Personal Health Maintenance

Physicians as Patient TeachersSTEPHEN A. BRUNTON, MD, Kansas City, Missouri

Physicians have a central role in educating patients and the public in the elements of personalhealth maintenance. -To be an effective teacher, one must recognize the learning needs of eachpatient and use methods of information transfer that will result in comprehension and compliance.To bring about a change in life-style, one must also have an understanding of a patient's healthbeliefs and the determinants of human behavior. Using this information together with behaviormodification strategies, physicians can forge an effective partnership with patients working towardthe goal ofoptimum health.(Brunton SA: Physicians as patient teachers, InWest J Med 1984 Dec; 141:855-860)

Personal health maintenance [Special Issue].

The physician 's fimction is fast becoming social andpreventive, rather than individual or curative. Upon[physicians] society relies to ascertain and throughmeasures essentially educational to enforce, the condi-tions that prevent disease and work positivelyforphys-ical and moral well-being.

ABRAHAM FLEXNER, 1910(emphasis added)

r he role of doctor as educator is implicit from the ety-mology of the word "doctor," which is from the Latin

docere, "to teach." However, despite the educational re-formist Flexner's perception, it is only within the past decadethat any emphasis has been placed on patient education skillseither in medical school or in postgraduate training programs.At the same time, the public appears increasingly interested

in learning about medicine and health, and in making inroadsinto areas that previously were the sole domain of health careproviders. Attesting to this are the burgeoning sections inbookstores dealing with health-related matters and the popu-larity of such reference books as the Physicians 'Desk Refer-ence. ' The mass media's focus on health has resulted in med-ical updates being shown on most news shows, and this hasnow culminated in a cable television network whose task it isto provide 24-hour programming ofpredominantly health-re-lated topics. This particular network also screens continuingmedical education programs for physicians that have gainedwide public viewing despite the highly technical language andthe specialized nature ofthe material.

What Is Patient Education?This widespread dissemination of information about medi-

cine and health has resulted in the public having a general

understanding about what constitutes an unhealthy life-style.That is, smoking, drinking to excess and overeating are nowwidely regarded as unhealthy behaviors.

Patient education, however, implies more than just im-parting facts. A useful operational definition was developedby a National Task Force on Training Family Physicians inPatient Education:Patient education is the process of influencing patient behavior, producingchanges in knowledge, attitudes, and skills required to maintain or improvehealth. The process may begin with the imparting of factual information, butit also includes interpretation and integration of the information in such amanner as to bring about attitudinal or behavioral changes which benefit theperson's health status. Thus, patient education not only involves the world ofmedical scientific facts, but in its process, is also closely interwoven withpsychology, sociology, behavioral science, and cultural anthropology.2

Patient education and preventive health services constitutea major portion of the care provided by physicians. An exten-sive statewide study in Virginia found that the most frequentdiagnosis made by family physicians was "other medicalexam for preventive and presymptomatic purposes," ac-counting for 8.3 % of patient visits,3 and it has been estimatedthat between 19% and 35% of the time primary care physi-cians spend in direct patient care involves health educationand counseling.4

Physicians are extremely important agents of change whohave significant influence over their patients, a relationshipthat can be central to patients' ability to attain and maintainhealth. To practice effective patient education, one must un-derstand the person and have a grasp of some fundamentalconcepts that can facilitate an effective partnership in health.An ambiguous message is given by physicians who display

inappropriate health behavior.5 Physicians who attempt toalter their own risks and achieve a greater degree of healthwill gain insight into the difficulties of behavior change, and

DECEMBER 1984 e 141 * 6

From the Division of Education, American Academy ofFamily Physicians, Kansas City, Missouri.Reprint requests to Stephen A. Brunton, MD, Director, Division ofEducation, American Academy ofFamily Physicians, 1740W 92nd St, Kansas City, MO 641 14.

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PHYSICIANS AS TEACHERS

they will then have an opportunity to share experiences withtheir patients and thus enhance their credibility.

