity," 2010, p. 471) , and further ensures that a researcher provides a persu asive argument that the measure of a constru ct make sense on its face (Riffe, Lacy, & Fico, 2014). - technical, unique insights into the evaluation of a measure or research endeavor ("Face Validity," 2010) . A ty pical way to assess the face validity of an instrument is to obtain evaluations of the measure from current or future individuals who will be directly affected by the measurement or research ("Face Validity," 2010) . The coding scheme was a direct reflecti on of the PC method, which was based on recommendations from major conferences regarding what a PC interview and PC communication should include , taking into account the people (i.e. the patients) who would be affected by the adoption of PC care (Makoul, 2 001; Makoul & Schofield, 1999). Additionally, the people involved in this research using the coding scheme (i.e. the coders) were only made sense in its given context, but also that the person felt able to use the item accurately while rating people. Examples were added to the coding scheme to help ensure that the coders understood the item in the medical interview context. Any item that was confusing or that the coder felt unable to use accurately was re - phrased or dropped from the measure. This resulted in 45 33 items that all coders and researchers felt were clear items that accurately reflected the variable they were purporting to assess. The final aspect of the logical analysis is the measurement procedures, which includes examining the method of measurement, directions to respondents, and the scoring procedures (Pedhazur & Schmelkin, 1991) . Each of the variables included in the PC coding scheme contains multiple items, which Pedhazur and Schmelkin (1991) endorse. The items on the coding scheme were created to tap into the constructs that the method attempts to measure. All items are measured the same way, as dichotomous (i.e. yes/no) items, and raters w ere given in - depth instructions during intensive training sessions regarding how to rate the residents. In particular, coders were not only given multiple examples and descriptions of the items on the coding scheme, but they were also given a codebook com plete with descriptions and examples that could be refer red to as needed, see Appendix J . Criterion Validity . Criterion validity refers to an outcome of the measure of interest (Pedhazur & Schmelkin, 1991) - related validation focuses on prediction, the overriding concern being the degree of successful prediction of a criterion, regardless of whether or not it is possible to explain the process or processes leading to the pheno (Pedhazur & Schmelkin, 1991, p. 32) . Riffe, Lacy, and Fico (2014) refer to criterion validity as predictive validity, which is a test that correlates a measure with a predictive outcome, such that when the outcome occurs, co nfidence placed in the measure can increase. The selection of a particular criterion is primarily determined by the person making the selection, including their values and goals; thus, what is important is decided by the person who is selecting the criter ion for the given setting for given individuals (Pedhazur & Schmelkin, 1991) . 46 There are two types of criteria as determined by Pedhazur and Schmelkin (1991) : ultimate and intermediate criteria. An ultimate criteri on is what is deemed important and warrants the efforts necessary to predict it; in other words, an ultimate criter ion is a final goal (Pedhazur & Schmelkin, 1991) . The ultimate criteria of this particular research would be improved health status for people receiving PC care; however, as noted by Pedhazur and Schmelkin (1991) , there are difficulties in defining and measuring ultimate criteria, so many people resort to measuring intermediate criteria instead. Intermediate criteria are easier to define and me asure, more economical to obtain, and require less time to collect than ultimate criteria (Pedhazur & Schmelkin, 1991) . In order to choose an intermediate criterion, the most important consideration is their relevance to the ultimate criteria of interest. Since the ultimate criteri on of this research, improved health status, is not attainable due to standardized patients being used as the subjects of this research, the intermediate criteri on of patient satisfaction will be used to provide evidence for the criterion validity of this measure. Past research has shown the connection between PC care and patient satisfaction, as well as between PC care and improved patient health outcomes (Andersen et al., 2008; Hojat et al., 2011; Kaplan et al., 1989; Kissane & Li, 2008; Spiegel, 2012) ; thus, patient satisfaction was deemed an acceptable criterion for validation purposes. The results of the criterion validation will be discussed in the results section of this paper. Training and Reliability A second way to ass ess whether a coding scheme is a good measure of a particular method is to assess its reliability, which was another component of this research. Two undergraduate students od. Coders (Fortin et al., 2012) , and were asked to 47 re - read the PC chapters of the book. Over the course of two months, coders met with trainers two times per week for two hours per visit. Coders were trained on a small selection of videotapes from the grant project and subsequently on additional medical student tapes provided by the university for training purposes only. Coders spent approximately two hours rating student videotapes outside of tr aining sessions, resulting in around six hours of training per week (i.e. around 48 hours of training total). Videotapes coded outside of the training sessions were e trainers themselves) were discussed until coding agreements could be reached. The unit of analysis was the entire interview. Riffe, Lacy, and Fico (2014) discuss assessing reliability in quantitative content analysis research, and explain that the reli that using a reliability coefficient that takes into account chance agreement is important, as some coder agreements might occur among untrained coders who are not guided by a protocol (Riffe, Lacy, & Fico, 2014). One reliability coefficient endorsed by the authors that takes into account statistic used for inter - rated reliability in this research. Inter - rater reliability was established by having coders independently rate 25 randomly selected videotapes (i.e. 20% of videotapes from the total number of videotapes to be rated). The overal Kappa (Cohen, 1960) . This included all items for all 25 videotapes; and Kappa was .902. Overall percent of agreement for all items for all 25 videotapes was 97.5%; percent of agreeme nt for each individ ual item can be found in Table 7 Agenda Setting variable was .941. The two coders agreed 48 100% of the time for the Physical Story and Indirect PC Skills variabl es for Kappas of 1.00. The Emotional Story variable had a Kappa of .86, and the General Patient - Centered Skills variable had a Kappa of .868. The percent of agreement for the Personal Story variable was 99.3%. 9 After establishing reliability, the coders then recoded all instances where there had been disagreement. Once agreement on all PC variables was consistently reached between both trainers and coders, coders began coding videotapes on their own. Instrumentation Patient - Centered Training. The PC training variable is a dichotomous variable indicating that a resident was either trained or untrained at the time of data collection (0 = untrained, 1 = trained) 10 . This is one of the independent variables of this research. Patient - Centered Skil ls. The PC Coding Scheme developed in this research c ontains six (Fortin et al., 2012) , and 33 behavioral items were developed to measure each of these six areas , s ee Appendix I . Stage 1, setting the agenda, contains three items that focus on opening the esident addresses only 9 calculated if either coder is constant, meaning that the coder uses the same code for a ll items of a particular variable. Therefore, percent of agreement was deemed an acceptable statistic of inter - rater reliability for this variable. 10 Eventually, the PC training variable will be a continuous variable, as training will include multiple com ponents at the end of the grant (e.g. psychosocial rotation, one year of complex patient clinic, two years of complex patient clinic). At the present time, however, PC training will be measured as either present or absent, since complex patient clinic dat a was limited. 49 ntains a dichotomous (0 = no, 1 = yes) variable indicating that the resident either exhibited the behavior or did not , and a higher score denotes more PC skills used . This aggregated measure serve s as a second independent variable. Patient - Centered Knowledge. Resident knowledge regarding the PC care techniques was a patient when being patient - cen (Smith et al., 1998) . The full kno wledge questionnaire contains 27 items regarding PC and mental health know ledge, but only the PC items were used in this assessment. Correct answers were aggregated into a proportion of correct answers to serve as one of the primary dependent variables. Munck and Verkuilen (2002) measure is a balance between the need for parsimony and the concern with underlying dimensionality. These three items should be reflecting only one dimension, PC knowledge. The aggregation of this scale was deemed appropriate, as the three items reflect ive of PC interviewing are each derived from the model, so although an aggregate correct score for each individual will not display which items a person answered correctly, it will give an overall PC knowledge score in which a higher score signifies greate r PC knowledge . In this context, an overall correct score is more meaningful than breaking the construct apart. Self - E fficacy. Twenty 5 - point Likert - type items ranging from strongly disagree to strongly agree with 5 signifying high self - efficacy and 1 signifying low self - efficacy confident that I can respond to emotion by naming, understanding, respecting, and supporting 50 - efficacy regarding mental health knowled ge and PC skills, see Table 4 (Smith et al., 1998) . Seven of these items were developed to measure - efficacy with PC interviewing (ite ms 1 - 7, see Table 4 ). These self - efficacy items were used to create a PC self - efficacy sca le with a higher score indicating greater perceived PC interviewing self - efficacy, and served as the second primary dependent variable. A CFA was conducted on these seven PC self - efficacy items and revealed that two items were weak indicators of PC interv iewing efficacy; thus, a five item scale was used in this research. The CFA conducted on the remaining five items (1, 2, 4, 5, 6) had ample factor loadings and small residuals (RMSE goodness of fit = .07). The reliability , factor loadings, and descriptive statistics of the PC interviewing efficac y factor can be found in Table 8 . These five self - efficacy items averaged to create a PC self - efficacy scale. Patient Satisfaction with Communication. The final dependent variable was patient satisfac tion with communication, which was measured using the ISQ . The ISQ is a 25 - item measure designed to measure four dimension of satisfaction: opportunity to disclose concerns, - po int Likert - type their resident. Previous research reduced th e measure to a 12 - item scale and also found the measure to be second order unidimensional (Grayson - Sneed, 2014) , see Table 5 . This 12 - item scale representing patient communication satisfaction was utilized for the current study. A CFA was conducted and t he scale had ample factor loadings and small error in all four factors (overall RMSE = .084); the reliability, factor loadings, and descriptive statistics for each of the factors can be found in Table 9 . The second order unidimensional measure was subsequ ently analyzed 51 using CFA and demonstrated acceptable fit, as factor loadings were ample and errors were small (RMSE = .014), see Table 10 for the reliability , factor loadings, and descriptive statistics. The second order unidimensional ISQ will be used as the patient satisfaction dependent variable in this research , and a higher score indicates higher patient satisfaction . Measurement Analysis In order to test the research hypotheses, a path model is proposed to depict the PC causal process, se e Figure 3 . The proposed path model predicts that PC training will lead to an increase in PC skills, and then PC skills will lead to greater provider PC knowledge, greater provider self - efficacy, and higher patient satisfaction. Additionally, in order to answer RQ1 which asks what the relationship is between the separate PC skills and patient satisfaction ratings, the separate components of the PC interview will be analyzed as proportions due to the varying number of items include d in each of the variables (e.g. personal story has six items whereas emotional story has 15 items, so 10/15 on emotional story would be 0.66, whereas 3/6 on personal story would be 0.5). The research question will be answered by correlating each of the s kill component proportions with scores on the overall patient satisfaction scale to discover which, if any, of the variables are significantly related to overall patient satisfaction. Finally, since random assignment to condition did not occur, independent samples t - tests were conducted for each of the variable s included in this research (i.e. provider PC skills, provider knowledge, provider self - efficacy, and patient satisfaction) in order to show that there were no significant differences between the inte rvention and control conditions at the beginning of research (i.e. at pretest) . Table 11 includes the descriptive statistics for the pretest intervention group versus the pretest control group for each of the variables. Results indicate that the 52 interven tion group and the control group were not significantly different from one another on any of the variables at the time of pretest . Specifically, results show that there was not a significant difference in PC skill use between the intervention pretest group ( M = 3.75, SD = 2.18) and the control pretest group ( M = 3.42, SD = 2.32, t ( 69) = .616 , p > .05). Results also indicate that at the time of pretest there were no significant differences in provider knowledge between the intervention group ( M = 0 .43 , SD = 0 .25 ) and the control group ( M = 0.53 , SD = 0.27 , t ( 70) = - 1.56 , p > .05). Further, results show that there were no significant differences at the time of pretest between the intervention and control groups for the variables provider self - efficacy or patient satisfaction. Specifically, there were no significant differences in provider self - effic acy between the intervention pretest group ( M = 4.02, SD = 0.46 ) and the control pretest group ( M = 4.11 , SD = 0.46 , t ( 70 ) = - 0.88 , p > .05 ), and there were no significant difference for patient satisfaction between the pretests of the intervention ( M = 4 .09, SD = 0.81) and control groups, ( M = 4.12, SD = 0.83, t (70) = - 0.186, p > .05 ) . These findings indicate that at baseline, the intervention and control conditions were equivalent, alleviating concerns regarding the limitation of not having had random assignment to condition. 