Heather-Lyn Haley - Academia.edu (original) (raw)

Papers by Heather-Lyn Haley

Purpose of program/study/research: To accelerate the advancement of women professionals at an aca... more Purpose of program/study/research: To accelerate the advancement of women professionals at an academic medical center through creative collaboration. Methodology (including study design, analysis, and evaluation): The UMass Medical School Women's Faculty Committee (WFC) initiated a partnership with the medical library to compete successfully to host the traveling exhibition "Changing the Face of Medicine: Celebrating America's Women Physicians." Concurrent with the 6-week exhibition, fifteen events brought local and nationally prominent women together for mentoring activities, an original dramatic production, and an awards luncheon for women faculty. Women featured in the exhibit as well as its Visiting Curator spoke at UMMS about their research and career challenges, read from their published works, and were featured at graduation and a regional medical society event. Results: Application-writing and event planning sessions forged robust working relationships amon...

As part of the mini-symposium entitled "Utilizing Community Voices to Translate Research int... more As part of the mini-symposium entitled "Utilizing Community Voices to Translate Research into Communities: Results from Three Pilot Studies Conducted by Academic and Community Partnerships," this presentation discusses a study that focuses on understanding the barriers refugees face when obtaining critical support services, benefits and housing. The aim is to improve individual and systemic level advocacy and training strategies designed to reduce the barriers impeding access to public benefits and housing for Worcester's growing and diverse refugee population.

Background: Refugees resettling in the US historically follow a trajectory of declining health as... more Background: Refugees resettling in the US historically follow a trajectory of declining health as they adopt American diet and physical activity. Methods: This participatory research study explored health beliefs and behaviors of refugees from Burma currently resettling in New England. Community members and researchers adapted a healthy living bilingual educational flipchart, which was piloted in two workshops with a total of 20 adult men and women. An interpreter translated the audio taped discussions which were transcribed and analyzed using standard qualitative methods. Conclusions/ Discussion: Refugee camps constrain food and physical activity related health behaviors. Refugees rely on traditional healing practices but are familiar with western public health care and preventive education. In camps, close living quarters encouraged social interaction and group play. Physical activity was built into daily life as transportation, occupation and food gathering method. Exercise was a...

Family medicine, 2005

BACKGROUND Many reports, including the Future of Family Medicine, have called for change in prima... more BACKGROUND Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. METHODS Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. RESULTS Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with ...

Community partnerships Eat Walk Sleep Discuss: Building a Multi-Dimensional Participatory Relatio... more Community partnerships Eat Walk Sleep Discuss: Building a Multi-Dimensional Participatory Relationship Heather-Lyn Haley1, Suzanne Cashman1, Mick Godkin1, Meredith Walsh2,3, Nang Maung2,4, Toy Lim3, Sarah Tracy5, Clara Savage6, James Madson II6 1 UMass Medical School Dept of Family Medicine and Community Health, 2 Worcester Refugee Assistance Project, 3 UMass Graduate School of Nursing, 4 UMass Graduate School of Biomedical Sciences, 5 UMass Medical School Class of 2014, 6 Common Pathways

Background/significance: Relationships between community and university partners need to be respo... more Background/significance: Relationships between community and university partners need to be responsive to opportunities for addressing emerging community needs as well as for identifying research resources. Building a long term partnership from a series of initiatives is challenging but achievable. Objective/Purpose: Guided by the Healthy Communities paradigm, a multi-faceted relationship developed between UMass Medical School, the MA Department of Public Health Community Health Network Area (CHNA) Common Pathways Coalition and the Worcester Refugee Assistance Project (WRAP). Methods: Student-engaged community work at WRAP was originally supported by an external foundation fellowship. Existing partnerships between the university and the local CHNA were leveraged to expand the relationship with WRAP. Portions of an ongoing CHNA-led summer conversation series were utilized for refugee community identification, needs assessment, and neighborhood asset mapping exercises. Prevention Rese...