Pedagogy Versus AndrogogyThe predominant educational model is that of a passive

dependent learner in a subject-centered curriculum. Gradesare based on the mastering of content with an assumption thatstudents will later find application for this knowledge. Thishas been described as the pedagogic model (from the Greekpaidos meaning child).An alternative model, androgogy (from andros meaning

man) implies a more mature learner who is directed to learnskills for immediate application. The material to be learned isbased on a needs assessment and the course material is prob-lem-oriented rather than simply described by subject. Perhapsmost important, the relationship between teacher and studentsis cooperative and born ofmutual respect.7The pedagogic model of learning is perhaps the most fa-

miliar to us and is therefore the most frequent method used inpatient teaching. The rise of the "consumer mentality" and adesire by patients to be more assertive in the therapeuticrelationship has discouraged a passive and dependent role.Because most patient education is education of adults, anandrogogic model may-be a more useful concept for planningpatient education activities. This provides patients with anopportunity to define their educational needs and to be inquisi-tive while exploring new areas of knowledge. It discouragesthe dependence that can create resistance and resentment.8

Doctor-Patient RelationshipThe importance of a quality interaction between patient and

physician cannot be overemphasized.A patient's desire for knowledge and a physician's ability to

communicate this information are to a large extent responsiblefor the degree of satisfaction and compliance that can beachieved.9"10

Studies of compliance consistently focus on aspects of thedoctor-patient relationship that are either conducive to orcounterproductive to a patient's adherence to the treatmentregimen. Examples of positive factors include a patient's per-ception of the physician as interested, friendly and empath-ic.9-'2 Other factors include the amount of time spent with apatient and the degree to which patients' expectations aremet.9"'0 Examples of factors that inhibit compliance includepoor communication skills exhibited by a physician,9"'3 failureto give feedback'4 and office procedures that result in a delayin being seen. 10,1"315The potency of this relationship and its ability to effect

life-style change were illustrated in some studies that showedthat simply giving advice to a patient to stop smoking was asignificant motivator for abstinence. 16 When this advice wasprovided firmly and emphatically, the chance for abstentionwas significantly greater. ''

In a recent study in Massachusetts examining primary carephysicians' role in health promotion, most of the respondentswere ofthe opinion that it was definitely physicians' responsi-bility to educate patients about risk factors. However, whilethey were prepared to counsel patients regarding unhealthylife-styles, only 3% to 8% of the respondents thought thatthey were "very successful" in helping patients achievechanges in behavior, although an additional 40% to 57%

thought that they were at least "somewhat successful" in oneor more areas. 18A physician's feeling of inadequacy and defeat when faced

with a patient who is on a fast track to life-style-related ill-nesses is understandable. Nevertheless, the need for appro-priate intervention is imperative. Physicians should adopt ateaching and counseling role to increase patients' awarenessand skills necessary to effect life-style changes.

Human BehaviorThe number of variables that come into play in a patient's

decision to undertake a particular health behavior has been thefocus of significant study and theory.The health belief model and the health locus of control

theory incorporate principles ofbehavior that facilitate under-standing of a patient's motivation and the likelihood of theiradhering to a particular regimen. These concepts also provideinsight into different strategies that may be effective in en-

couraging individual health promotion.In the health belief model, several factors are proposed that

can predict a patient's likelihood that a particular therapeuticor preventive action will be undertaken. These are the per-

ceived level of personal susceptibility to a particular illness orcondition; the perceived degree of severity or seriousness ofthe illness should it occur; the assessment of the potentialbenefits for the recommended action in preventing or reducingsusceptibility or severity, and the perceived barriers related tothe particular actions, which include the estimates of phys-ical, psychological, financial and other costs. 19

This suggests that a patient's interpretation and perceptiondetermine a particular health behavior and that these may bemodified by a number of personal and environmental factors.The model also proposes that various stimuli or "cues toaction" are necessary to motivate change in health behavioror to make persons consciously aware of their feelings abouttheir condition. These cues can include mass media cam-

paigns, illness in a family or a personal physician's advice.20The health decision model represents an evolution of this

paradigm. It incorporates the major strengths of the healthbelief model but additionally addresses patient preferences,including decisions regarding trade-offs between benefits andrisks and quality and quantity of life and emphasizes the pro-cess by which a patient interprets information.2' This modelemphasizes the significance of patients' feelings about theirhealth and the decisions that are affected by these feelings.The model reinforces the intuitive awareness that by incorpo-rating a patient's preferences into a proposed regimen, thelikelihood ofsuccess is increased significantly.