53 CHAPTER 3: RESULTS The path model tested in this investigation posited that PC training leads to an increase in PC skills, and PC skills lead to an increase in provider knowledge, provider self - efficacy, and patient satisfaction. The causal model provided in Figure 3 was tested using an ordinary least squares criterion to estimate model parameters, examine parameter size, and to assess the fit of the model (see Hunter & Gerbing, 1982) . Ordinary least squares is a procedure which generates predicted correlations that can be compared to obtained values of correlations. A global test for goodness of fit was assessed by examining the difference between the predicted and obtained correlations using a chi - square statistic. A signific ant chi - square specifies that the predicted model departs substantially from the data obtained. Thus, a non - significant chi - square indicates that the predicted path model is consistent with the data. Table 12 contains the correlation matrix used to estim ate th e model parameters, and Figure 4 presents the path coefficients. Figure 4 indicates that some, but not all, path coefficients were in the predicted direction. The coefficient linking the PC training and PC skills was .54 [ P ( that those who received PC training increased in PC skills, relative to those who did not receive PC training. These results provide support for hypothesis one. The coefficient linking PC skills and provider self - effica cy was .127, .144 when corrected for attenuation due to error of measurement [ P ( - significance and is in the predicted direction of the path model, such that people using more PC sk ills have greater PC self - efficacy. These results indicate support for hypothesis three. The coefficient linking provider PC skills to provider PC knowledge was - .108 [ P ( - .95], which was not in the predicted direction and indicates that the size of the parameters were not substantial; therefore, this path and hypothesis two fail. Similarly, the coefficient linking 54 provider PC skills to patient satisfact ion was .108, .11 when corrected for attenuation due to error of measurement [ P ( - , and this path and hypothesis four also fail. 11 Therefore, th e original model is rejected 12 . Fig u re 5 presents an altered version of the path model presented in Figure 4 that will be probed further here. Figure 5 asse sses the only path from Figure 4 that appeared viable. T he original path model (Figure 3 ) proposed that an increase in PC skills would lead to provider knowledge, provider self - efficacy, and patient satisfaction. Since provider knowledge and patient satisfaction failed, they were dropped from the model. Provider self - efficacy was retained and the new path model was further assessed. F igure 5 specifies that PC training will lead to PC skill, and PC skills will lead to an increase in provider self - efficacy. T he coefficient linking the PC training and PC skills was .54 [ P trained in PC care inc reased in PC skills. Although the coefficient linking the PC skills and provider efficacy was marginal, .144 [ P ( - explored further. Specifically, the difference between the predicted and obtained co rrelation for the constrained correlation (i.e. the correlation between PC training and provider self - efficacy) was examined. The residual was of very small magnitude, .012, and well within sampling error of zero. A chi - square was thus employed as a glob al test for goodness of fit . This model yielded a small and insignificant chi - p > .05]. Thus, although the path coefficient linking PC skills and provider self - efficacy was marginal, the overall model is a good fit. Specifically, the path coefficient linking PC training and PC skills was large, and the model and 11 In order to probe this path model more closely, the first two factors of patient satisfaction, openness and empathy, were looked at separately in the path model to see if the model was a better fit with the factors that contained items b ased solely on provider - patient communication. The model still failed with the inherently communication - based factors. 12 A global test for goodness of fit was not conducted due to the model parameters not being met. 55 parameter estimates accurately predicted the unconstrained correlations; therefore, the model and data are judged to be consistent with one another. Research question one asks what the relationship is between the separate PC skills and patient satisfaction ratings. Presented in Table 13 are the correlations between each of the skill component proportions with the overall rating of patient satisfaction. Descriptive statis tics for each of the PC skill variables for each group (i.e. pretest and posttest for the control and intervention conditions) are presented in Table 14 . Patient satisfaction descriptive statistics for each group (i.e. pretest and posttest for the control and intervention conditions) as well as the overall patient satisfaction score and all other PC outcome variables discussed are presented in Table 11 . None of the skill component proportions were significantly related to patient satisfaction, so this res earch question was not probed further. 56 CHAPTER 4: DISCUSSION Overview of Findings and Practical Implications Th is work centered on the development of an objective PC coding scheme that could be PC literature and research, as there has been much time and effort dedicated to underst anding filled a gap in the literature by presenting a behaviorally - defined, evidence - based method that providers could easily learn and implement into their pract ice. The method has b e en shown in past research to be associated with patient satisfaction and enhanced outcomes for patients. For these reasons, this method has received attention from PC advocates in the healthcare realm. The next needed step was to d evelop a way of assessing people adopting the method. This research sought to establish a systematic way to objectively rate individuals using the PC method via a developed coding scheme. A dichotomous coding scheme rating specific PC behaviors specified by the PC interviewing model allows for an objective way of determining whether training in the method leads to enacted skills, and if the use of those skills leads to other positive outcomes such as provider knowledge, provider self - efficacy, and patient satisfaction. Moreover , it was important to provide evidence for the validity of the measure, and to ensure that the coding scheme was reliable. Both the validity and reliability were established here ; specifically, the validity was ensured in a number of ways (i.e. face, content, and construct), and inter - rater reliability between two trained coders was very high across the coding scheme (Kappa = .902), showing that coders were seeing the same PC behaviors in the provider - patient interactions. This res earch was able to develop a meaningful coding scheme that adopters of 57 Of considerable importance here was the fact that results indicate d that training providers iew via a psychosocial rotation focusing on PC skills and mental health issues results in a significant increase in PC skill use by providers , which provided support for hypothesis one in this research . Additionally, people using a higher number of PC ski lls had higher self - efficacy regarding using PC skills , lending support to hypothesis three . These results are depicted in the path model in Figure 5 , which shows that training in PC interviewing leads to an increase in PC skill use, and PC skills lead to provider PC self - efficacy. The correlation, and - efficacy was moderate ( r = .144, when corrected for attenuation due to measurement error); however, Abelson (1985) explains that even small cor relations may be extremely important, and suggests that researchers tend to rely too heavily on statistical significance tests as a basis for making substantive assertions. In light of this, the path indicating that PC skills leads to an increase in provi der self - efficacy is informative, but may be interpreted with caution. Confidence in this path will increase with additional data. The current research is ongoing for several more years; thus, if the trend continues in the direction currently seen, the p arameters of the path coefficient linking PC skills and provider PC self - efficacy will be ample. This path will be re - examined when additional data is obtained. The preliminary results showing that PC skills l ead to provider self - efficacy are important f or a number of reasons. Research shows that students with high self - efficacy tend to persist longer, work harder, participate more readily, show enhanced interest in learning, and achieve at higher levels (Bandura, 1997). This is extremely important in t he PC realm because many health facilities want their employees to adopt a PC approach to care. Since people with high self - efficacy tend to persist longer and achieve at higher levels, it is logical that a person with high 58 PC self - efficacy would continue using the skills in practice after the training period , and that is confirmed here with these results . The point of training is not merely to show that people can learn the PC skills; but more importantly, institutions training in PC care are striving fo r a behavior change in their trained pe rsonnel , where by PC care becomes habitual in practice. Therefore, a training program focused on PC care needs to ensure that people are leaving training with a strong sense of self - efficacy, as this will increase the likelihood that learned skills will continue with the provider into their practice and become the norm. Moreover, a meta - analysis examining the relationship between self - efficacy and performance indicates that there is a strong , positive relationship between self - efficacy and work - related performance (Stajkovic & Luthans, 1998), such that a person with high self - efficacy will be more inclined to perform well at work than a person with low self - efficacy. The authors claimed that self - efficacy may be a better predictor of work - related performance than other personality - based constructs commonly found in the literature (Stajkovic & Luthans, 1998). This meta - analysis is particular ly important here, as this finding indicates that a person with high PC self - efficacy will be more likely to perform PC care in practice than a person low in self - efficacy. Si nce an overarching g oal of this research is to have trained people adopt a PC approach to care after the training period , the findings from Stajkovic and Lu suggest that high self - efficacy will result in performance. Therefore, the results showing that an increase in PC skills led to provider self - efficacy is an important step, as this will hopefully lead to PC performance in the workplace. O ne additional important note to make regarding self - efficacy is that the directionality of self - efficacy and PC skills could have been reversed, such that a provider with high self - efficacy leads to greater skill performance. According to Stajkovic and Lu thans (1998), a person with 59 high self - efficacy will be more inclined to perform at work. This finding could have meant for the current research that the providers with the highest self - efficacy regarding their PC abilities would lead to the highest PC ski ll use ; this is the opposite of the prediction made in this research, which said that a greater use of PC skills would lead to greater provider self - efficacy. The path model in the given research shows that the direction posed in this research (i.e. great er PC skills leads to higher self - efficacy) was the accurate prediction . P ast research supports the prediction found in the current research. Ammentorp, Sabroe, Kofoed, and Mainz (2007) found that communication training focusing on skill use can improve some of the essential communication demands they face, and the communication skills lead to an increase in provider self - efficacy. Therefore , hypothesis three, which stated th at an increase in PC skills would lead t o an increase in provider self - efficacy, was supported. There were two surprising findings of note in this research; specifically, PC skills did not lead to provider PC knowledge or patient satisfaction, as the literature posits and this research hypothes ized. Although this was unanticipated, there are plausible explanations for these discrepant findings. To begin, the researchers discovered during the data anal ysis process that the different groups involved in this research (i.e. the control group and i ntervention group) received different versions of the knowledge questionnaire across the time s of the data collection. The control group is located in a different city from the control group, making data collection in the respective cities of the differen t groups clear ; however, this split in location resulted in two different versions of the knowledge questionnaire being administered. The original 78 - item knowledge questionnaire was reduced to 49 items after data was collected on the pilot group. The jus tification for the reduction in items was twofold: (1) several of the items on the questionnaire were not being addressed in training and therefore would not 60 contribute meaningful outcome data, and (2) boredom effects on participants were visible during da ta collection. It was observed that participants started showing signs of fatigue halfway through the questionnaire, so a reduction in items was reasoned to be necessary. When asked to adjust the knowledge questionnaire to reflect these changes, the diff erent data collection facilities included different items on the new version(s) of the knowledge questionnaire. After careful examination of the items remaining on each version, there were only 27 common items that all residents received across time ; of t hose 27 items, only 3 items were PC related. The original version contained 13 PC items, which more fully encompass ed a measure of well - rounded, PC knowledge. This major glitch in the research resulted in a knowledge questionnaire that was no longer an accurate assessment of PC knowledge. For these reasons, the link between PC skills and PC knowledge is not considered a viable refle ction of the PC training process or of PC knowledge in general. Similar to self - effi cacy, the directionality in PC skills leading to provider knowledge could have been reversed, such that a prediction could have been made that suggests provider knowledge l eads to an increase PC skills. Past research suggests that people learn general, declarative, verbal knowledge to begin, and through practice, turn knowledge into usable, procedural skills (Ackerman, 1988; Anderson, 