Refugees resettling in the US historically follow a trajectory of declining health as they adopt ... more Refugees resettling in the US historically follow a trajectory of declining health as they adopt American habits of poor diet and low levels of physical activity and sleep. This participatory research study explored health beliefs and behaviors of the new community of refugees from Burma currently resettling in New England from refugee camps. Community members and researchers worked together to adapt a healthy living curriculum entitled Eat Walk Sleep for Health (EWS), creating a bilingual educational flipchart. The flipchart was piloted in two workshops with a total of 20 adult men and women. Workshop discussion focused on participants' prior and current health behaviors as well as their current health challenges. An interpreter translated during the discussions which were audio taped, then transcribed and analyzed using standard qualitative methods. Refugee camps constrain food and physical activity related health behaviors. Refugees rely on traditional healing practices but a...

Family medicine, 2005

Many reports, including the Future of Family Medicine, have called for change in primary care, bu... more Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with significant institutional a...

Journal of Correctional Health Care, 2015

Providing health care in corrections is challenging. Attracting clinicians can be equally challen... more Providing health care in corrections is challenging. Attracting clinicians can be equally challenging. The future holds a shortage of nurses and primary care physicians. We have a unique opportunity, now, to develop and stabilize our workforce, create a positive image, and enhance quality before the health care landscape changes even more dramatically. Focus groups were conducted with 22 correctional health care professionals divided into three groups: physicians (6), nurses (4), and nurse practitioners/physician assistants (12). Content focused on curricular themes, but additional themes emerged related to recruitment and retention. This article describes recruitment challenges, strategic themes identified, and the proposed initiatives to support a stable, high-quality correctional health workforce.

Teaching and Learning in Medicine, 2009

Little has been published describing curricular experiences in correctional health (CH). Our goal... more Little has been published describing curricular experiences in correctional health (CH). Our goal is to articulate a curriculum cognizant of the special needs of the correctional health care worker. We conducted focus groups with nurses, nurse practitioners, physician assistants, and physicians focused on content crucial to prepare competent medical professionals committed to careers in correctional health. Six main themes emerged from the data, which were used to confirm and add to the growing curriculum on correctional health used in our university's correctional health electives. The themes are (a) characteristics of the population being served; (b) prevalent conditions requiring clinical expertise; (c) public health opportunities in correctional facilities; (d) ethical considerations; (e) medical-legal issues; and (d) the CH system, structure, and administration. The successful provision of health care in correctional settings requires specialized knowledge, skills, and awareness not typically available in other health care training settings.

Teaching and Learning in Medicine, 2007

The importance of assessing physician-patient communication skills is widely recognized, but asse... more The importance of assessing physician-patient communication skills is widely recognized, but assessment methods are limited. Objective structured clinical examinations are time-consuming and resource intensive. For practicing physicians, patient surveys may be useful, but these also require substantial resources. Clearly, it would be advantageous to develop alternative or supplemental methods for assessing communication skills of medical students, residents, and physicians. The Video-based Test of Communication Skills (VTCS) is an innovative, computer-administered test, consisting of 20 very short video vignettes. In each vignette, a patient makes a statement or asks a question. The examinee responds verbally, as if it was a real encounter and he or she were the physician. Responses are recorded for later scoring. Test administration takes approximately 1 h. Generalizability studies were conducted, and scores for two groups of physicians predicted to differ in their communication skills were compared. Preliminary results are encouraging; the estimated g coefficient for the communication score for 20-vignette test (scored by five raters) is 0.79; g for the personal/affective score under the same conditions is 0.62. Differences between physicians were in the predicted direction, with physicians considered "at risk" for communication difficulties scoring lower than those not so identified. The VTCS is a short, portable test of communication skills. Results reported here suggest that scores reflect differences in skill levels and are generalizable. However, these findings are based on very small sample sizes and must be considered preliminary. Additional work is required before it will be possible to argue confidently that this test in particular, and this approach to testing communication skills in general, is valuable and likely to make a substantial contribution to assessment in medical education.