Physicians also need to have an understanding of each per-son's family and social networks because they have an impor-tant role in a patient's decision-making process.22-24The locus of control theory reflects persons' perceptions of

the source of their power to effect change in particular lifeevents. Within this psychological construct is described a

continuum with one end of the scale reflecting those personswho believe in fate, luck, chance or powerful others. This isthe external locus of control. On the other end ofthe spectrumare those who feel totally self-determined and who believethat they have the ability to realize goals once set. Thesepersons are known as "internals."25

It would be rare for a person to be either totally internal or

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external in all areas of life, but in most instances each personis nearer one end of the continuum than the other.26 Thistheory is useful in predicting both health and sick role behav-iors, with "internals" taking greater responsibility in under-taking and maintaining positive health behaviors.27

This has important implications for the patient educationprocess. "Internals" respond better to programs that providemore information, have opportunities for decision makingand responsibility and rely on self-motivation and self-re-ward. On the other hand, "externals" have more success withgroup strategies and support; with knowledge, training andexperience, however, they can generally develop greaterself-reliance.26Working with patients' belief systems and in some in-

stances reeducating them regarding beliefs, myths and misin-formation requires a careful assessment of these beliefs andattitudes with open-ended questions and a tolerant attitude.These theoretic frameworks emphasize the importance of

thorough patient interviews about not only life events, butalso patients' perceptions of themselves, their conditions andtheir ability to effect change. By aligning new informationwith some aspects of patients' previously held beliefs, sug-gestions can be presented in such a way that they are able toaccept aspects ofthese new attitudes while discarding some oftheir old beliefs.28

Influencing BehaviorBy understanding a person's "reasons" for a particular un-

healthy activity, one can gain insight into mechanisms thatmight be used in behavior change. The perception of dangerand the arousal of fear regarding a particular action can beimportant factors in assisting patients to consider undertakingchange. Fear per se, however, may not necessarily motivatechange, but may provoke alternate mechanisms such as deni-al.629 To be effective, advice against unhealthy behavior mustbe accompanied by significant information and support thatconvinces patients that they are capable of achieving the de-sired behavioral change. This should be directed to helpingthem feel some control in a situation despite previous evi-dence to the contrary.

Physicians should be aware that patients receive a lot ofcontradictory information. Advertising stresses the sexual re-wards of smoking, the comforting effects of empty caloriesand the social benefits of drinking.30 These influences can bereinforced by the attitudes ofa patient's peer group.The personal relationship that develops between a patient

and that person's physician can provide an unequaled oppor-tunity for intervention that cannot be produced by public edu-cation campaigns.3' This unique relationship can enable phy-sicians to help patients gain insight into the meaning of theirbehavior and consider alternatives. This can then lead to asignificant breakthrough, that of gaining patients' commit-ment to attempt behavioral change.Using the precepts of the health behavior model, a consulta-

tion can emphasize the importance of the risk, the potentialfor personal susceptibility, the value to the persons in makinga change and the ability of persons to achieve change, in sucha way as to activate patients to consider reforming their un-healthy life-styles.32 The decision to actually make a change isbased on a psychological readiness and acceptance of the

information presented to patients, coupled with a belief intheir ability to effect changes.A valuable mechanism that may be useful for developing

patients' insights into the danger associated with their be-havior is a risk-appraisal. Use of these programs in conjunc-tion with consultation with a physician can provide graphicevidence of a patient's life-style risks and the benefits of be-havioral change. Taking into consideration the factors in-volved in a patient's decision to undertake a particular preven-tive activity as elucidated in the health behavior model, theuse of this tool can provide an invaluable adjunct of consulta-tion.Another opportunity to bring about awareness on behalf of

a patient is the "teachable moment." This is an opportunityfor heightened receptiveness occasioned by an experience inthe patient's life that brings about an understanding ofthe needfor life-style changes. This may be initiated by the death of arelative, by the occurrence of new symptoms or merely by anexpression ofa willingness to learn.33The ability of persons to transform their behavior is influ-

enced by the feeling of control they have over their life aselucidated within the health locus of control theory. This isaffected by their previous success or failure at achieving alife-style change. It is important for physicians to be awarethat for many patients, success will be preceded by severalabortive attempts; in this process, however, patients gainexperience in methods of altering behavior. This should serveto remind physicians not to become disheartened by initialfailures ofpatients to effect change, but rather to support themin their further attempts by encouragement and by offeringdifferent strategies for success.