1993). However, Sun, Merrill, and Pe terson (2001) suggested that in some domains, a bottom - up skill learning process may happen, whereby some knowledge is constructed only after a skill is at least partially developed. This type of learning was hypothesized to happen in the current research due to the longitudinal nature of the research. Specifically, provider PC skills were hypothesized to lead to an increase in provider knowledge due to the time lag between training and data collection. Residents went through PC training in the first yea r of their residency. Data collection did not occur for an additional one to 61 two years. For this reason, it was believed that a resident would need to continue enacting the prescribed skills in practice in order for them to do well on a knowledge questio nnaire administered years later. If a resident went through training and never enacted a PC skill after the training period ended, it is unlikely that the resident would retain PC knowledge and perform well on a written test covering the topic. In contra st, a resident who goes through training and adopts the skills taught in tra ining into their practice should retain the PC knowledge because they have incorporated PC care into their practice and are therefore using the PC knowledge with regularity . In co ntrast to either of these predictions, however, t he current research found a negative relationship between PC skills and PC knowledge ( r = - .11, see Table 12 ), such that an increase in one leads to decrease in the other , causing hypothesis two to fail. Fu ture research should probe further to discover how the path between PC skills and knowledge functions in medicine , as the research here is limited due to the faulty PC knowledge questionnaire. Similarly, and in contrast to what was hypothesized, PC skills did not lead to an increase in patient satisfaction. This was unexpected, as the literature clearly shows this relationship (Fossum & Arborelius, 2004; Hall, Roter, & Katz, 1988; Krupat et al., 2000; Smith et al., 1998; Zyzanski et al., 1998) ; however, t he literature also shows that most surveys report high patient satisfaction levels, calling to question the interpretation of satisfaction as an outcome of an active evaluation due to a possible ceiling effect (Williams, Coyle, & Healy, 1998) ; the overall patient satisfaction mean in this research was 4.09 out of 5.0, showing that standardized patients were rating residents highly across all conditions, see Table 11 . A common factor found in the patient satisfaction literature is that few patients are crit ical of their care to the point of expressing dissatisfaction (Abramowitz, Cote, & Berry, 1987; Hopton, Howie, & Porter, 1993; Sitzia & Wood, 1997) . Moreover, Sitzia and Wood (1997) point out that although such favorable patient 62 satisfaction data may plea se healthcare educators, the lack of variability in patient satisfaction responses is a problem in research, as researchers must compare positive with slightly less positive responses. This lack in variability makes patient satisfaction difficult to analy ze. However, research has also shown that when specific components of care are specified, specifically noted was communication in primary care, substantial dissatisfaction exists and is exemplified in research (Williams & Calnan, 1991) ; therefore, the cur rent research hypothesized that skills in provider - patient communication would lead to an increase in patient satisfaction. Nonetheless, the current research failed to find any significant differences between the pretest and posttest or between the contro l group and intervention group, supporting past research that shows patient satisfaction consistently being positive , see Table 11 . An explanation for this finding could be that providers who are still in training programs and are being evaluated tend to have high patient satisfaction (Hall & Dornan, 1988) . A meta - analysis examining satisfaction with medical care indicates that patient satisfaction is higher for providers who are still in training; specifically, such providers engage in more behaviors th at have shown to result in patient satisfaction than do providers not in training (Hall & Dornan, 1988) 13 . Hall and Dornan (1988) suggest that this finding could be due to these providers increasing behavior s taught during training because they feel they a re being evaluated. This could have affected the results in the current study, as the residents were aware that they were being evaluated. Residents knew they were being videotaped with standardized patients on particular medical scenarios, and they were in the same facility that many evaluation tests were data. The inflation in the current research provided little to no variation in patient satisfaction 13 The specific behaviors being discusse d in this research were not discussed. 63 scores across the different conditions , see Table 11 , thus hypothesis four fail ed to find support . The proposed relationship would establish scientific evidence for the criterion validity of the PC coding scheme by showing that PC skills (i.e. a higher score on the PC coding scheme) would lead to the outcome variable of patient satisfaction. However, as this relationship was not est ablished by showing that PC skills lead to patient satisfaction , the criterion validity of the coding scheme was not established. An additional concern regarding patient satisfaction was that a close examination of the items on the questionnaire showed that not all items were directly focused on communication , the p atient satisfaction questionnaire was flawed. This concern was explored further by looking at only patient satisfaction factors, openness and empathy, that had items based solely on ) in the originall y posed path model, see Figure 3 ; the model failed with only communication - based patient satisfaction items. After further consideration, it was decided that the items that were not inherently communication based were not problematic. T he only way for a person to have the is through communication. Although the items may not be directly based on communication, the items are a result of the interaction and only communication in the interaction would result in patient satisfaction as deemed by the patient satisfaction questionnaire used in this research. Some of the items are more specific regarding the actual communication that took place, b ut all of the items come about because of communication. Therefore, the questionnaire itself was decided to be acceptable. 64 Finally, a research question posed in this research asked whether there was a relationship between any of the PC skills prescribed by the PC interviewing method and patient satisfaction ratings; there were no significant relationships found. This finding is also a likely reflection of the inflated patient satisfaction scores across all levels of data, making any relationship between specific skills and patient satisfaction undetectable. Directions for Future Research Future research should explore how the coding scheme will be best used in actual practice. Currently, the coding scheme is 33 items that trained providers can learn and implement, but a more important question is how best to use the skills in practice, both at a first time visit and with long - time patients the provider knows well. Future research should address this issue by exploring what is ideal when using the method traditional medical interview is the personal and emotional stories. It is going to be important in the future to find out what is the ideal number of skills to use in an interview to be efficient yet patient - centered. Once the ideal number of skills is determined, it will be important to adapt the coding scheme to fit that ideal. Important here is the fact that a provider should not try and use all 33 behavioral skills included on the coding scheme, this would result i n an interview where the provider sounds forced in their conversational technique, which would have the opposite effect for which the method strives. Therefore, it is going to be important to determine how best to use the coding scheme, what the ideal numb er of skills to use will be, and what patients seem to like best. Research by Horner, Rew, and Torres (2006) discusses how intervention fidelity needs to be an integral component in study design, and explains that the validity of the outcomes of researc h is based on the degree to which intervention fidelity is evaluated and maintained. Part 65 of the training of residents in the present study was that residents should tailor material learned in the intervention to be appropriate for their skill set and the ir personal PC interactions. This means that some providers may effectively carry out a PC interview with fewer skills because the skills used are far advanced, whereas another provider with less PC abilities may need to use several skills to achieve the same outcome with their patient. Both of these examples would stay true to the fidelity of the intervention, making it difficult to determine an ideal number of skills to use in practice, and further, how to effectively use the PC coding scheme. Therefor e, future research needs to study the training process and the coding scheme thoroughly to determine how best to adapt the coding scheme to be used in actual practice with providers. This iterative process will be both informative and impactful for the me thod and the coding scheme. Similarly, although the face validity of the coding scheme was established by having the coders in this research review the scheme in full, a next step will be taking the coding scheme to providers and patients in focus groups to determine what is important to them. Since the medical interview is performed by providers and impacts patients, getting feedback from both will be crucial to the future of the coding scheme. Discovering what is important to both the pr ovider and pati ent will help make significant updates to the coding scheme, and possibly the PC method, that will ultimately enhance both and result in a medical interview that the provider and patient both find ideal. Another aim of future research should be to create and validate a reliable provider PC knowledge questionnaire. The literature is lacking in this regard as many people are expending effort on PC care and teaching PC interviewing, but there are no validated, reliable questionnaires designed to me attention. The literature has many definitions of PC care, examples of what it means to be PC, 66 and ways to enact PC care via PC interviewing; however, research has yet to consolidate this lit regarding what PC care or PC interviewing entails. In order to accomplish this, conceptual agreement among PC researchers regarding what constitutes good PC car e is needed . Once good PC care and PC skills are agreed upon and behaviorally - defined, a questionnaire regarding a The creation of a standardized knowledge measure would allow for reliable comparisons across stud ies, which would be a better indication to researchers of how to best train providers in PC care in terms of gaining PC knowledge. Additionally, in order to accurately assess patient satisfaction, researchers should collect patient satisfaction data of pr oviders in their respective clinics. In the research setting, providers know they are being evaluated so they may act differently than they would in their own practice. Once providers are in their own practice after the training and evaluation period, pa tient satisfaction data could be collected routinely to obtain a gestalt patient satisfaction score for providers. Such non - vid e o taped , non - evaluated interactions between providers and their patient s would likely give a more accurate patient satisfaction rating. The fact that providers were aware that they were being evaluated in the current research could have added to the inflated patient clinics and compari ng providers trained in PC care to untrained PC providers would give a more robust indication of the hypothesized path leading from PC training to PC skills to patient satisfaction. This research has shown that PC training leads to PC skills, so discoveri ng if those skills lead to higher patient satisfaction in actual practice would be enlightening. 67 Limitations This research had several limitations that should be addressed. To begin, the number of participants involved in this research was limited. Ea ch condition had an average of 34 people, which is not large. This made it difficult to draw conclusions based on the findings. The current research is part of a larger project, and once all data are collected the results will be re - analyzed. The major contribution of the current research was the development of the PC coding scheme and establishing the validity and reliability of the scheme. The current research, involving only half of the data of the larger project, was used for preliminary analyses to ensure that the coding scheme was reflecting the PC interviewing method accurately. Since PC training le d to a significant increase in PC skills, confidence can be placed in the PC coding scheme which measured PC skills . Once all data ha ve been collecte d, the path model will be reanalyzed, and patient satisfaction data will be reassessed to ensure that the current findings are reflective of the larger project. A second limitation was that people in the trained intervention condition were not trained in full at the time of data collection. A large portion of the full training for this project in PC care involves several hours 14 a t a Complex Patient C linic where residents receive individual attention from core faculty and PC experts regarding their mental healt h and PC interviewing skills. The resident data included in the current project was lacking in these additional PC training hours, as the first several years of this project involved teaching the core faculty who would subsequently teach residents. For this reason, most resident s involved in this research received limited to no additional training at the Complex Patient Clinic. Future residents receiving additional training may produce different outcomes , so re - analyzing data at the end of 14 Residents will attend the Complex Patient Clinic approximately six times per year during their second and third years of residency for a total of 48 additional hours of training by the completion of their residency. 68 the entir e project is critical. The current research was able to show that PC training leads to PC skills as shown via the PC coding scheme; therefore, confidence placed in the PC coding scheme is high and it will be used in the final data analysis of this project . Finally, the results regarding provider knowledge are severely limited due to the different data collection facilities administering different versions of the knowl edge questionnaire. This resulted in only three PC questions that were used with regularity across sites , which were not encompassing of what would be c onsidered robust PC knowledge; p rovider knowledge should therefore be interpreted with caution . 