Teaching and Learning in Medicine, 2005

Objective structured teaching exercises (OSTEs) are relatively new in medical education, with few... more Objective structured teaching exercises (OSTEs) are relatively new in medical education, with few studies that have reported reliability and validity. To systematically examine the impact of OSTE design decisions, including number of cases, choice of raters, and type of scoring systems used. We examined the impact of number of cases and raters using generalizability theory. We also compared scores from standardized students (SS), faculty raters (FR) and trained graduate student raters (TR), and examined the relation between behavior checklist ratings and global perception scores. Generalizability (g) coefficients for checklist scores were higher for SSs than TRs. The g estimates based on SSs' global scores were higher than g estimates for FRs. SSs' checklist scores were higher than TRs' checklist scores, and SSs' global evaluations were higher than FRs' and TRs' global scores. TRs' relative to SSs' global perceptions correlated more highly with checklist scores. SSs provide more generalizable checklist scores than TRs. Generalizability estimates for global scores from SSs and FRs were comparable. SSs are lenient raters compared to TRs and FRs.

Teaching and Learning in Medicine, 2006

Background: A previous study described 7 elements of teacher identity: intrinsic satisfaction fro... more Background: A previous study described 7 elements of teacher identity: intrinsic satisfaction from teaching, knowledge and skill about teaching, belonging to a community of teachers, receiving rewards for teaching, believing that being a doctor means being a teacher, feeling a responsibility to teach, and sharing clinical expertise. Purpose: To conduct the initial testing of an instrument to measure the 7 elements of teacher identity in clinical educators and to consider the potential applications of such an instrument. Methods: A 37-item questionnaire was mailed to 153 preceptors of preclinical students. Categories reflected the elements of teacher identity listed here. Demographic data were collected. Means, alphas, ANOVAs, and paired t tests were calculated. Results: Of 153 preceptors, 127 (83%) completed the questionnaire. Cronbach's alpha for the overall scale and several subscales were high. Salaried physicians and those who had completed a faculty development program scored significantly higher on several subscales than physicians who volunteered to teach or who did not have faculty development. Conclusions: This study provides preliminary evidence that teacher identity can be measured and that preceptors do not respond as a homogeneous group. Assessing 117 The authors acknowledge Rebecca Spanagel, MD, for her help identifying the sample population.

Patient Education and Counseling, 2008

Objective: Caring is closely associated with reduced malpractice litigation, adherence to treatme... more Objective: Caring is closely associated with reduced malpractice litigation, adherence to treatment and even symptom relief. Caring also is included in pay for performance formulas as well as widely utilized for quality improvement purposes. Our objective in this prospective qualitative study was to define caring behaviors associated with three challenging encounters: discussing the transition from curative to palliative care, delivering bad news (cancer), and discussing a medical error (misplaced test result). The purpose was to lay the groundwork for the creation of a 'patient-centered' caring attitude checklist that could help the healthcare provider understand and ultimately enhance the patient's experience of care. Methods: Groups of randomly selected lay people, henceforth referred to as patients: (1) engaged in 'think aloud' exercises to help create a 15item caring behavior checklist; (2) used the checklist to rate videotapes of simulated challenging encounters conducted by twenty primary care physicians (total of 600 ratings sets); and (3) participated in 12 separate 1.5 h focus groups discussing the caring (and non-caring) behaviors exhibited in videotapes of the highest and lowest rated encounters. Results: Thirteen behaviors emerged as focal for describing a doctor's caring attitude but with disagreement as to whether specific examples of these behaviors were 'caring' or 'uncaring.' For example, although the concept of empathic inquiry was considered important by most patients, the physician question, ''Is there someone you can call or talk with'' (about a cancer diagnosis) was interpreted by one patient as 'very caring' while another was 'impressed with how uncaring' the statement appeared. Conclusion: At the conceptual level there is a set of behaviors that represent caring, however, the manifestation of these behaviors is 'in the eye of the beholder.' The most important element of caring may not be the set of behaviors but a set of underlying abilities that include taking the patient's perspective and reflecting on the patient's responses. Practice implications: Medical education must focus on the underlying abilities of caring.