It is important that physicians maintain the viewpoint thattheir role is that of a supportive consultant and that it is thepatients' responsibility and in their best interests to developrisk-reducing behavior. Attempts by patients to transfer thelocus ofcontrol over to a physician should be resisted.

Modifying BehaviorThe work of Pavlov, Skinner and others provides further

understanding that the determination of any individual be-havior can be viewed as a process of antecedents and conse-quences. The antecedents set the stage for behavior and theconsequences determine the frequency and the tendency thatthe activity will be repeated.34

This is the underlying theory behind behavior modification,which is directed at controlling these antecedents (stimuli orcues) and consequences (rewards or punishments). Habits arebased on learned patterns that are developed between anteced-ents, behaviors and consequences. For example, a personusing the antecedents of anxiety plus the availability of ciga-rettes will exhibit the behavior of smoking with the conse-quence of a short-term reduction in anxiety. Because the ef-fect is desirable, this behavior is reinforced and the presenceof stressful situations will continue to serve as a cue for thesmoker to use cigarettes. Although long-term harmful conse-quences exist, it is apparent that short-term and immediateoutcomes are more effective in influencing behavior.Once a pattern has been established, the cue alone may be

enough to instigate a particular behavior. For example, if aperson uses alcohol to relax on arriving home from a stressfulday at work, the mere act of coming home from work may

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determine that that person will start drinking whether or notstress was involved on that particular day.34 This cycle ofbehavior can provide insight into strategies that might be usedin facilitating change by substituting different behaviors andmodifying or controlling antecedents and consequences.The principles of behavior modification offer health care

professionals the opportunity to provide patients with an un-derstanding of their behavior, establishing a method of con-trol and consequently instituting new behavioral patterns. Aphysician's task is to assist patients in developing an appro-priate program to achieve these desired actions.

Steps to Behavioral ChangesThe first step of this process is to define the problem accu-

rately in behavioral terms. One should attempt to changeeating patterns rather than just focusing on weight loss be-cause this reduction of weight will occur inevitably from theappropriate behavioral change. Patients may wrestle withsuch considerations as the belief that they "lack willpower"or that there is some inherent personality flaw that makes themthe victim of their particular habit. These considerations maymake it difficult for them to develop a realistic perspective ofwhat is required to achieve success.6

Involving a patient in self-observation by the creation of acomprehensive record of the behavior will help to define itwithin its various components. A useful method to use re-quires keeping a diary that elucidates antecedents (cues,stimuli) and consequences.35 To use the example of smoking,several pieces of information should be recorded. With thedate and time of each cigarette that is smoked, one shouldinclude the activity that preceded the desire-such as stress, acup of coffee, completion of a meal-and then the responsethat was achieved-relaxation, irritation of others,cough-and the moods and thoughts that the patient felt at thetime-that is, boredom, anger, "wondering why I amsmoking so much." Additionally, a scale of 1 to 3 can be usedfor each cigarette, with 1 representing the cigarette that onecould not do without, 2 for one that is less necessary and 3 forone that,could have been avoided altogether. This record canprovide patients with insight into the nature of their habits andrecognition of opportunities for modification.36 A similardiary is useful for other life-style-related activities such aseating and drinking. The mere act ofkeeping such a diary mayaccrue the additional benefit of some alteration of a patient'sbehavior toward the desired outcome.37 The effort involved inrecording each cigarette smoked coupled with the fact that apreviously relatively automatic activity is now being con-sciously documented, will usually reduce consumption.This baseline recording provides the basis for a physician-