69 CHAPTER 5: CONCLUSION S With the increased attention PC care has re ceived in the past decade due to the many positive outcomes associated with it, creating a standardizing way of evaluating people adopting a PC approach to care was a gap this research sought to fill. The primary aim of this research was to develop a reli able, valid PC coding scheme to be used as a standardized way of rating - based method available. Having a standardized way of rating adopters of the method will be useful to both providers and institutions choosing to adopt the PC method, as having a coding scheme to go hand - in - hand with the method will ensure that all people using the PC method are conceptualizing and measuring PC interviewing and the appropriate s kills in the same way. This research indicates that the developed coding scheme is both valid and reliable and is accurately training leads to an increase in PC skill s, and an increase in PC skills leads to an increase in provider PC self - efficacy. These results not only indicate that PC training can effectively teach PC skills and that the developed coding scheme is accurately assessing those skills, but also that tr ained providers have greater self - efficacy than untrained providers regarding their ability to enact PC skills. This is important, as research shows that people with higher self - efficacy regarding particular skills tend to use those skills more frequently than people low in self - efficacy. These findings will offer providers and medical institutions interested in adopting a PC approach to care with vital info - efficacy . Educators of students and residents w ould s imilarly be interested. Ultimately, this will provide reliable way. 70 APPENDICES 71 Appendix A Four Habits Coding Scheme (Krupat et al., 2006) 1. Invest in the Beginning a. Shows familiarity with patient b. Greets patient warmly c. Makes small talk d. Uses primarily open - ended questions e. f. Elicits the full range of concerns 2. a. b. c. 3. Demonstrate Empathy a. Encourages expression of emotion b. c. Helps to identify/label feelings d. Disp lays effective nonverbal behavior 4. Invest in the End a. b. Allows time for information to be absorbed c. Explains clearly/uses little jargon d. Explains rationale for tests and treatments e. Effectively tests for comprehensio n f. Encourages involvement in decision making g. Explores acceptability of treatment plan h. Explores barriers to implementation i. Encourages additional questions j. Makes clear plans for follow - up 72 Appendix B Four Habits Coding Scheme Extended (Krupat et al., 2006) Habit 1. Invest in the Beginning or visit information based on previous chart notes) 3. Clinician makes some reference to past visits or histor y, but familiarity with these does not seem strong 5. Clinician needs to refer to chart continually to familiarize self with case or does not relate current visit B1. Patient is greeted in man ner that is personal and warm (e.g., clinician asks patient how s/he likes to be addressed, uses patient's name) 3. Patient is greeted in manner that recognizes patient, but without great warmth or personalization 5. Greeting of patient is cursory, imperso nal, or non - existent C1. Clinician makes non - medical comments, using these to put the patient at ease 3. Clinician makes cursory attempt at small talk (shows no great interest, keeps discussion brief before moving on) 5. The clinician gets right down to business without any attempt at small talk (or cuts patient off curtly and abruptly, or if later in visit, shows only passing interest) D1. The clinician tries to identify the problem(s) using primarily open - ended questions (asks questions in a way that a llows patient to tell own story with minimum of interruptions or closed ended questions) 3. The clinician tries to identify the problem(s) using a combination of open and closed ended questions (possibly begins with open - ended but quickly reverts to closed ended) 5. The clinician tries to identify the problem(s) using primarily closed - ended questions (staccato style) E1. The clinician encourages the patient to expand in discussing his/her concerns (e.g., using various continuers such as Aha, Tell me more, Go on). 3. Clinician neither cuts the patient off nor expresses great interest in learning more (listens, but does not encourage expansion or further discussion) 5. The clinician interrupts or cuts the patient off in his/her attempt to expand (is clearly not very interested). F1. The clinician attempts to elicit the full range of the patient's concerns by generating an agenda early in the visit (clinician does other than simply pursue first stated complaint) 3. The clinician makes some reference to other possible complaints, or asks briefly about them before pursuing the patient's first complaint, or generates an agenda as the visit progresses. 5. The clinician immediately pursues the patient's first concern without an attempt to discover other possible concerns of the patient's . Habit 2. Elicit the Patient's Perspective A1. Clinician shows great interest in exploring the patient's understanding of the problem (e.g., asks the patient what the symptoms mean to him/her). 3. Clinician shows brief or superf icial interest in understanding the patient's understanding of the problem 5. Clinician makes no attempt/shows no interest in understanding the patient's perspective 73 B1. Clinician asks (or responds with interest) about what the patient hopes to get out of the visit (e.g., can be general expectations or specific requests such as meds, referrals). 3. Clinician shows interest in getting a brief sense of what the patient hopes to get out of the visit, but moves on quickly. 5. Clinician makes no attempt to determine (shows no interest in) what the patient hopes to get out of the visit. C1. Clinician attempts to determine in detail/shows great interest in how the problem is affecting patient's lifestyle (work, family, daily activities). 3. Clinician attempts to determine briefly/shows only some interest in how the problem is affecting patient's lifestyle. 5. Clinician makes no attempt to determine/shows no interest in how the problem is affecting patient's lifestyle. Habit 3. Demons trate Empathy A1. Clinician openly encourage/is receptive to the expression of emotion (e.g., through use of continuers or appropriate pauses (signals verbally or nonverbally that it is okay to express feelings) 3. Clinician shows relatively little interes t or encouragement for the patient's expression of emotion; or allows emotions to be shown but actively or subtly encourages patient to move on em otion by the patient (signals verbally or nonverbally that it is not okay to express emotions) B1. Clinician makes comments clearly indicating acceptance/validation of patient's feelings (e.g., I'd feel the same way... I can see how that would worry you.. .) 3. Clinician briefly acknowledges patient's feelings but makes no effort to indicate acceptance/validation 5. Clinician makes no attempt to respond to/validate the patient's feelings, or possibly belittles or challenges them (e.g., It's ridiculous to b e so concerned about...) C1. Clinician makes clear attempt to explore patient's feelings by identifying or labeling them (e.g., So how does that make you feel? It seems to me that you are feeling quite anxious about...) 3. Clinician makes brief reference to patient's feelings, but does little to explore them by identification or labeling 5. Clinician makes no attempt to identify patient's feelings D1. Clinician displays nonverbal behaviors that express great interest, concern and connection (e.g., eye contact, tone of voice, and body orientation) throughout the visit. 3. Clinician's nonverbal behavior shows neither great interest or disinterest (or behaviors over course of visit are inconsistent). 5. Clinician's nonverbal behavior displays lack of inter est and/or concern and/or connection (e.g., little or no eye contact, body orientation or use of space inappropriate, bored voice) D. Invest in the End A1. Clinician frames diagnostic and other relevant information in ways that reflect patient's initial presentation of concerns 3. Clinician makes cursory attempt to frame diagnosis and information in terms of patient's concerns 74 5. Clinician frames diagnosis and information in terms that fit physician's frame of reference rather than incorporating those of the patient B1. Clinician pauses after giving information with intent of allowing patient to react to and absorb it 3. Clinician pauses briefly for patient reaction, but then quickly moves on (leaving the impression th at the patient may not have fully absorbed the information). 5. Clinician gives information and continues on quickly with giving patient opportunity to react (impression is that this information will not be remembered properly or fully appreciated by the p atient) C1. Information is stated clearly and with little or no use of jargon 3. Information contains some jargon and is somewhat difficult to understand 5. Information is stated in ways that are technical or above patient's head (indicating that the pati ent has probably not understood it fully or properly). D1. Clinician fully/clearly explains the rationale behind current, past, or future tests and treatments so that patient can understand the significance of these to diagnosis and treatment 3. Clinicia n only briefly explains the rationale for tests and treatments 5. Clinician offers/orders tests and treatments, giving little or any rationale for these. E1. Clinician effectively tests for the patient's comprehension. 3. Clinician briefly or ineffective ly tests for the patient's comprehension 5. Clinician makes no effort to determine whether the patient has understood what has been said. F1. Clinician clearly encourages and invites patient's input into the decision making process 3. Clinician shows litt le interest in inviting the patient's involvement in the decision making process, or responds to the patient's attempts to be involved with relatively little enthusiasm. ignores patient's efforts to be part of decision making process G1. Clinician explores acceptability of treatment plan, expressing willingness to negotiate if necessary 3. Clinician makes brief attempt to determine acceptability of treatment plan, and mo ves on quickly 5. Clinician offers recommendations for treatment with little or no attempts to elicit patient's acceptance of (willingness or likelihood of following) the plan H1. Clinician fully explores barriers to implementation of treatment plan 3. Clinician briefly explores barriers to implementation of treatment plan 5. Clinician does not address whether barriers exist for implementation of treatment plan I1. Clinician openly encourages and asks for additional questions from patient (and responds to them in at least some detail) 3. Clinician allows for additional questions from patient, but does not encourage question asking nor respond to them in much detail 5. Clinician makes no attempt to solicit additional questions from patient or largely igno res them if made unsolicited J1. Clinician makes clear and specific plans for follow - up to the visit 3. Clinician makes references to follow - up, but does not make specific plans 5. Clinician makes no reference to follow - up plans 75 Appendix C ient - Centered Interviewing Method (Fortin et al., 2012) 5 - STEPS, 21 - SUBSTEPS STEP 1 -- Setting the Stage for the Interview 1. Welcome the patient 2. Use the patient's name 3. Introduce self and identify specific role 4. Ensure patient readiness and privacy 5. Remove barriers to communication 6. Ensure comfort and put the patient at ease STEP 2 -- Chief Complaint/Agenda Setting 1. Indicate time available 2. Indicate own needs 3. Obtain list of all issues patient wants to discuss; e.g., specific symp toms, requests, expectations, understanding 4. Summarize and finalize the agenda; negotiate specifics if too many agenda items STEP 3 -- Opening the HPI 1. Open - ended beginning question 2. 'Nonfocusing' open - ended skills (Attentive Listening): silence, n eutral utterances, nonverbal encouragement 3. Obtain additional data from nonverbal sources: nonverbal cues, physical characteristics, autonomic changes, accouterments, and environment STEP 4 -- Continuing the Patient - Centered HPI 1. Physical Story -- Obtain description of the physical symptoms [Focusing open - ended skills] 2. Personal Story -- Develop the more general personal/psychosocial context of the physical symptoms [Focusing open - ended skills] 3. Emotional Story -- Develop an emotional focus [E motion - seeking skills] 4. Empathic Responses -- Address the emotion(s) [Emotion - handling skills: NURS] 5. Expand Story and Responses -- Expand the story to new chapters (focused open - ended skills, emotion - seeking skills, emotion - handling skills) STEP 5 -- Transition to the Doctor - Centered Process 1. Brief summary 2. Check accuracy 3. Indicate that both content and style of inquiry will change if the patient is ready 76 Appendix D The Seven Descriptors of Symptoms (Fortin et al., 2012) 1. O nset and Chronology a. Time of onset of symptom and intervals between recurrences b. Duration of symptom c. Periodicity and frequency of symptom d. Course of symptom i. Short - term ii. Long - term 2. P osition and radiation a. Precise location b. Deep or superficial c. Localized or diffuse 3. Q uality a. Usual descriptors b. Unusual descriptors 4. Q uantification a. Rate of onset b. Intensity or severity c. Impairment or disability d. Numeric description i. Number of events ii. Size iii. Volume 5. R elated symptoms 6. S etting (Circumstances that contribute to or precipitate the symptom) a. Environmental factors b. Social factors c. Activity d. Emotions 7. T ransforming factors a. Precipitating and aggravating factors b. Reliev ing factors 77 Appendix E Total Videotapes Available Chart Residents from Intervention Site with NO TRAINING (i.e. resident JUST entered the program): 41 Residents from Intervention Site with training: 43 Residents from Control Site with NO TRAINING (entering first years): 31 Residents from Control Site with NO TRAINING, but have been in program for 3 years: 21 Total Tap es: 136 Residents from Intervention Site = 84 Residents from Control site = 52 78 Appendix F Christina Smith Instructions for Provider Michigan State University Learning and Assessment Center HRSA Grant McFee Internal Medicine Practice Patient: Christina Smith Chief Complaint: Pain in Left Leg Your Task: You have not previously seen this woman, but are filling in for a colleague who is out of town and the office staff thought she needed to be seen before he returned because of recent leg pains 79 Appendix G Data Gathering Instructions to Standardized Patient DATA - GATHERING SP INTERVIEW: Christina Smith REGULAR DOCTOR IN THE CLINIC Initial History: Christina Smith is a 38 year old woman who has come to the clinic