models (classical conditioning, cognitive social learning theory, health belief model, theory of reasoned action, stages-of-change or transtheoretical model, and social action theory) are available to guide behavior change interventions that address various behavioral attributes (Bandura, 1986; IOM, 2001b; Prochaska and DiClemente, 1986; Williams et al., 1998). Although each of these models has its limitations, they are useful constructs for thinking about behavior change and can be applied to a variety of desirable changes, including adhering to weight loss regimens, actively seeking breast cancer screening, reducing risk-taking sexual activities, and maintaining smoking cessation (Ashing-Giwa, 1999; Farkas et al., 1996; Keller and Allan, 2001).

Learning and conditioning models are among the oldest and most widely researched models. Conditioning models are of particular importance for various aspects of health-related interventions, such as reinforcement, stimulus–response relationships, modeling, cues to action, and expectancies. Medical students should be made aware of the stimulus-control concept, which posits that patients vary their responses according to the situation in which they find themselves. For example, a person may be in the habit of smoking after a meal and may crave cigarettes only after eating lunch or dinner. Likewise, someone who has a drink every day after work grows to expect a drink at that time. By identifying such almost obligatory responses, the physician can target interventions to have a direct impact on the patient’s risky behavior.

Positive reinforcement (being rewarded) and negative reinforcement (getting rid of something unpleasant) are also important concepts for medical students to understand. Encompassed by these concepts are avoidance and escape behaviors—actions that make it possible to escape or prevent pain or discomfort. In such cases, a desirable action is reinforced by the relief it provides. Because different patients respond well to different stimuli, it is prudent for physicians to know which reinforcement will most likely produce the desired effect in their patients.

Medical students should have a grasp of the theoretical and empirical foundations of our understanding of how behaviors are acquired, maintained, and eliminated in the context of health risk. They should also possess a basic understanding of how patients’ social and economic situations, physical status, and psychological states affect their motivation to change their behavior and how this information can be linked to the appropriate behavior reinforcement method.

Impact of Psychosocial Stressors and Psychiatric Disorders on Manifestations of Other Illnesses and on Health Behavior

In a recent survey, six of seven physicians indicated their belief that people with chronic conditions have unmet mental health needs, and about half said they



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