patient discussion and a meaningful analysis of the habit andthe desired outcome. From this base, one can set into actionthe other steps required to effect behavioral change.The second step involves realistic goal setting. The patient,

with the assistance of a physician, should determine the goalsto be achieved, with the steps leading up to their attainmentbeing clearly defined. The definition of these short-termachievements is extremely important, because their accom-plishment serves to reinforce the desired behavior. Accompa-nying these steps and the eventual goal should be appropriaterewards. An example may be that a patient put money thatnormally would be spent on cigarettes into a jar to be spent

after three months' abstinence on some desired luxury. Someshort-term rewards can include going out to a movie eachweek during which more than 2 lb are lost, or going for a30-minute walk on a day when no cigarettes have beensmoked. These provide simple mechanisms for short-termpositive reinforcement. Perhaps the most effective compensa-tion is the results of the behavioral change itself. Control ofovereating that results in weight loss and a more physicallyattractive appearance or stopping smoking and developing anexercise program that results in an increase of vitality are theirown rewards.

This process can be greatly facilitated by a formal contract.This is a powerful and effective mechanism for helping toensure behavioral change.38"' The components of a contractshould include statements ofthe long-term goals in behavioralterms, rewards and a deadline for accomplishment. The stepsrequired to reach the goals and the rewards to be achievedalong the way should also be clearly stated. Reporting andmonitoring methods should be delineated as well as whereresponsibility lies for each of the actions.4' By explicitly de-tailing the activities a patient must undergo to fulfill the termsof the contract, a very effective and subtle form of patienteducation is accomplished. This contract, which should besigned by the patient, serves to formalize a patient's commit-ment to the program and in so doing reinforces the desiredbehavioral change. This contract can be renegotiated if itappears that the original goals were unrealistic; however,frequent revisions should be avoided.By continuing self-recording of a behavior, a patient is

provided with a visual reminder of the activity and the prog-ress achieved in its modification. This is, in itself, some re-

ward; however, adding some fun to the process and making ita game rather than a chore can help ensure success.The reward that accrues when others, including a person's

physician, notice the effects of these life-style changes is animportant mechanism that maintains motivation. Follow-upvisits to a physician should provide an opportunity for enthu-siastic support when the desired goals are achieved. Patientsshould continue to incorporate these new habits into their livesso that the role ofphysicians can become more peripheral.Aversion techniques are other behavioral strategies that can

result in life-style change. These include rapid smokingmethods, faradic stimulation and other procedures that can be.used to modify antecedents and consequences. While many ofthese methods are effective, they will not be discussed herewithin the context ofpatient education.

Other Office StrategiesIncorporating patient education into a regular office visit

can be facilitated through a variety of methods. Waitingrooms provide an appropriate setting in which patients maybegin to develop an understanding of the therapeutic milieuthat is being created by the physician. For example, variouspatient education posters may be displayed. Humorousposters, such as those produced by the American Cancer So-ciety and DOC (Doctors Ought to Care),42 which parodyMadison Avenue prosmoking advertisements, are particu-larly well received. A notice board in a waiting room can be a

way of displaying important information such as health pro-motion articles from magazines, activities within the commu-nity and a variety of other relevant materials.

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Waiting room magazines afford an opportunity for physi-cians to take a moral stance. Providing magazines that do notaccept cigarette advertising prevents patients from receivingsubliminal counterproductive messages within physicians'premises. Some have advocated a stronger position wherebyperiodicals are scrutinized for those advertisements that en-hance an unhealthy life-style and then, with a felt-tip pen oran appropriate rubber stamp, a disparaging statement is ap-plied such as "This advertisement is a rip-off."43 A patienteducation library or an audiovisual room can provide an op-portunity for patients to select material of interest or to havesome programming scheduled.The use of a health behavior questionnaire as a part of the

patient record data base can be revealing and educational.This can also stimulate dialogue about selected life-style-re-lated activities.To supplement a physician's advice, handouts can be effec-

tive; these should not supplant one-to-one communication,but rather augment the message by offering further clarifica-tion of the directions provided and by serving as a record towhich a patient can later refer. Unfortunately, many patienteducation materials are at levels beyond the average person'scomprehension."I It has been estimated that most persons readat the 7th or 8th grade level whereas most patient educationmaterials are written at 10th through 12th grade levels.45