today because she has had a pain in her left leg for the last three days (points to her calf). She also has been having right - sided chest pain for several weeks, needs her birth control patch refilled, would like some medications for the pain, and needs a job - related form completed to indicate When asked for more information about the chief complaint: Christina has noticed a small amount of swelling in her calf. Also, it has felt slightly warm to the touch, even though she has not had a fever. At least her cold is much better now, except she does feel a bit short of breath when walking (in actuality, limping). When asked for more information about the chief complaint: Christina describes the leg pain as an ache, not a sharp pain. The pain does not travel anywhere else. It feels a bit better at night. It feels worse when she is walking or standing. It also hurts more if she sq ueezes her calf or presses along the slightly red area on the inside of her knee. The other leg feels normal. Tylenol (two extra strength) has not helped. She thinks the leg may be slightly swollen but just at the ankle. The chest pain occurs in right lat eral chest near the lower aspect of the ribs. It hurts to take a breath but is somewhat better over the last week; no rib injury or fall but this did seem to begin after she lifted a heavy piece of equipment at work, and it hurts when she pushes on it. The shortness of breath is more needing to take a deep breath rather than being winded; if she history of leg injury or other muscular pains, and she has not had a fever or chills or coughed up anything, especially no coughing blood. Her appetite has been good and she feels well otherwise. The leg pain and chest pain and shortness of breath have never occurred before. When asked she gives this Personal Story: She works as a home health care aide, which means get paid when she is sick, like her friend does who is a patient care tech at the hospital. She already misse d work last week, except to go to the bathroom. Christina lives with her four - year - old son, Elijah, and her mother, who helps her with childcare. When asked, she gives this Emotional Story: Christina is worried about finances and also feels tired and overwhelmed . She has been taking night classes at the local community college in hopes of becoming a patient care technician at a hospital, like her friend, or working in a nursing home. Her son about it. She is very worried 80 her friends as soon as she got fat during her pregnancy. Christina has no interes t in having her buy a few boxes of Pampers her son was born, but recently had started seeing Kevin, who works construction and likes to play with her son. But she broke it off because little Elijah threw tantrums when Kevin spent the night. Christina is lonely and would like to hang out with people her own age. She is unhappy with her life. On th e other hand, she enjoys her work, going to church, and her son. She does not situation will improve. Her mother and older sister provide considerable support for her when she needs it. Her emotional reactions are as follows: loves her mother and sister; angry at her Other Background Information IF NEEDED Past and Family Medical History: The only time Christina has been in the hospital was when her son , Elijah, was born. He was a big baby, weighing 9 1/2 pounds, and she needed a C - section. She has wheezing and coughing several time asthma. Her father died of an alcohol - related illness and her mother says she is in pain all of the Medications and Allergies: Christina has a birth control patch because she used to forget when she was on the pill. She takes Tylenol for headaches and drinks a lot of Coca Cola® because it gives her more energy. She has no allergies. Tobacco, Alcohol and Street Drugs: Christina has smoked one pack of cigarettes a day for about five years (before that about one - half - a - pack - a - day for two years). She knows too much about alcoholism and drug addiction to touch anything. Social History: since that marriage fell apart when she was a junior i n high school. Christina used to live alone but was overwhelmed. She got pregnant her senior year in high school, but did finish. She gets no child support payments and is not able to afford health insurance on what she makes working as a home health care aide. Her son is on Medicaid. She was on Medicaid too when her son was born, but she no longer is allowed to have the coverage. Someone said she worked too much, which makes no sense, since they were the ones who told her she had to work. She regularly att ends church and many older people there have taken an interest in her and Elijah and are supportive and sometimes help out with baby - sitting when her mother and sister are not available. 81 Appendix H Knowledge Questionnaire Instructions: Choose only one answer for each of the following questions. *Indicates item was used for the PC scale 1. ___ *It is inappropriate to interrupt the patient when being patient centered a. True b. False 2. ___ Which of the following is most accurate when diagnosing disable chronic pain patients as having unexplained symptoms a. You have to be honest with the patient that you can never really be sure there is no underlying disease b. When many psychological symptoms are present, this is a good clue there is no disease basis for the chronic pain c. You often need to repeat previous diagnostic studies because a disease explanation often has developed in the interim d. A high false positive rate using just physical and psychological symptoms as diagnostic criteria means that most requir e a full diagnostic work - up 3. ___ *All but one of the following is a clue that counterproductive(harmful) countertransference is present a. An intense emotional response towards the patient b. Similar reactions, such as anger or fear, to many different patients c. The failure of a physician to use skills s/he is known to possess d. A positive reaction a patient reminding one of a much loved parent or grandparent e. An emotional reaction to the patient similar to that of other doctors 4. ___ *Which of the following stat ements would be the LEAST effective when interacting with a severe, chronic somatizing patient a. We may be able to help you live a more normal life b. Things seem especially bad for you right now; how are you able to cope? acetaminophen with each meal and at bedtime, not just when you think you need it 82 5. ___ The depression often seen in somatizin g patients typically is unresponsive to antidepressants a. True b. False 6. ___ When attempting to convince a patient to change an undesirable health behavior (e.g., smoking) a physician should begin by b. Encouraging the patient to verbally commit to quitting smoking c. Explaining to the patient why quitting smoking is necessary d. Employing emotional handing skills repeatedly 7. ___ In the US suicide is the 4 th leading cause of death for adults between the ages o f 18 and 65 years. The following statement is true regarding the epidemiology of suicide. a. Men complete suicide less often than women. b. The suicide rate decreases in men over the age of 60 years c. HIV, cancer, and asthma are associated with the highes t risk of suicide attempts among those with medical diseases d. The presence of young children living in a household increases the risk of suicide 8. ___ In the sleep disruption of depression, the following statement is accurate a. Sedative hypnotics are counterp roductive and are likely to perpetuate sleep difficulties b. Caffeine may be helpful in countering daytime tiredness and improving alertness c. Sleep hygiene methods including daily exercise, avoiding naps, and a relaxing sleep time routine are not benefi cial d. Sedative antidepressants such as mirtazapine and trazodone have no role 9. ___ In the longitudinal course of bipolar disorder, depressive episodes often precede manic episodes. This can lead to misdiagnosis. Which one of the following clinical features i s more common in bipolar depression as opposed to major depressive disorder a. Insomnia more than hypersomnia b. Postpartum episodes c. Psychomotor agitation more than retardation d. Later onset (30s vs. teens) e. Insidious vs. abrupt episode onset 83 10. ___ Which of the following interventions would not be acceptable as first line in the initial treatment of an acute episode of bipolar (Type 1) depression? a. Antidepressant monotherapy b. A combination of lithium and lamotrigine c. Olanzapine and fluoxetine d . Quetiapine 11. ___ In panic disorder, which of the following statements is not true? a. 90% of patients present with physical symptoms b. 30 - 50% of patients develop agoraphobia c. 25% of patients who present to ERs with chest pain have panic disorder d. 10% of p atients with panic disorder have major depressive disorder 12. ___ The pharmacotherapy of panic disorder includes all but one of the following options a. SSRIs/SNRI antidepressants b. Atypical antipsychotics c. Beta - blockers d. Buspirone 13. ___ Patients with major depre ssion who experience a partial response to the initial antidepressant drug may benefit from augmentation with one of several different agents. Which of the following compounds is not commonly used as an adjunctive drug in managing depressed patients a. Lithium carbonate b. Triiodothyronine c. Buspirone d. Metoprolol 14. ___ Risk factors for the development of Post - Traumatic Stress Disorder include all but one of the following a. Inadequate social support b. Severity of stressor c. History of childhood abuse d. Male gender 15. ___ The pharmacotherapy of Social Anxiety Disorder includes which one of the following options a. Sedative serotonin - dopamine antagonist antipsychotics b. Lithium carbonate c. SSRI antidepressants d. Stimulants 84 16. ___ Delirium is commonly observed in hos pitalized patients. Which of the following clinical features is not characteristic of delirium a. Disruption of the sleep wake cycle b. Auditory hallucinations are more common than visual hallucinations c. Can be missed in children, wherein the hallucinations can be misattributed to d. Symptoms fluctuate from hour to hour 17. ___ Which of the following statements is acceptable regarding use of antidepressants in non - depressed patients taking interferon for hepatitis C a. All patients should receive antidepressant therapy b. Only patients with a past history of depression should receive antidepressants c. Antidepressants should be reserved for patients with suicidal ideation d. Patients with a past history of any psychiatric disorder 18. ___ Corticosteroids are commonly associated w ith neuropsychiatric sequelae. Which of the following statements is true a. Serious psychiatric sequelae are observed in 50% of patients receiving steroids b. Manic and hypomanic states are more commonly observed with prolonged exposure c. Depressive symptoms are more commonly observed with short courses d. A dose dependent relationship is observed 19. ___ Which of the following statements is incorrect a. Varenicline is the antidepressant of choice in the depressed smoker b. Depressed patients have a higher prevalence of cigaret te smoking than others c. Smoking cessation is more likely to trigger a depressive relapse in patients with depression than others d. Depressed patients have more difficulty quitting and often require a combination of bupropion, varenicline and nicotine replacem ent methods along with supportive psychotherapy 20. ___ Delirium can be distinguished from dementia by the following clinical features. Choose the single correct answer a. The presence of hallucinations, delusions and ideas of reference b. Agitated behavior that requi res antipsychotic medication and physical restraint c. An acute onset, fluctuating course and a change of consciousness d. Disorientation to time and place is generally more severe than disorientation to person and situation 85 21. ___ In managing hospitalized patients with delirium the following is an appropriate first choice a. Cognitive restructuring b. Antipsychotics such as olanzapine c. Disulfiram for alcohol withdrawal states d. Sedative antidepressants 22. ___ In managing late - onset depression, whi ch of the following is correct a. Antidepressant medications should be used at lower doses and should be discontinued after the remission of depressive symptoms to minimize adverse effects b. Psychosocial approaches such as interpersonal and cognitive behavior therapy are preferred to pharmacotherapy, because of the risk of antidepressant - induced seizures c. Electroconvulsive is a reasonable therapeutic option when patients fail to respond to antidepressant medications d. Adequate management of hypertension, diabetes and dyslipidemia have a profound effect upon mood 23. ___ Major depression is associated with comorbid psychiatric disorders less than one half the time a. True b. False 24. ___ Which of the following is incorrect about the antidepressant discontinuation syndrome a. An increased death rate has been reported b. Fluoxetine is least likely to do this c. It is unrelated to the serotonin syndrome d. The best treatment is to reinstitute the antidepressant 25. ___ Which of the following antidepressants is most likely to have all these side - effects: seda tion, weight gain, sexual dysfunction a. Citalopram b. Paroxetine c. Venlafaxine d. Buproprion e. Fluoxetine 26. ___ Which of the following side effects are more likely with SNRIs a. Elevated blood pressure b. Sexual side effects c. Weight gain d. Cardiac arrhythmias 86 27. ___ Stimulants such as Ritalin have no place in managing depression a. True b. False 87 Appendix I Simple Coding Sheet Setting the Agenda 1. Uses own and 2. Indicates time available (1 = No 2 = Yes) 3. Obtains agenda and inquires for additional items (1 = No 2 = Yes) Physical Story 4. The resident starts open - endedly focusing on physical agenda item (1 = No 2 = Yes) 5. Addresses only physical issues volunteered by the patient (1 = No 2 = Yes) Personal Story 6. Keeps p atient focused open - endedly on personal story(ies) to elaborate them (1 = No 2 = Yes) 7. Addresses only personal topics volunteered by the patient (1 = No 2 = Yes) 8. Encourages personal information open - endedly when patients do not volunteer it and patient remains focused on the physical story (1 = No 2 = Yes) 9. Uses echoing to expand understanding of personal story (1 = No 2 = Yes) 10. Uses requests to expand understanding of personal story (1 = No 2 = Yes) 11. Uses summarizing to expand understandin g of personal story (1 = No 2 = Yes) Emotional Story 12. Keeps patient focused open - endedly on emotional story(ies) to elaborate them (1 = No 2 = Yes) 13. Addresses only emotional topics volunteered by the patient (1 = No 2 = Yes) 14. Inquires about emotio 15. Inquires about emotions by using other emotion seeking question (1 = No 2 = Yes) 16. Uses echoing to expand understanding of emotional story (1 = No 2 = Yes) 17. Uses requests to expan d understanding of emotional story (1 = No 2 = Yes) 18. Uses summarizing to expand understanding of emotional story (1 = No 2 = Yes) 19. 