Purpose of program/study/research: To accelerate the advancement of women professionals at an aca... more Purpose of program/study/research: To accelerate the advancement of women professionals at an academic medical center through creative collaboration. Methodology (including study design, analysis, and evaluation): The UMass Medical School Women's Faculty Committee (WFC) initiated a partnership with the medical library to compete successfully to host the traveling exhibition "Changing the Face of Medicine: Celebrating America's Women Physicians." Concurrent with the 6-week exhibition, fifteen events brought local and nationally prominent women together for mentoring activities, an original dramatic production, and an awards luncheon for women faculty. Women featured in the exhibit as well as its Visiting Curator spoke at UMMS about their research and career challenges, read from their published works, and were featured at graduation and a regional medical society event. Results: Application-writing and event planning sessions forged robust working relationships amon...

As part of the mini-symposium entitled "Utilizing Community Voices to Translate Research int... more As part of the mini-symposium entitled "Utilizing Community Voices to Translate Research into Communities: Results from Three Pilot Studies Conducted by Academic and Community Partnerships," this presentation discusses a study that focuses on understanding the barriers refugees face when obtaining critical support services, benefits and housing. The aim is to improve individual and systemic level advocacy and training strategies designed to reduce the barriers impeding access to public benefits and housing for Worcester's growing and diverse refugee population.

Background: Refugees resettling in the US historically follow a trajectory of declining health as... more Background: Refugees resettling in the US historically follow a trajectory of declining health as they adopt American diet and physical activity. Methods: This participatory research study explored health beliefs and behaviors of refugees from Burma currently resettling in New England. Community members and researchers adapted a healthy living bilingual educational flipchart, which was piloted in two workshops with a total of 20 adult men and women. An interpreter translated the audio taped discussions which were transcribed and analyzed using standard qualitative methods. Conclusions/ Discussion: Refugee camps constrain food and physical activity related health behaviors. Refugees rely on traditional healing practices but are familiar with western public health care and preventive education. In camps, close living quarters encouraged social interaction and group play. Physical activity was built into daily life as transportation, occupation and food gathering method. Exercise was a...

Family medicine, 2005

BACKGROUND Many reports, including the Future of Family Medicine, have called for change in prima... more BACKGROUND Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. METHODS Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. RESULTS Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with ...

Community partnerships Eat Walk Sleep Discuss: Building a Multi-Dimensional Participatory Relatio... more Community partnerships Eat Walk Sleep Discuss: Building a Multi-Dimensional Participatory Relationship Heather-Lyn Haley1, Suzanne Cashman1, Mick Godkin1, Meredith Walsh2,3, Nang Maung2,4, Toy Lim3, Sarah Tracy5, Clara Savage6, James Madson II6 1 UMass Medical School Dept of Family Medicine and Community Health, 2 Worcester Refugee Assistance Project, 3 UMass Graduate School of Nursing, 4 UMass Graduate School of Biomedical Sciences, 5 UMass Medical School Class of 2014, 6 Common Pathways

Background/significance: Relationships between community and university partners need to be respo... more Background/significance: Relationships between community and university partners need to be responsive to opportunities for addressing emerging community needs as well as for identifying research resources. Building a long term partnership from a series of initiatives is challenging but achievable. Objective/Purpose: Guided by the Healthy Communities paradigm, a multi-faceted relationship developed between UMass Medical School, the MA Department of Public Health Community Health Network Area (CHNA) Common Pathways Coalition and the Worcester Refugee Assistance Project (WRAP). Methods: Student-engaged community work at WRAP was originally supported by an external foundation fellowship. Existing partnerships between the university and the local CHNA were leveraged to expand the relationship with WRAP. Portions of an ongoing CHNA-led summer conversation series were utilized for refugee community identification, needs assessment, and neighborhood asset mapping exercises. Prevention Rese...