Bibliotherapy, the use of selected well-written books andmaterials, is an effective and useful adjunct. This providespatients with information in a more comprehensive formatthan that available in a brief office visit. It also helps toprovide insight into a patient's condition and strengthens theimpact ofthe physician's advice."6A patient education newsletter can be an additional method

of information transfer. This can reinforce data presentedpreviously and provide further evidence of the physician'scommitment to patient education.Some patients do well with one-on-one counseling whereas

others benefit by group support and encouragement.47 Devel-opment of interest groups focusing on weight control,smoking cessation and the like is an activity that physiciansmay wish to initiate within the context oftheir office.Perhaps the most important place where patient education

occurs is within the examination room during the doctor-pa-tient interview. The influence of a physician's advice hasalready been discussed and its impact should not be underesti-mated.

Community ActivitiesPhysicians should also be aware of other community health

education resources. Various public and private organizationsprovide services in most communities. The offerings mayconsist of exercise classes, smoking cessation clinics and nu-trition education; these can provide a valuable point of re-ferral.

Physicians can also be important agents of social change byvirtue of their prominent position in their communities.Speaking engagements at service clubs, high schools and el-derly citizens' groups and involvement with the media andlocal press can provide valuable opportunities for inter-vention and consciousness-raising. Involvement in other com-munity activities such as health fairs or "fun runs" can fur-nish other opportunities.

The workplace is a wonderful venue for health education.The American Academy of Family Physicians has recentlyexpanded its activities in this area after a successful pilotstudy with the International Ladies Garment Workers Union.In this study, employees at several factories were surveyedregarding subject areas in which they would like health infor-mation. Family practice residents then went to the work sitesand gave lectures followed by audiovisual presentations, con-cluding with question-and-answer sessions. These presenta-tions have been very well received by workers and have pro-vided information not available through other means. Aprogram has now been developed for expanding this to otherindustries around the country, with family practice residentsand private practitioners as educators.

ReimbursementThe question of payment for patient education is posed as a

significant barrier to the provision of these services. A whitepaper published by Blue Cross and Blue Shield in 1974 rec-ommended that plans support patient education financiallythrough existing health care payment mechanisms.48 Patienteducation, therefore, is considered as an integral part of anytherapeutic intervention and, for this reason, reimbursementis considered within the regular office visit for the usual illnesscare.49Embarking on a life-style-modification program and billing

for services as such will most likely not be reimbursed bythird-party payors. It has been suggested that ifbilled servicesand procedures are supported by diagnoses listed in theclaim-such as chronic obstructive pulmonary disease or hy-pertension, rather then smoking-cessation therapy-reim-bursement would be provided for a physician's service to theextent that it is covered by a patient's policy.50A study currently in progress is investigating the issue of

direct reimbursement for health education. This is the IN-SURE Project on Life-Cycle Preventive Health Services.This feasibility study, which has significant support frommany insurance companies, is analyzing the planning, imple-mentation and evaluation of a wide range ofpreventive healthservices including patient education. It is anticipated that thefindings from this study will provide some direction regardingthe future of reimbursement for patient education and other

51.52preventive services.

ConclusionThe changing priorities of the public and the health profes-

sion regarding the prevention of disease and the maintenanceof health demand the sharing of knowledge and skills to forma partnership in health.

Physicians are in a unique position to have an importantpersonal impact on the health of their patients and that ofsociety by fulfilling their teaching role.