20. n response to expression of emotion (1 = No 2 = Yes) 21. Uses other understanding statements in response to expression of emotion (1 = No 2 = Yes) 22. 23. statement in response to expression of emotion (1 = No 2 = Yes) 24. 2 = Yes) 25. tion (1 = No 2 = Yes) 26. (1 = No 2 = Yes) Indirect Patient - Centered Skills 27. 28. atement (1 = No 2 = Yes) 29. 30. - General Skills 31. Indicates change in direction of questioning at end of interview to disease focus (1 = No 2 = Yes) 32. Interruptions are appropriate or nonexistent (1 = No 2 = Yes) 33. Resident determines content and direction of interview (1 = No 2 = Yes) 88 Appendix J ent - Centered Interviewing Codeb ook Setting the Agenda : Code 1 1. The resident uses own and (Code: 1=No, 2=Yes) The resident uses the at the start of the interaction. The resident MUST use the last name ; so, they can use only last name or both the f irst and last name. In some instances, the this category. This should occur at the very beginning of the interview when the resident walks into the patient ro om. The resident also must introduce themselves to the patient, by name, for this category to receive last name of the doctor must be included here to count. Examples : 89 Setting the Agenda : Code 2 2. The resident i ndicates th e time a vailable (Code: 1=No, 2=Yes) The resident positively or neutrally indicates how much time is available for interaction. The resident could actually specify a time frame (such as 10 minutes), or they may use phrases that indicate time, such as short, m edium, or long. the resident should never use the word ONLY when indicating time available or otherwise conve y negativity about the duration of the visit. The resident should not make a negative impression by conveying shortage of time if they do, Examples : 90 Setting the Agenda : Code 3 3. The resident obtains the agenda from the patient AND inquires for additional items (Code: 1=No, 2=Yes) At the beginning of the interview, the resident needs to obtain a list of the issues the patient wants to discuss to ensure that the most important concerns are addressed during the encounter and to minimize the chance of an important concern being raised at the end of the conversation when time has run out. Possible patient agenda items include, but are not limited to symptoms, requests (e.g. prescription for a sleeping pill), expectations (e.g. get sick leave), and understanding about the purpose of the interaction (e.g. perform an exercise stress test) This category only asked, at least once , what else the patient wants to cover after having obtained the first agenda item. The resident thus helps the patient enumerate all of the problems. The resident may use their fingers to indicate that a list is being made (i.e. as the patient lists their problems , the resident may hold up a new finger for each concern the patient wants to talk about). Also, it should be noted here that the resident may need to, and in some instances SHOULD, interrupt the patient in order to get all of the information needed. Int erruption is part of a patient - centered interview, but should be done in a respectful manner (see last example below). Examples : THEN: nute, but first I need to know if there is a second problem you would like to discuss. I want to be certain that we 91 Physical Story: Code 4 4. The resident starts open - endedly at the beginning of the interview, focusing on the physical agenda item (Code: 1=No, 2=Yes) choose the chief concern that the patient brought up in their agenda, and focuses on that item to start the interview. The resident could do this asking one open - ended question, or by making one open - ended request, and then allowing the patient to talk. It establishes an easy flow of talk from the patient, conveys that the clinician is attentivel before the personal and emotional story, after the agenda is set. Examples : 92 Physical Story: Code 5 5. The reside nt addresses only the physical issues volunteered by the patient (Code: 1=No, 2=Yes) The resident does not introduce any new physical issues, such as symptoms, medications, doctors, hospitals, or referrals. The resident focuses only on the physical is sues/symptoms that en patient has not previously mentioned back pain). Everything that the resident addresses in the physical story is something that the patient has already brought up. *There can be no closed - ended questions used in the physical story, or this obligatorily receives - ended question is asked, Examples : headaches and nausea). 93 Personal Story: Code 6 6. The resident keeps the patient focused open - endedly on personal story to elaborate them (Code: 1=No, 2=Yes) The resident uses many open - ended skills to maintain the flow of information, leading eventually to the personal story. Open - ended skills story. Focu sing skills including reflecting/echoing, requesting, and summarizing. Reflecting/Echoing : signals that the interview has heard what the patient said by repeating a word or phrase that was just said by the patient. It encourages the patient to proceed and Requesting patient in an Summarizing : Instead of echoing only a word or phrase, the interviewer echoes a wider range of talk by summarizing it. This invites the patient to focus on the material things that are not part of your job description and which you believe are adding 94 Personal Story: Code 7 7. The resident only addresses personal topics volunteered by the patient (Code: 1=No, 2=Yes) already introduced by the patient. The resident focuses only on the personal topics/symptoms wh en the patient has not mentioned their spouse). Everything that the resident addresses in the personal story is something that the patient has already brought up. Examples : d children) 95 Personal Story: Code 8 8. The resident encourages personal information open - endedly when patients do not volunteer it and patient remains focused on the personal story (Code: 1=No, 2=Yes) The resident uses any of the indirect emotion seeking skills to encourage the patient to provide personal information (indirect emotion seeking skills actually encourage personal information, inquiring about impact, elicit ing beliefs/attributions, demonstrating understanding through self - disclosure, and triggers. The resident may use any of these skills to help the patient develop their personal story. This may include the use of some closed - ended skills, but the closed - e nded skills should be used less often than the indirect emotion - seeking skills to generate the personal story. physical story. The resident either uses indire ct skills to get to the personal story, OR the technically patien t - centered (because the resident is inserting new information), sometimes this is necessary in order for the resident to get the patient away from the physical and into the personal story. Indirect Emotion Seeking Skills : Inquiring about impact : Inquiring about how the physical symptom or disease in question has affected the life of the patient, family member, or friend uncovers important information and increases emotional expression. Examples: o o Eliciting beliefs/attributions : Asking what the patient thinks caused the problem is not uncover an underlying feeling or emotion, particu larly if the patient believes that a serious condition may be causing the symptom. Examples: o o Demonstrating understanding through self - disclosure : Sharing how the resident or ot hers might feel in similar circumstances can help the patient identify her or his own emotions because the patient may not feel comfortable endorsing them; instead, resid ent uses o o Triggers : Determining why the patient is seeking care at this preci se time, especially if the problem has been present for more than a few days, can uncover the underlying o o 96 Personal Story: Code 9 9. The resident uses echoing to expand understanding of personal story (Code: 1=No, 2=Yes) The resident uses this focusing, open - ended skill to maintain the focus on the personal story. Reflection (echoing) signals that the interviewer has heard what the patient said by repeating a word or phrase that was just said. It encourages the patient to proceed and focuses the patient on the word or phrase echoed. For Code 9, the echo must be ab out the personal story (not the physical or emotional story). An echo involves the resident echoing a word or a couple of words the patient has just said, and then remains silent, enticing the patient to go on. It is not considered an echo if the residen t - ended Examples : Pati ball game when my back really started hurting, we were sitting in the BAD Example : 97 Personal Story: Code 10 10. The resident uses requests to expand understanding of personal story (Code: 1=No, 2=Yes) Open - the patient in an already mentioned area that the story, not the physical or emotional stories. Like other focusing skills, open - ended requests should be used to move patients to deeper levels of their stories by focusing on something that the patient has already mentioned. They should has not said anything about her or his family. No new information should be inserted from the doctor (that is not patient - centered); rather, a request is used to help the patient to expand/elaborate their story. Examples : 98 Personal Story: Code 11 11. The resident uses summarizing to expand understanding of personal story (Code: 1=No, 2=Yes) Instead of echoing only a word or phrase, the i nterviewer echoes a w ider range of talk by summarizing it. This invites the patient to focus on the material summarized and express deeper levels of her or his story. It signals that she or he has been heard and that she or he should proceed beyond that personal story (not the physical story or emotional story). Here, the resident must be enticing the patient to give more information (i.e. this is not a recap. This is a summary that is looking for more information at the end.) Examples: on 99 Emotional Story: Code 12 12. The resident keeps the patient focused open - endedly on emotional story to elaborate it (Code: 1=No, 2=Yes) The resident pursues an extended story from the patient regarding their particular emotion/emotion s, and encourages the patient to continue sharing information to get a well - rounded, descriptive emotional story. The resident can do this by using open - ended skills repeatedly. This will allow them to not just get a single emotion from their patient, bu t the entire story that surrounds that particular emotion. Open - ended skills Focusing Skills story. Focusing skills including reflecting/echoing, requesting, and summarizing. Reflecting/Echo ing : signals that the interview has heard what the patient said by repeating a word or phrase that was just said by the patient. It encourages the patient to proceed h Requesting Summarizing : Instead of echoing only a word or phrase, the interviewer echoes a wider range of talk by summarizing it. This invites the patient to focus on the material summarized and express deeper levels of her/his story. 100 Emotional Story: Code 13 13. The resident addresses only emotional topics volunteered by the patient (Code: 1=No, 2=Yes) The resident addresses only emotional topics volunteered by the patient. In other words, the resident does not ask about emotions that the patient has not said, and instead, only focuses on emotions that the patient has mentioned themselves. Good examples : ing frustrated) appear that way; the patient must actually have said it) 101 Emotional Story: Code 14 14. (Code: 1=No, 2=Yes) The patient has not offered an emotion, so the resident directly inquires about the em otion to try word FEEL in their statement. If they are asking purely about emotions (without saying the ode 15. Emotion Seeking: Because emotions are so important, the resident must actively seek them even when they are not frankly presented, or when only hinted at. Direct Inquiry : The resident allows the patient to identify the specific feeling by asking how she or he is feeling about the situation. Examples: Examples: 102 Emotional Story: Code 15 15. The resident inquires about emotions by using other emotion seeking question (Code: 1=No, 2=Yes) elicit an emotion from the patie nt. For this category, if the resident uses any word other than Examples: 103 Emotional Story: Code 16 16. The resident uses echoing to expand understanding of emotional story (Code: 1=No, 2=Yes) The resident uses this focusing, open - ended skill to maintain the focus on the emotional story. Reflection (echoing ) signals that the interviewer has heard what the patient said by repeating a word or phrase that was just said. It encourages the patient to proceed and focuses the patient on the word or phrase echoed. For Code 16, the echo must be about the emotional story (not the physical or personal story). An echo involves the resident echoing a word or a couple of words the patient has just said, and then remains silent, enticing the patient to go on. It is not considered an echo if the resident repeats a word, - ended Echoing is used to EXPAND what t he patient is saying. Echoing can apply to a statement of emotion that the resident is trying to fully understand (i.e. the resident is drawing out the the resident is no longer trying to understand the emotion, but rather, is re - stating the emotion in a closing statement to show the patient they understand. Examples : Resi to be burdened by me, Bad Example: you work really hard and you were having trouble that particular day due to your leg pain. I think you and I can work 104 Emotional Story: Code 17 17. The resident uses requests to expand understanding of emotional story (Code: 1=No, 2=Yes) Open - the patient in an already mentioned area that the interview wants to expand upon, such as, Like other focusing skills, open - ended requests should be used to move patients to deeper levels of their stories by focusing on something that the patient has already mentioned. They should not be used to direct the p No new information should be inserted from the doctor (that is not patient - centered); rather , a request is used to help the patient to expand/elaborate their story. personal stories. Examples : 105 Emotional Story: Code 18 18. The resident uses summarizing to expand understanding of em otional story (Code: 1=No, 2=Yes) Instead of echoing only a word or phrase, the interviewer echoes a w ider range of talk by summarizing it. This invites the patient to focus on the material summarized and express deeper levels of her or his stor y. It signals that she or he has been heard and that she or he should emotional story (not the physical story or personal story). Here, the resident must be entic ing the patient to give more information (i.e. this is not a recap. This is a summary that is looking for more information at the end.) Examples: in front of everyone, which made you really sad and embarrassed, Bad Example: Here, the resident is recapping, and is not trying to get more information. They are fact checking, but not enticing the patient to go on with more information. 