Technology-based education and
intervention tools in medical
education: Lessons and methods
for the University community
Scott M. Strayer, MD, MPH
Associate Professor
Department of Family Medicine
University of Virginia Health System
My Colleagues and Co-Authors
Sandra Pelletier, PhD
Crista Warniment, MD
Karen Ingersoll, PhD
Steve Heim, MD
John Schorling, MD, MPH
Preventable Causes of Death
The most common causes of disease,
disability, premature death, and health
care burden in the US can be directly
attributed to 4 health risk behaviors:
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Smoking tobacco
Risky use of alcohol
Unhealthy diet
Physical inactivity
1. McGinnis JM, Foege W. Actual causes of death in the United States.
JAMA. 1993;270:2207-2212.
2. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of
death in the United States, 2000. JAMA. 2004;291:1238-1245.
Health Behavior Counseling
Obesity
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In surveys of patients who had a routine checkup with a
physician in the past 12 months, only 14% of
respondents reported receiving advice from their
physician to lose weight, even though approximately
34% of the sample was classified as overweight and
19% as obese (Sciamanna et al., 2000).
Moreover, only 16% of overweight individuals and 40%
of obese individuals reported receiving advice from
their physician to lose weight during their checkup
within the past twelve months (Loureiro, 2006).
Health Behavior Counseling
Alcohol Use
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Only 23% of binge drinkers are counseled about
alcohol use (Am J Prev Med 2003;24(1):71–74)
A survey of family physicians and internists found that
only 64.9% of respondents screened 80-100% of their
patients for alcohol abuse or dependence during the
initial visit and a mere 34.4% screened that many
patients during an annual visit
Only 20% said treatment resources for early problem
drinkers was adequate
72% preferred not to counsel patients themselves
(Spandorfer & Turner 1999)
Health Behavior Counseling
Smoking Cessation
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Smoking cessation counseling only occurs at
23 to 46% of primary care visits
Only 35% of physicians assist with smoking
cessation attempts
Less than 10% arrange follow-up for smoking
patients
•Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers
by physicians. JAMA 1998; 279:604-608
•Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern
Med 1991; 114:54-58.
•Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking
cessation counseling practices. Prev Med 1998; 27:720-729.
Barriers
Physicians
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Competing demands
Conflicting recommendations
Lack of training
Patients
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Lack of knowledge
Fear of discomfort
Cost
Office
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Poor reimbursement
Lack of systems
Opportunities for Intervention
Most people visit a primary care doctor about
three times per year.
Even 2-3 minute interventions are effective,
especially when followed up with telephone,
e-mail, nurse calls, referrals, 1-800 numbers,
etc.
Many primary care providers provide 2-3
minute health promotion/behavior
interventions at every outpatient visit.
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The power of
leveraging to fulfill the promise of health behavior counseling. Am J Prev Med,
2002; 22:320-323.
Integrating the Behavioral Theories
Strayer SM, et al. Development and evaluation of an instrument for assessing brief behavioral
change interventions. Patient Educ Couns (2010), doi:10.1016/j.pec.2010.04.012
Research Design
 RCT with 3rd year family medicine clerkship students
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All students received smoking cessation workshop based on 5 A’s, Stages of Change and
MI
Randomization by paired rotation blocks to receive either a reminder card or a handheld
computer tool - the Educational Smoking Mobile Intervention Tool (E-SMOK-I.T.)
 Students assessed pre and post study for smoking cessation counseling knowledge
and self-reported behavior and comfort using a previously validated survey
instrument
 Students assessed for appropriate smoking cessation counseling using video-taped
standardized patient interview using an instrument that was developed to assess
combined smoking cessation counseling interventions
 2 independent observers assessed key smoking cessation counseling activities using
videotapes and rating form
 Focus groups held with E-SMOK-I.T. tool users post clerkship
Study Flow Diagram
Educational Smoking Intervention
Tool (E-SMOK-I.T.)
Main Screen
Assessment Screen
E-SMOK-I.T. (cont).