REFERENCES

1. Physicians' Desk Reference, 38th Ed. Oradell, NJ, Medical Economics, 19842. Fass MF, Vahldieck LM, Meyer DL: Teaching Patient Education Skills: A

Curriculum for Residents. Kansas City, Mo, Society of Teachers ofFamily Medicine,1983

3. Marsland D, Wood M, Mayo F: The content of family practice. J Fam Pract1976; 3:37-68

4. Bartlett E: The contributions of consumer health education to primary carepractice: A review. Med Care 1980; 18:862-871

5. Bates RC: Doctors who smoke, In The world cigarette pandemic (Special Issue).NYState IMed 1983 Dec; 83:1294

DECEMBER 1984 * 141 * 6 859

PHYSICIANS AS TEACHERS

6. Greenlick MR: Helping patients achieve risk-reducing behavior change, chap 2,In Arnold CB (Ed): Advances in Disease Prevention. New York, Springer, 1981, pp29-57

7. Knowles M: The Modem Practice ofAdult Education: Andragogy vs. Pedagogy.New York, Association Press, 1970

8. Titus EJ, Low JC, Clark RV, et al: Patient education is adult education-Work-shop. Patient Education in the Primary Care Setting. Proceedings of the 4th NationalConference in Memphis, Tennessee, 1980

9. Korsch BM, Negrete VF: Doctor/patient communication. Sci Am 1972;227:66-74

10. Francis V, Korsch BM, Morris MJ: Gaps in doctor-patient communication. NEngl J Med 1969; 280:535-540

11. Thawrani YP, Mukherji B, Taluja RK, et al: A study of patient-compliance inurban out-patient pediatric practice. Indian Pediatr 1975; 12:679-683

12. Rosenzweig SP, Folman R: Patient and therapist variables affecting prematuretermination in group psychotherapy. Psychother Res Pract 1974; 1 1:76-79

13. Finnerty FA, Mattie EC, Finnerty FA: Hypertension in the inner-city: Analysisofclinic drop-outs. Circulation 1973; 47:73-75

14. Davis MS: Variations in patients' compliance with doctors' orders: Medicalpractice and doctor-patient interaction. Psychiatry Med 1971; 2:31-54

15. Finnerty FA: The D.C. General Hospital experience, In Barofsky I (Ed): Medi-cation Compliance: A Behavioral Management Approach. Thorofare, NJ, CB Slack,1977, pp21 1-214

16. Hjermann I, Holme I, Velve BK, et al: Effect of diet and smoking interventionon the incidence of coronary heart disease: Report from the Oslo Study Group of arandomized trial in healthy men. Lancet 1981; 2:1303-1310

17. Russell MA, Wilson C, Taylor C, et al: Effect of general practitioners' adviceagainst smoking. Br Med J 1979; 2:231-235

18. Wechsler H, Levine S, Idelson RK, et al: The physician's role in health promo-tion-A survey ofprimary-care practitioners. N Engl J Med 1983 Jan 13; 308:97-100

19. Rosenstock IM: The health belief model and preventive health behavior, InBecker MH (Ed): The Health Belief Model and Personal Health Behavior. San Fran-cisco, Society for Public Health Education, 1974, pp 27-29

20. Maiman LA, Becker MN: The health belief model: Origins and correlates inpsychological theory. Health Educ Monogr 1974; 2:336-353

21. Eraker S, Kirscht JP, Becker MN: Understanding and improving patient com-pliance. Ann Intern Med 1984; 100:258-268

22. Bartlett E: Reference groups. Physician's Patient Education Newsletter. Balti-more, Johns Hopkins Med Instit 1979 Dec; 2:4

23. Brownell KD, Heckerman CL, Westlake RJ, et al: The effect ofcouples trainingand partner cooperativeness in the behavioral treatment of obesity. Behav Res Ther1978; 16:323-33324. Pilisuk M, Froland C: Kinship, social networks, social support and health. Soc

Sci Med 1978; 12:273-28025. Wallston KA, Wallston BS, DeVellis R: Development of the Multidimensional

Health Locus of Control (MHLC) scales. Health Educ Monogr 1978 Spring;6:160-170

26. Hopp J, Gerken C: Making an educational diagnosis to improve patient educa-tion. RespirCare 1983 Nov; 28:1456-146127. Saltzer EB: Locus of control and the intention to lose weight. Health Educ

Monogr 1978 Spring; 6:118-12828. Patient Education Primer: A Guide for Practicing Physicians. Kansas City, Mo,