106 Emotional Story: Code 19 19. The r (Code: 1=No, 2=Yes) NURS: that their patients are feeling, as providers shoul d be responding verbally to their patients about emotions. Responding verbally to emotions can help the patient to feel understood and cared for, and the NURS skills are important when developing a positive relationship and being patient - centered (Fortin et al, 2012). on. Naming is used to respond to the emotion, and the resident is typically not looking for more information. In other words, the doctor DOES NOT insert an emotion, the patient must bring it up. Also, naming is usually used with other components of NURS. *Naming should not be used until the resident can legitimately say that they understand. Unless the resident can truly say that they understand the emotion (because the patient has explained it thoroughly and the resident has asked sufficient questions to ensure their understanding), then n aming should not be used. Examples : 107 Emotional Story: Code 20 20. emotion (Code: 1=No, 2=Yes) Understanding (also called legitimating): the particular issue to be able to understand it. Examples : 108 Emotion al Story: Code 21 21. emotion (Code: 1=No, 2=Yes) understandin g statement focuses on the other. Understanding (also called legitimating): It is not necessary to have sufficient experience with the particular issue to be able to understand it. Examples : this so I cannot possibly understand what you are going through, but 109 Emotional Story: Code 22 22. (Code: 1=No , 2=Yes) The resident RESPECTS the patient specifically by using a praising statement, which is a efforts. Examples : resident is showing that they admire the patien t for the way they are handling the situation.) 110 Emotional Story: Code 23 23. of emotion (Code: 1=No, 2=Yes) point in the interview. The resident, here, acknowledges how difficult things have been for the patient, or may indicate future difficulties that the patient may face as a result of treatment/illness. Examples: the treatment path they have decided on). 111 Emotional Story: Code 24 24. expression of emotion (Code: 1=N o, 2=Yes) The resident gives direct support to the patient in the interview. Supporting statements signal to the patient that the resident is prepared to work together with her or him as a team (i.e. form a partnership with her or him) and help in what ever way the resident can. Examples : can figure this out and help to alleviate the pain you are feeling, I 112 Emotional Story: Code 25 25. expression of emotion (Co de: 1=No, 2=Yes) The resident may not be the person who will work directly with the patient at all times, so the resident may need to indicate that the patient has support coming from elsewhere. Here, the resident must CLEARLY be indicating support, not just a passing comment regarding joint support between the patient and others. The resident needs to indicate some form of personal or group support beyond describing a treatment plan (i.e. the following statement would not count for indirect support Examples: The nurses here are outstanding, I know that they are going to work closely with you to get your that you in a way that indicates that the patient is receiving joint support) 113 Emotional Story: Code 26 26. patients expression of emotion (Code: 1=No, 2=Yes) The resident supports the patient by signaling to the patient that the resident is prepared to work together with her or him as a team. Th the resident must actively show that the two are working together as a team, and that the resident is supporting the patient in helping them to get better. *In order for t Examples : Bad Example 114 Indirect Patient - Centered Skills: Code 27 27. (Code: 1=No, 2=Yes) Inquiring about impact : Inquiring about how the illness or other situation in question has affected the life of the patient uncovers important information and increases emotional expression. Examples: 115 Indirect Patient - Centered Skills: Code 28 28 . (Code: 1=No, 2=Yes) person. Inquiring about impact : Inquiring about how the illness or other sit uation in question has emotional expression. Examples : This can also include feelings : 116 Indirect Patient - Centered Skills: Code 29 29. (Code: 1=No, 2=Yes) The resident uses a specific beliefs/attribution statement in the interview. Eliciting beliefs/attributions : Asking what the patient thinks caused the problem is no t only underlying feeling or emotion, particularly if the patient believes that a serious condition may be causing the symptom. Examples : 117 Indirect Patient - Centered Skills: Code 30 30. - (Code: 1=No, 2=Yes) The resident specifically uses a self - disclosure statement in the interview at some point. Demonstrating understanding through self - disclosure : Sharing how the resident or others might feel in similar circumstances can help the patient identify her or his own emotions and feelings. The resident avoids Examples : 118 General: Code 31 31. The resident indicates change in direction of questioning at the end of the interview (Code: 1=No, 2=Yes) The resident indicates to the patient that the content of the interview and, more importantly, the patient - centered style is about to change. This occurs towards the END of the interview. Examples : some different types of questions about your ay with you, I would like to switch gears a little bit and ask you some specific questions 119 General: Code 32 32. Interruptions are appropriate or nonexistant (Code: 1=No, 2=Yes) The resident may interrupt the patient at times; however, the interruptions are used to focus the patient on something that they have already said (i.e. it must not interrupt the flow of the conversation by changing the focus). Similarly, the resident may (and often should) interrupt the pati ent during the Agenda Setting stage. If the patient jumps right into the story, it is appropriate (and necessary) for the resident to interrupt to obtain the full agenda. . For instance, when a patient goes on and on for far too long about an issue and the resident never cuts them off, this is seen as a negative aspect of patient - centered care. The resident should not allow the patient to take up the entire time talking a bout one thing. If the resident does this, they Examples : from you of everything you want to cover today. You said back pain, w 120 General: Code 33 33. Doctor determines content and direction of interview (Code: 1=No, 2=Yes) Most of the interaction throughout the entirety of the interview is focused on what the doctor wants to discuss (i.e. mostly closed - ended questions bringing up new information that the patient did not introduce). This is NOT patient - centered. This is a reverse - coded item to show that the doctor determined what was discussed, and not the patient. 121 Appendix K Patient - Centered Definitions , Glossary, and Emotion Guide Setting the Agenda: Setting the agenda is the introduction stage at the beginning of a medical interview where the provider orients the patient by ensuring that the patient is comfortable and at ease and by obtaining a full list of issues to cover. Physical Story: wrong with them, and does not include personal or emotional aspects. Personal Story: The personal story is the personal, non - emotional psych osocial story regarding the context in which the physical disease problem occurs, but does not directly discuss the physical illness. Emotional Story: regarding what is wrong with them and focuses on the felt emotions and expressed feelings that the patient conveys to their provider during their medical interview. Indirect Patient - Centered Skills: Indirect patient - centered skills are tools that the physician uses to try and elicit expre ssions of feeling or emotion from the patient. General Patient - Centered Skills: General patient - centered skills are tools that the provider uses to guide the patient through the patient - centered portion of the interview Operational Definitions Setting the Agenda: This is the first step of the interview. Setting the agenda is a step that includes the following components: (1) the resident introduces themselves by using their own last name and the patients last name, (2) the resident indicates how much time they have available to speak with the patient, and (3) the resident obtains an agenda from the patient and inquires for additional items to discuss. These three steps are necessary for setting a complete agenda. Physical Story : The physical story physically wrong with them. A story will go with this (how long the pain has been occurring, when it started, when it is at its worse, etc.) The physical story is ONLY physical (i.e. the patient is not di scussing a personal or emotional story). o Physical Clue words : Disease, symptom, doctor, medication, tests, prescriptions, hospital, nurses, pain, surgery, treatments Personal Story : Psychosocial, Non - Emotional Topics: a re the context in which physical disease problems occur but do not directly talk about the physical illness (e.g. A patient talks about how difficult their job is and that they cannot keep up. Although these are not medical features, they will aid the res ident in making key observations about the patient that may lead to a better medical diagnosis and physical disease problem: physical symptoms (e.g., pain, short of brea th), doctors, 122 hospitals, treatments/medications/surgeries. 2) they are not rated when they refer to emotion; emotion is rated separately even though it is a psychosocial topic. o Personal Clue words: Anything NOT physical and NOT emotional Emotional Story: This is the story the patient tells regarding their emotional response to what is happening in their lives. It can be embedded in the other two types of stories (more frequently in the personal story). Many times the patient is hesitant to share this story, so the physician will need to try and elicit this part of their story. Emotions: Clore, & Collins, 1998). Eckman (1999) distinguishes feelings from emotions, explaining that feelings are cognitive and internal whereas emotions are expressed and are visible. Feelings are the conscious, subjective experience of emotion, and are more n uanced and numerous (Fortin et al., 2012). For this topic, the emotions are the responses (laughing, crying, etc) that one can observe in the patient, while feelings are what the patient says (the more conscious elaboration of the emotion). o Emotional Cl ue Words: See attached Emotion Sheet. Indirect emotion seeking skills include the following: inquiring about impact, eliciting beliefs/attributions, demonstrating understanding through self - disclosure, and triggers. The resident may use any of these skil ls to help the patient develop their emotional story. o Inquiring about impact : Inquiring about how the illness or other situation in question has affected the life of the patient, family member, or friend uncovers important information and increases emoti onal expression. Examples: o Eliciting beliefs/attributions : Asking what the patient thinks caused the problem is ical explanatory model, but it may also uncover an underlying feeling or emotion, particularly if the patient believes that a serious condition may be causing the symptom. Examples: o Demonstrating understanding through self - disclosure : Sharing how the resident or others might feel in similar circumstances can help the patient identify her or his own emotions and feeling. The resident avoids strong affective terms like o Triggers : Determining why the patient is seeking care at this precise time, especially if the problem has been present for more than a few days, can uncover the underlying reason for the visit and provide a window into t feelings/emotions. Examples: 123 GLOSSARY Agenda A complete list of the issues to be considered during the interview. Antidepressant Zoloft, Prozac, C ymbalta, Wellbutrin, Remeron, Celexa, Effexor, Paxil, Lexapro, Baseline interview. Behavioral Outcomes The specific behaviors the physician desires the patient to exhib it (e.g. lose 10 pounds, stop smoking) Biomedical Portion - The segment of the interview which focuses on disease and its symptoms, chief presenting complaint, treatment/management options, examination, etc. Chapters of Story one chapter is a distinct event, a second one is related but clearly different content, etc. Commitment An explicit statement by the patient to attempt a particular behavior or course of action. Course of Action A plan for achieving desired outcomes. Jargon Technical language. Mind - body link how disease and personal/emotional life link together *NAMES Feelings Explicitly naming an emotional response exhibited or implied by the Narcotics Percocet, morphi ne, vicodin, oxycodone, hydrocodone, methadone, dilaudid, narco, Lortab, fentanyl Negotiate Mutual decision - making. (e.g. regarding treatment) Nonverbal Facilitators Nonverbal cues which encourage the patient to continue talking. Pace The speed a t which the interview moves. Patient Comfort Physical and emotional ease. Patient Cues - Verbal and nonverbal signs exhibited by the patient during the interaction. Patient Understanding The degree to which the patient comprehends information provi ded by the physician. 124 Physical Therapy a formal referral to a physical therapist where exercises are performed Psychosocial Cues Information (verbal or nonverbal) provided by the patient that indicates his/her psychological state or social circumstan Psychosocial Portion The segment of the interview that focuses on gathering psychosocial information about the patient. Psychosocial data includes information about the emotional and psychological state of the patient as well as contextual information such as personal background, living arrangements, information about family and friends, daily activities, etc. *RESPECT Res ponds to Feelings someone a tissue.) *SUPPORT Any indication that the patient is not al one and is not going to be abandoned; also Tracking t interrupting the patient or changing the subject presented by the patient. Transition Smoothly moving from the psychosocial portion to the biomedical portion of the interview. This ideally includes summarizing information discussed to this point, g iving the patient the opportunity to give additional information, and previewing the shift to biomedical topics. *UNDERSTANDING * NURS 125 EXAMPLES OF EMOTIONS/FEELINGS text, but there are important distinctions and several theories drawn from more than a century and a half of research, beginning with Charles Darwin. To summarize, feelings are cognitive and Paul Ekman has described fifteen distinguishable emotions (Ekman , 1999): Amusement Anger Contempt Contentment Disgust Embarrassment Excitement Fear Guilt Pride in achievement Relief Sadness/distress Satisfaction Sensory pleasure Shame These emotions are all visible and discernable from one another by facial exp ression and other non - vocal cues. Feelings are the conscious, subjective experience of emotion, and are more nuanced and numerous. Examples of some feelings are listed below. This dichotomous approach to feelings and emotions may be useful to you as a beg inning student because it gives you visible sign posts for emotion that you can observe in patients and see yourself exhibit on video recordings. You can then process the feelings your observations trigger in you, thereby increasing your personal awareness and improving your mindful practice. 