Assist Screen
Arrange screen
Analysis
Frequency and descriptive analyses
Inter-rater reliability for videotape
assessment
Pre/post survey analysis using mixed
ANOVA
Smoking cessation counseling skills using
Independent t-tests
Results
 116 students completed the study and had complete
video observations (N=63, control, N=53 intervention).
 Mean age for participants was 26 and 52% were male.
 62% reported handheld computer literacy as
intermediate on a 3 point scale.
 Average Inter-rater reliability was 0.82 (Intraclass
correlation)
Results
 Overall smoking cessation counseling behaviors, knowledge and
comfort increased among all participants (p<.001)
 Paper-based group performed better than the handheld tool group
(69% vs 62%; t=2.318, p=.022) at end of clerkship
 No difference between groups at end of academic year (61% vs.
59%; t=.621, p=.538)
 Focus groups of each rotation block revealed several possible
reasons for results.
Pre-post Survey Results
Mean Summary Score Survey
Subcategories
18.97
20.0
12.89
15.0
10.0
11.98
9.71
9.00
6.95
Pre
Post
5.0
0.0
Knowledge
Behavior
Comfort
Knowledge pre/post increase 0.71 (F=15.54, p<0.001)
Behavior pre/post increase 7.026 (F=194.45, p<0.001)
Comfort pre/post increase 5.93 (F=163.620, p<0.001)
69
Mean Proportion Correct Counseling
Skills
62
61
60
70
59
51
60
50
40
Paper-Based
30
ESMOK-I.T
20
10
0
Counseling
MI Spirit
Retention
Counseling** p<.022, MI Spirit** p=.004, Retention p=.538
Smoking Cessation Counseling Skills
Focus Group Themes
 Discomfort using at point of care or patient not receptive:
 “I think I might have used it more if I were more comfortable
with all the other aspects of being in that room.”
 “… but the patients were either like I don’t want to quit or they
knew what they needed.”
 Forgot or Gossip about tool:
 “I was afraid of it … I heard that there were problems with it
with info-retriever I was afraid about that”
Focus Group Themes
 Would have used if more review / training:
 “It might be useful if I spent more time learning how to use it.”
 Not enough time, smoking not priority:
 “The times that it really gets brought up it is a long
appointment you don’t have enough time to spend on
smoking”
 Tool used as educational reference
 “I did like how you could go to related things inside the
program. But mostly I went through it to review it.”
 “Looked at it once or twice but not with patient”
Conclusions
 Smoking cessation counseling by 3rd year medical
students was improved using a combination of workshop
and a supplementary reference tool.
 Our hypothesis that the point of care tool would enhance
skills significantly did not occur (unlike with our studies in
practicing physicians)
 Barriers specific to the 3rd year training period need to
be addressed in order for a point of care tool to be
effective in this setting
Using the Tool With a Patient
SBIR Phase 2 Contract
Phase II Research Aims

Conduct user-centered design evaluations to validate
design and usability of new functionality
Assess the ability of QuitAdvisorMD to influence smoking
cessation as measured by
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The increase in clinician initiated smoking cessation counseling
The increase in ability of clinicians to provide appropriate smoking
cessation counseling based on the PHS guidelines (and in
particular, physician performance of the 5 A’s of: asking patients
about smoking status, advising patients to quit smoking,
assessing patient readiness to quit smoking, assisting patients
with their quit attempts or in giving motivational interventions if they
are not ready to quit smoking, and arranging follow-up for all
patients who are smokers)
The increase in patient quit attempts.
Cross-study Themes
Content is a valued reference/resource
(AMIT, QA, ACS)
Users liked the software as an
educational tool (AMIT, ACS)
Need more practice and training (ACS,
AMIT, QA)
Discomfort using computers with
patients (AMIT, ACS)
Lack of time (ACS, QA, AMIT)
Conclusions
The content for computer-assisted counseling
tools was appealing to all levels of learners
Many users see this software as an educational
tool
All levels of learners requested more training
and practice
Discomfort using computers with patients
affects learners and even some practicing
physicians
Lack of time for counseling is a persistent barrier
Questions?