Refugees resettling in the US historically follow a trajectory of declining health as they adopt ... more Refugees resettling in the US historically follow a trajectory of declining health as they adopt American habits of poor diet and low levels of physical activity and sleep. This participatory research study explored health beliefs and behaviors of the new community of refugees from Burma currently resettling in New England from refugee camps. Community members and researchers worked together to adapt a healthy living curriculum entitled Eat Walk Sleep for Health (EWS), creating a bilingual educational flipchart. The flipchart was piloted in two workshops with a total of 20 adult men and women. Workshop discussion focused on participants' prior and current health behaviors as well as their current health challenges. An interpreter translated during the discussions which were audio taped, then transcribed and analyzed using standard qualitative methods. Refugee camps constrain food and physical activity related health behaviors. Refugees rely on traditional healing practices but a...

Family medicine, 2005

Many reports, including the Future of Family Medicine, have called for change in primary care, bu... more Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with significant institutional a...

Journal of Correctional Health Care, 2015

Providing health care in corrections is challenging. Attracting clinicians can be equally challen... more Providing health care in corrections is challenging. Attracting clinicians can be equally challenging. The future holds a shortage of nurses and primary care physicians. We have a unique opportunity, now, to develop and stabilize our workforce, create a positive image, and enhance quality before the health care landscape changes even more dramatically. Focus groups were conducted with 22 correctional health care professionals divided into three groups: physicians (6), nurses (4), and nurse practitioners/physician assistants (12). Content focused on curricular themes, but additional themes emerged related to recruitment and retention. This article describes recruitment challenges, strategic themes identified, and the proposed initiatives to support a stable, high-quality correctional health workforce.

Teaching and Learning in Medicine, 2009

Little has been published describing curricular experiences in correctional health (CH). Our goal... more Little has been published describing curricular experiences in correctional health (CH). Our goal is to articulate a curriculum cognizant of the special needs of the correctional health care worker. We conducted focus groups with nurses, nurse practitioners, physician assistants, and physicians focused on content crucial to prepare competent medical professionals committed to careers in correctional health. Six main themes emerged from the data, which were used to confirm and add to the growing curriculum on correctional health used in our university's correctional health electives. The themes are (a) characteristics of the population being served; (b) prevalent conditions requiring clinical expertise; (c) public health opportunities in correctional facilities; (d) ethical considerations; (e) medical-legal issues; and (d) the CH system, structure, and administration. The successful provision of health care in correctional settings requires specialized knowledge, skills, and awareness not typically available in other health care training settings.

Teaching and Learning in Medicine, 2007

The importance of assessing physician-patient communication skills is widely recognized, but asse... more The importance of assessing physician-patient communication skills is widely recognized, but assessment methods are limited. Objective structured clinical examinations are time-consuming and resource intensive. For practicing physicians, patient surveys may be useful, but these also require substantial resources. Clearly, it would be advantageous to develop alternative or supplemental methods for assessing communication skills of medical students, residents, and physicians. The Video-based Test of Communication Skills (VTCS) is an innovative, computer-administered test, consisting of 20 very short video vignettes. In each vignette, a patient makes a statement or asks a question. The examinee responds verbally, as if it was a real encounter and he or she were the physician. Responses are recorded for later scoring. Test administration takes approximately 1 h. Generalizability studies were conducted, and scores for two groups of physicians predicted to differ in their communication skills were compared. Preliminary results are encouraging; the estimated g coefficient for the communication score for 20-vignette test (scored by five raters) is 0.79; g for the personal/affective score under the same conditions is 0.62. Differences between physicians were in the predicted direction, with physicians considered "at risk" for communication difficulties scoring lower than those not so identified. The VTCS is a short, portable test of communication skills. Results reported here suggest that scores reflect differences in skill levels and are generalizable. However, these findings are based on very small sample sizes and must be considered preliminary. Additional work is required before it will be possible to argue confidently that this test in particular, and this approach to testing communication skills in general, is valuable and likely to make a substantial contribution to assessment in medical education.

