A large burden of cancer morbidity and mortality is potentially preventable by changes in personal health behaviors. Health behavior advice (HBA) by primary care physicians, who provide basic health care to most Americans, holds great promise as a strategy to alter cancer-related health behaviors and to reduce morbidity and mortality. One potentially powerful strategy is the use of illness visits as a 'teachable moment'(TM) for health behavior change. Our in-depth analysis of audio recorded physician-patient interactions has led to new discoveries of the communication elements of a TM. First, effective TM's involve linking a health behavior to a salient patient problem and positioning the health behavior as a problem. Persuasion is accomplished by suggesting that changing the health behavior will improve the patient's salient concern. If done skillfully, the patient accepts the portrayal of the health behavior as a relevant problem and exhibits uptake of the health behavior change talk, possibly expressing a commitment to change. Our data reveal that TMs occur in 20% of health behavior discussions between physician and patient. More frequent (43%) , however, are TM 'attempts'which fail to engage the patient. These attempts lack two essential aspects of good patient-centered advice 1) eliciting the patient's readiness to change and 2) responding in alignment with the patient's expressed stage of change. We also observed 'missed opportunities'(20%) where the health behavior advice failed to link to a salient patient concern. Therefore, the goal of this randomized trial is to test an intervention that trains clinicians to integrate the use of TMs with the key skills of motivational interviewing tailored to address smoking and weight management in the outpatient visit setting. This goal will be accomplished using a group randomized trial of 32 clinicians (1920 patients) and a crossover study design. The initial Brief Teachable Moment Skills (B- TEAMS) intervention will focus on smoking cessation as the health behavior topic. At the crossover point, the delayed intervention group will receive the B-TEAMS intervention but with a focus on weight management. B-TEAMS involves multiple modalities including skills-based training, practice with standardized patients and on-site coaching. Video recordings of visits with patients who smoke or are obese will be used to assess both intervention and control clinicians'health behavior change strategies at baseline and post intervention. Patient surveys will be used to assess the effect of the observed health behavior change strategies on immediate and short-term patient outcomes. Leveraging clinicians'naturally- occurring health behavior change strategies by fostering the development of more effective communication skills has great potential to enhance patient health behavior change. This study will test this strategy and generate rich data about its effectiveness and how it is tailored by physicians in practice for both smoking and weight management;two important risk factors for cancer and other devastating chronic diseases.

Public Health Relevance

This project will teach primary care physicians skills to improve their communication with patients when addressing talk about quitting smoking or managing weight. The approach is designed to enhance what physicians naturally do well by adding patient-centered listening skills, and thus is likely to be effective.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
Project #
Application #
Study Section
Health Services Organization and Delivery Study Section (HSOD)
Program Officer
Nebeling, Linda C
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Case Western Reserve University
Family Medicine
Schools of Medicine
United States
Zip Code
Flocke, Susan A; Step, Mary M; Lawson, Peter J et al. (2017) Development of a Measure of Incremental Behavior Change Toward Smoking Cessation. Nicotine Tob Res 20:73-80
Goodwin, Meredith A; Stange, Kurt C; Zyzanski, Stephen J et al. (2017) The Hawthorne effect in direct observation research with physicians and patients. J Eval Clin Pract 23:1322-1328
Antognoli, E L; Smith, K J; Mason, M J et al. (2014) Direct observation of weight counselling in primary care: alignment with clinical guidelines. Clin Obes 4:69-76
Flocke, Susan A; Step, Mary M; Antognoli, Elizabeth et al. (2014) A randomized trial to evaluate primary care clinician training to use the Teachable Moment Communication Process for smoking cessation counseling. Prev Med 69:267-73
Flocke, Susan A; Clark, Elizabeth; Antognoli, Elizabeth et al. (2014) Teachable moments for health behavior change and intermediate patient outcomes. Patient Educ Couns 96:43-9
Werner, James J; Lawson, Peter J; Panaite, Vanessa et al. (2013) Comparing primary care physicians' smoking cessation counseling techniques to motivational interviewing. J Addict Med 7:139-42
Flocke, Susan A; Antognoli, Elizabeth; Step, Mary M et al. (2012) A Teachable Moment Communication Process for smoking cessation talk: description of a group randomized clinician-focused intervention. BMC Health Serv Res 12:109
Cohen, Deborah J; Clark, Elizabeth C; Lawson, Peter J et al. (2011) Identifying teachable moments for health behavior counseling in primary care. Patient Educ Couns 85:e8-15
Carroll, Jennifer K; Antognoli, Elizabeth; Flocke, Susan A (2011) Evaluation of physical activity counseling in primary care using direct observation of the 5As. Ann Fam Med 9:416-22
Flocke, Susan A; Kelly, Robert; Highland, Janelle (2009) Initiation of health behavior discussions during primary care outpatient visits. Patient Educ Couns 75:214-9

Showing the most recent 10 out of 12 publications