126 Appendix L Tables Table 1 Pathway for the End of the Interview (Fortin et al., 2012) Pathway for the End of the Interview Throughout the end of the interview elicit the permission before giving advice or unexpected news. Include some or all of the following as you deem appropriate. 1. Orient patient to close of visit 2. Summarize the information that you gathered a) from the interview and b) the physical examination. 3. With permission, explain your thoughts about diagnosis, in plain language. 4. With permission, offer suggestions as to tests and treatment. 5. Address any counseling issues that may be present. 6. Collaboratively develop a plan for any tests, tr eatment, self - care, and follow - up that may be appropriate. 7. Give instructions and confirm understanding and agreement. 8. Ask if there are any further questions or concerns 9. Acknowledge and support patient before saying goodbye 127 Table 2 Resident Training Level by Grant Year Grant Year Grant dates Resid calendar (resident class) Pre Post Pilot - Y1 Pilot - Y2 Pilot - Y3 1 9/11 9/12 7/11 7/12 (2014) (2012) +/ - A 0 + (2014) + (2013) + (2012) 2 9/12 9/13 7/12 7/13 (2015) (2013) + B 0 + (2013) 3 9/13 9/14 7/13 7/14 (2016) (2014) + C +/ - A + (2014) 4 9/14 9/15 7/14 7/15 (2017) (2015) + D + B 5 9/15 9/16 7/15 7/16 (2018) (2016) +/ - E + C 6 (no cost ext.) 9/16 9/17 7/16 7/17 DEL + D --------- +/ - (pgy2) E 1. Pre - post links: B - B; C - C; D - D. Incomplete pre - post links: A - A; E - E 2. First data collection point May of Year One where all three years completed measures. Thereafter, data obtained pre/post for only PGY - 1 and PGY - 3 residents. Thus, Y1 pre data obtained in May 2012 after PS rotation [but also have had mental health lecture s and clinical experiences in some clinics]; Y3 post data on same group (A) has had CPC for just one year = opportunity to compare impact of just one CPC without either PS rotation of second year of CPC for class of 2014. This is not a good test of hypoth esis and better as pilot. PS Rotation running for all five years of grant CPC training began 7/13 and continues to end of grant: 2014 class will have had only one year CPC; later years have had both 3. Y6 is no - cost extension, carrying over any available fun ds 128 Table 3 Demographic Information Resident Questionnaire Demographic Information (DI) Instructions . The following questions ask you to provide some information about yourself. These questions are for statistical purposes only and your responses are completely anonymous and confidential. 1. What is your year of birth? 19___ (NS) 2. PLEASE INDICATE YOUR GENDER: ( ) Female (NS) ( ) Male (NS) 3. PLEASE INDICATE YOUR RACE (If you consider yourself to be multiracial , please check all that apply): [ ] AFRICAN - AMERICAN (NS) [ ] AMERICAN INDIAN/ALASK A NATIVE (NS) [ ] ASIA N (NS) [ ] HISPANIC/LATIN O (NON - WHITE) (NS) [ ] NATIVE HAWAIIN/PACIFI C ISLANDER (NS) [ ] WHITE (NS) [ ] OTHE R (NS) 4. WHAT IS YOUR CURRENT MARITAL STATUS? ( ) MARRIE D (NS) ( ) NOT MARRIED (NS) 5. Is English your native language? If no, please indicate your native language. (NS) 6. Where were you born (City/ State/ Country)? (NS) 7. If you were not born in the United States, how old were you when you moved to this country? (NS) 8. Where did you attend medical school? (NS) 9. Do you intend to complete a fellowship? If so, in which sub - specialty? (NS) 129 Table 4 Efficacy Questionnaire For each statement below, circle the number that best represents your degree of confidence with every patient encounter. I am confident that I can: Strongly disagree Disagree Unsure Agree Strongly agree 1. Indicate the time available for the interview 1 2 3 4 5 2. Obtain a list of all issues the patient wants to discuss 1 2 3 4 5 3. Use open - ended skills to obtain a description of 1 2 3 4 5 4. Use open - ended skills to develop a general personal context of the physical symptoms 1 2 3 4 5 5. Use emotion - seeking skills to develop an emotional focus 1 2 3 4 5 6. Respond to emotion by naming, understanding, respecting, and supporting it 1 2 3 4 5 7. Recognize when my own negative emotional reactions to the patient occur 1 2 3 4 5 8. Give bad news, such as a cancer or AIDS diagnosis, to a patient 1 2 3 4 5 9. Determine if a patient is ready to change an adverse health habit, such as smoking 1 2 3 4 5 10. Inform and motivate patients to change adverse health habits, such as smoking 1 2 3 4 5 11. Conduct a complete diagnostic history in a psychiatric patient 1 2 3 4 5 12. Diagnose a patient as somatization (unexplained symptoms) 1 2 3 4 5 13. Distinguish unipolar from bipolar depression 1 2 3 4 5 14. Initiate effective treatment in a newly diagnosed patient with bipolar depression 1 2 3 4 5 15. Diagnose and manage a suicidal patient 1 2 3 4 5 16. Treat a patient with disabling chronic pain where there is no underlying disease explanation for the pain 1 2 3 4 5 17. Identify misuse of alcohol and prescription opiates 1 2 3 4 5 18. Treat misuse of prescription opiates 1 2 3 4 5 19. Know and can utilize community resources, including mental health referral, for managing patients with mental health problems 1 2 3 4 5 20. Work effectively with nurses and other caretakers 1 2 3 4 5 130 Table 5 Interview Satisfaction Questionnaire *Indicates item was used for patient satisfaction scale Please indicate how much you agree or disagree with each statement regarding your visit with this doctor Strongly disagree Somewhat disagree Undecided Somewhat agree Strongly agree 1. I told the doctor everything that was on my mind 1 2 3 4 5 2. *I was able to tell the doctor what was bothering me 1 2 3 4 5 3. I felt understood by the doctor 1 2 3 4 5 4. The doctor made me feel rushed 1 2 3 4 5 5. 1 2 3 4 5 6. The doctor made me feel comfortable enough to tell everything that was bothering me 1 2 3 4 5 7. *The doctor made it easy to understand what, if anything, was wrong with me 1 2 3 4 5 8. *The doctor gave me undivided attention 1 2 3 4 5 9. I got to ask the doctor all the questions I wanted 1 2 3 4 5 10. *The doctor spent the right amount of time with me 1 2 3 4 5 11. *I was pleased with my visit with the doctor 1 2 3 4 5 12. *The doctor always seemed to know what he/she was doing 1 2 3 4 5 13. *I have a good deal of confidence in the doctor 1 2 3 4 5 14. The doctor really cared about me as a person 1 2 3 4 5 15. 1 2 3 4 5 16. *The doctor treated me with a great deal of respect 1 2 3 4 5 17. 1 2 3 4 5 18. The doctor was kind and considerate of my feelings 1 2 3 4 5 19. *The doctor tried to make me feel relaxed 1 2 3 4 5 20. The doctor relieved my worries about medical conditions 1 2 3 4 5 21. *The doctor made it easy for me to ask questions 1 2 3 4 5 22. The doctor listened to me closely 1 2 3 4 5 23. I trust the doctor 1 2 3 4 5 24. The doctor did not spend enough time with me 1 2 3 4 5 25. *Overall, I am satisfied with the doctor 1 2 3 4 5 131 Table 6 Communication Assessment Tool (Makoul et al., 2007) 132 Table 7 - Centered Interview Coding Scheme # Item Percent of Agreement Setting the Agenda (Kappa = .941) 1 Uses own and 100 2 Indicates time available 100 3 Obtains agenda and inquires for additional items 91.7 Physical Story (Kappa = 1.00) 4 The resident starts open - endedly focusing on physical agenda item 100 5 Addresses only physical issues volunteered by the patient 100 Personal Story (Percent of Agreement = 99.3%) 6 Keeps patient focused open - endedly on personal story(ies) to elaborate them 100 7 Addresses only personal topics volunteered by the patient 100 8 Encourages personal information open - endedly when patients do not volunteer it and patient remains focused on the physical story 100 9 Uses echoing to expand understanding of personal story 96.0 10 Uses requests to expand understanding of personal story 100 11 Uses summarizing to expand understanding of personal story 100 Emotional Story (Kappa = .86) 12 Keeps patient focused open - endedly on emotional story(ies) to elaborate them 100 13 Addresses only emotional topics volunteered by the patient 100 14 100 15 Inquires about emotions by using other emotion seeking question 96.0 16 Uses echoing to expand understanding of emotional story 100 17 Uses requests to expand understanding of emotional story 96.0 18 Uses summarizing to expand understanding of emotional story 100 19 100 20 Uses 96.0 21 Uses other understanding statements in response to expression of emotion 96.0 22 92.0 23 84.0 24 96.0 25 92.0 26 response to expression of emotion 92.0 Indirect Patient - Centered Skills (Kappa = 1.00) 27 100 28 100 29 Uses 100 30 - 100 General Patient - Centered Skills (Kappa = .868) 31 Indicates change in direction of questioning at end of interview to disease focus 100 32 Interruptions are appropriate or nonexistent 100 33 Resident dominates content and direction of interview 84.0 133 Table 8 Confirmatory Factor Analysis for the Patient - Centered Interviewing Self - Efficacy Variable Including Factor Loadings, Means, and Standard Deviations # Item Factor Loading M SD 1 Indicate the time available for the interview .60 4.11 .55 2 Obtain a list of all issues the patient wants to discuss .53 4.21 .59 3 Use open - ended skills to develop a general personal context of the physical symptoms .75 4.15 .60 4 Use emotion - seeking skills to develop an emotional focus .79 4.06 .71 5 Respond to emotion by naming, understanding, respecting, and supporting it .65 4.09 .62 Note : Patient - Centered Interviewing Self - 134 Table 9 Confirmatory Factor Analysis for the Data Gathering and Relationship Building (Smith) Case Patient Satisfaction Items Including Factor Loadings, Means, Standard Deviations, and Scale Reliabilities # Item Final Factor Loading M SD 2 I was able to tell the doctor what was bothering me. .79 4.12 1.09 10 The doctor spent the right amount of time with me. .86 3.65 1.30 21 The doctor made it easy for me to ask questions. .68 4.11 .99 8 The doctor gave me undivided attention. .55 4.75 .45 16 The doctor treated me with a great deal of respect. .77 4.43 .85 19 The doctor tried to make me feel relaxed. .81 3.74 1.12 5 .85 4.18 .97 12 The doctor always seemed to know what he/she was doing. .94 4.12 1.00 13 I have a good deal of confidence in the doctor. .98 4.03 1.00 7 The doctor made it easy to understand what, if anything, was wrong with me. .56 3.98 1.17 11 I was pleased with my visit with the doctor. .86 3.83 1.15 25 Overall, I am satisfied with the doctor. .96 3.91 1.10 135 Table 10 Secord Order Unidimensional Factor Analysis for the ISQ Including Factor Loadings, Means, and Standard Deviations Item Factor Loading M SD Factor 1: Opportunity to Disclose Concerns .79 3.81 1.01 .64 4.22 .69 .85 4.00 .99 Factor 4: General Satisfaction .97 3.80 1.02 Note 136 Table 11 Descriptive Statistics of all Patient - Centered Outcome Variables by Condition Range Variables by Condition n M SD Potential Actual Overall PC Skills 136 4.99 3.95 0 - 33 0 - 22 Pretest Intervention 41 3.75 2.18 0 - 33 1 - 10 Posttest Intervention 43 8.12 4.92 0 - 33 1 - 22 Pretest Condition 31 3.42 2.32 0 - 33 0 - 9 Posttest Condition 21 3.29 2.30 0 - 33 0 - 9 Overall Provider Knowledge 136 .46 .25 0 - 3 0 - 1 Pretest Intervention 41 .43 .25 0 - 3 0 - 1.0 Posttest Intervention 43 .38 .24 0 - 3 0 - 1.0 Pretest Condition 31 .53 .27 0 - 3 .33 - 1.0 Posttest Condition 20 .58 .18 0 - 3 .33 - 1.0 Overall Provider Self - Efficacy 136 4.12 .46 1 - 5 3.0 - 5.0 Pretest Intervention 41 4.02 .46 1 - 5 3.4 - 5.0 Posttest Intervention 43 4.17 .47 1 - 5 3.0 - 5.0 Pretest Condition 41 4.11 .46 1 - 5 3.0 - 5.0 Posttest Condition 20 4.21 .41 1 - 5 3.6 - 5.0 Overall Patient Satisfaction 136 4.06 .80 1 - 5 1.92 - 5.0 Pretest Intervention 41 4.09 .81 1 - 5 1.92 - 5.0 Posttest Intervention 43 3.97 .84 1 - 5 2.50 - 5.0 Pretest Condition 31 4.12 .83 1 - 5 2.42 - 5.0 Posttest Condition 21 4.10 .68 1 - 5 2.75 - 5.0 137 Table 12 Correlations among All Variables Note : Correlations corrected for attenuation due to measurement error in upper quadrant. *Correlation significant at the p < .05 level. **Correlation significant at the p < .001 level. 1 2 3 4 5 1. Physician Training 1.00 .54 - .22 .09 .08 2. Physician PC Skills .54** 1.00 - .11 .14 .11 3. Physician Knowledge - .22* - .11 1.00 - .07 .18 4. Physician Efficacy .08 .13 - .07 1.00 .02 5. Patient Satisfaction - .08 .11 .17* .02 1.00 138 Table 13 Co rrelations among the Separate Patient - Centered Skills and Patient Satisfaction Ratings 1 2 3 4 5 6 7 1. Agenda Setting 1.00 2. Physical Story .41** 1.00 3. Personal Story .31** .27** 1.00 4. Emotional Story .23** .14 .17 1.00 5. Indirect Patient Centered Skills .21* .19* .3** .45** 1.00 6. General Patient - Centered Skills .35** .16 .59** .43** .37** 1.00 7. Patient Satisfaction .13 - .02 - .03 .12 - .007 .05 1.00 *Correlation significant at the p < .05 level. **Correlation significant at the p < .001 level. 139 Table 14 Descriptive Statistics of Patient - Centered Variables by Condition Range Patient - Centered Variables by Condition M SD Potential Actual Setting the Agenda Pretest Intervention 1.07 .61 0 - 3 0 - 3 Posttest Intervention 1.77 .99 0 - 3 0 - 3 Pretest Control .71 .53 0 - 3 0 - 2 Posttest Control .90 .44 0 - 3 0 - 2 Physical Story Pretest Intervention .41 .50 0 - 2 0 - 2 Posttest Intervention .84 .48 0 - 2 0 - 2 Pretest Control .35 .49 0 - 2 0 - 1 Posttest Control .24 .44 0 - 2 0 - 1 Personal Story Pretest Intervention .15 .36 0 - 6 0 - 1 Posttest Intervention .47 1.03 0 - 6 0 - 5 Pretest Control .19 .60 0 - 6 0 - 3 Posttest Control .19 .51 0 - 6 0 - 2 Emotional Story Pretest Intervention 1.83 1.63 0 - 15 0 - 6 Posttest Intervention 3.77 3.15 0 - 15 0 - 11 Pretest Control 1.81 2.1 0 - 15 0 - 7 Posttest Control 1.81 1.94 0 - 15 0 - 7 Indirect PC skills Pretest Intervention .18 .45 0 - 4 0 - 2 Posttest Intervention .56 .63 0 - 4 0 - 2 Pretest Control .16 .37 0 - 4 0 - 1 Posttest Control 0 0 0 - 4 0 - 0 General PC Skills Pretest Intervention .13 .33 0 - 3 0 - 1 Posttest Intervention .44 .63 0 - 3 0 - 2 Pretest Control .16 .37 0 - 3 0 - 1 Posttest Control .14 .36 0 - 3 0 - 1 140 Appendix M Figures Figure 1 Integrated Medical Interviewing (Fortin et al., 2012) Key : PTC Patient - Centered CC Chief Complaint/Concern HPI History of Present Illness OAP Other Active Problems PMH Past Medical History SH Social History FH Family History ROS Review of Symptoms 141 Figure 2 Patient - Centered Core Skills (Forti n et al., 2012) Figure 3 142 A Proposed Patient - Centered Path Model to Test The model proposes that patient - centered training will lead to an increase in patient - centered skills. 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