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Addict Behav Rep. 2019 Mar 28;9:100179. doi: 10.1016/j.abrep.2019.100179. eCollection 2019 Jun.

Igniting activation: Using unannounced standardized patients to measure patient activation in smoking cessation.

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Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, 462 1st Avenue, New York, NY 10016, United States of America.
Vassar College, 124 Raymond Ave, Poughkeepsie, NY 12604, United States of America.
Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, United States of America.
Institute for Innovation in Medical Education, Division of Quality and Evaluation and Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, 550 First Avenue, New York, NY 10016, United States of America.



Despite a decline, smoking rates have remained high, especially in communities with lower income, education, and limited insurance options. Evidence shows that physician-initiated counseling on smoking cessation is effective and saves lives, and that specific skills are needed to appropriately lead this type of patient-physician communication. Residency is a critical moment for future physicians and may be the optimal time to learn, practice, and refine this skillset. Unannounced Standardized Patients (USPs) have been found to be effective, incognito evaluators of resident practices.


This study introduced rigorously trained actors (USPs) into two urban, safety-net clinics to assess resident ability to engage, activate, and counsel a pre-contemplative smoker. A complementary chart review assessed appropriate documentation in the patient's electronic health record (EHR) and its relationship to counseling style and prescribing practices.


Resident scores (% well done) on patient education and engagement were low (33% and 23%, respectively). Residents who coupled cessation advice with an open discussion style activated their patients more than those who solely advised cessation across all comparable measures. On EHR documentation, residents who accurately documented smoking history were more likely to directly advise their patient to quit smoking when compared to residents who did not document (t(97) = 2.828, p = .006, Cohen's D = 0.56).


Results highlight the need to reinforce training in patient-centered approaches including motivational interviewing, counseling, and shared decision-making. Future research should focus on the effects of smokers in pre-contemplation on physician counseling style and examine the relationship between medical training and provider communication to guide interventions.


Counseling; Curricula; Medical education; Motivational interviewing; Patient activation; Smoking cessation; Training; Unannounced standardized patient

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