Teaching and Learning in Medicine, 2005

Objective structured teaching exercises (OSTEs) are relatively new in medical education, with few... more Objective structured teaching exercises (OSTEs) are relatively new in medical education, with few studies that have reported reliability and validity. To systematically examine the impact of OSTE design decisions, including number of cases, choice of raters, and type of scoring systems used. We examined the impact of number of cases and raters using generalizability theory. We also compared scores from standardized students (SS), faculty raters (FR) and trained graduate student raters (TR), and examined the relation between behavior checklist ratings and global perception scores. Generalizability (g) coefficients for checklist scores were higher for SSs than TRs. The g estimates based on SSs' global scores were higher than g estimates for FRs. SSs' checklist scores were higher than TRs' checklist scores, and SSs' global evaluations were higher than FRs' and TRs' global scores. TRs' relative to SSs' global perceptions correlated more highly with checklist scores. SSs provide more generalizable checklist scores than TRs. Generalizability estimates for global scores from SSs and FRs were comparable. SSs are lenient raters compared to TRs and FRs.

Teaching and Learning in Medicine, 2006

Background: A previous study described 7 elements of teacher identity: intrinsic satisfaction fro... more Background: A previous study described 7 elements of teacher identity: intrinsic satisfaction from teaching, knowledge and skill about teaching, belonging to a community of teachers, receiving rewards for teaching, believing that being a doctor means being a teacher, feeling a responsibility to teach, and sharing clinical expertise. Purpose: To conduct the initial testing of an instrument to measure the 7 elements of teacher identity in clinical educators and to consider the potential applications of such an instrument. Methods: A 37-item questionnaire was mailed to 153 preceptors of preclinical students. Categories reflected the elements of teacher identity listed here. Demographic data were collected. Means, alphas, ANOVAs, and paired t tests were calculated. Results: Of 153 preceptors, 127 (83%) completed the questionnaire. Cronbach's alpha for the overall scale and several subscales were high. Salaried physicians and those who had completed a faculty development program scored significantly higher on several subscales than physicians who volunteered to teach or who did not have faculty development. Conclusions: This study provides preliminary evidence that teacher identity can be measured and that preceptors do not respond as a homogeneous group. Assessing 117 The authors acknowledge Rebecca Spanagel, MD, for her help identifying the sample population.

Patient Education and Counseling, 2008

Objective: Caring is closely associated with reduced malpractice litigation, adherence to treatme... more Objective: Caring is closely associated with reduced malpractice litigation, adherence to treatment and even symptom relief. Caring also is included in pay for performance formulas as well as widely utilized for quality improvement purposes. Our objective in this prospective qualitative study was to define caring behaviors associated with three challenging encounters: discussing the transition from curative to palliative care, delivering bad news (cancer), and discussing a medical error (misplaced test result). The purpose was to lay the groundwork for the creation of a 'patient-centered' caring attitude checklist that could help the healthcare provider understand and ultimately enhance the patient's experience of care. Methods: Groups of randomly selected lay people, henceforth referred to as patients: (1) engaged in 'think aloud' exercises to help create a 15item caring behavior checklist; (2) used the checklist to rate videotapes of simulated challenging encounters conducted by twenty primary care physicians (total of 600 ratings sets); and (3) participated in 12 separate 1.5 h focus groups discussing the caring (and non-caring) behaviors exhibited in videotapes of the highest and lowest rated encounters. Results: Thirteen behaviors emerged as focal for describing a doctor's caring attitude but with disagreement as to whether specific examples of these behaviors were 'caring' or 'uncaring.' For example, although the concept of empathic inquiry was considered important by most patients, the physician question, ''Is there someone you can call or talk with'' (about a cancer diagnosis) was interpreted by one patient as 'very caring' while another was 'impressed with how uncaring' the statement appeared. Conclusion: At the conceptual level there is a set of behaviors that represent caring, however, the manifestation of these behaviors is 'in the eye of the beholder.' The most important element of caring may not be the set of behaviors but a set of underlying abilities that include taking the patient's perspective and reflecting on the patient's responses. Practice implications: Medical education must focus on the underlying abilities of caring.