Society ofTeachers ofFamily Medicine, 197929. Powers M, Wooldridge PJ: Factors influencing knowledge, attitudes and com-

pliance ofhypertensive patients. Res Nurs Health 1982; 5:171-182

30. The business of smoking, In Blum A (Ed): The world cigarette pandemic(Special Issue). NY StateJ Med 1983 Dec; 83:1324-1332

31. Renner JH, Currie BF, Widmar B, et al: Patient Education. Home Study Self-Assessment Monograph, Vol 61. Kansas City, Mo, American Academy of FamilyPhysicians, 1984

32. Horn D: A model for the study of personal choice health behavior. Int J HealthEduc 1976; 19:89-98

33. Curry B, Beasley J: Health promotion, the medical encounter, chap 6, In TaylorRB (Ed): Health Promotion, Principles and Clinical Applications. Norwalk, Conn,Appleton Century Crofts, 1982, pp 143-160

34. Ferguson JM: Behavior modification and health care systems, chap 5, In TaylorRB (Ed): Health Promotion, Principles and Clinical Applications. Norwalk, Conn,Appleton Century Crofts, 1982, pp 123-142

35. Zifferblatt S: Increasing patient compliance through the applied analysis ofbehavior. Prevent Med 1975; 4:173-182

36. Johnson SM, White GA: Self-observation as an agent of behavioral change.Behav Res Ther 1971; 2:40-48

37. Thoresen CE, Mahoney MJ: Behavioral SelfControl. New York, Holt Rinehart&Winston, 1974

38. Montgomery AG, Montgomery DJ: Contractual psychotherapy: Guidelines tostrategies for change. Psychother Theory Res Pract 1975; 12:348-352

39. Dunbar JM, Marshall GD, Hovell MF: Behavioral strategies for improvingcompliance, chap 11, In Haynes B (Ed): Compliance in Health Care. Baltimore, JohnsHopkins University Press, 1979, pp 174-192

40. Harris MB, Bruner CJ: A comparison ofa self-control and a contract procedurefor weight control. Behav Res Ther 1971 Nov; 9:347-354

41. Tapp JT, Krull RS, Tapp M, et al: The application ofbehavioral modification tobehavior management: Guidelines for the family physician. J Fam Pract 1978;6:293-299

42. "What's Up Doc?" (Patient Education), In The world cigarette pandemic(Special Issue). NY StateJ Med 1983 Dec; 83:1377

43. Richards JW Jr: A positive health strategy for the office waiting room, In Theworld cigarette pandemic (Special Issue). NY State J Med 1983 Dec; 83:1358-1360

44. Dalton L, Gartenfeld E: Evaluating printed health information for consumers.Bull Med Libr Assoc 1981 Jul; 69:322-324

45. Doak LG, Doak CC: Patient comprehension profiles: Recent finding and strate-gies. Patient Counseling Health Educ 1980; 2:3101-3106

46. Anstett R, Poole S: Bibliotherapy: An adjunct to care of patients with problemsof living. J Fam Pract 1983; 17:845-853

47. Kelly AB: A media role for public health compliance, chap 12, In Haynes B(Ed): Compliance in Health Care. Baltimore, Johns Hopkins University Press, 1979,pp 193-201

48. Billes D (Ed): Blue Cross and Blue Shield White Paper-Patient health educa-tion, In Practical Approaches to Patient Teaching. Boston, Little, Brown, 1981

49. Henes C, LeBrun P: Blue Cross and Blue Shield plan support for health educa-tion services: Current policies and future directions in patient education in the primarycare setting. Proceedings of the 5th Annual Conference, Kansas City, Mo, Sep 20-21,1982. Kansas City, Mo, St Mary's Hospital Family Practice Residency, 1983, pp111-11750. Sachs D: Office strategies to help your patients stop smoking. J Respir Dis 1984

Feb; 5:35-4851. Demak MM, Rosen MA, Logsdon DN: Prevention in primary medical care:

The INSURE project. Md State Med J 1983; 32:279-28352. Logsdon DN: The feasibility of health insurance coverage for preventive ser-

vices in patient education in the primary care setting. Proceedings of the 5th AnnualConference, Kansas City, Mo, Sep 20-21, 1982. Kansas City, Mo, St Mary's HospitalFamily Practice Residency, 1983, pp 33-37

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