Physicians' attitudes toward preventive care services: a seven-year prospective cohort study.

We report results of a seven-year prospective cohort study of physicians' attitudes about and intentions to provide 27 preventive care services in their future practices. Respondents in the cohort were surveyed three times: first, during orientation to medical school; second, during their third year of medical school; and finally, following completion of their third-year of residency training. The majority of preventive care services were viewed as more important to clinical practice in primary care than in non-primary care specialties. Positive attitudes toward preventive care services generally persisted among both primary and non-primary care physicians. Respondents expressed only fair to medium levels of confidence in the ability of physicians in their specialty areas to provide any of the preventive services examined. Respondents reported low levels of confidence in the ability of primary care physicians to provide nutritional counseling, though they ranked it as important. Respondents were fairly or moderately confident in the ability of primary care physicians to provide counseling about smoking cessation, health, AIDS education, and substance abuse. Participants ranked smoking cessation counseling, health counseling, AIDS education, cancer detection education, and substance abuse counseling and education as very important. In general, physicians were less likely to plan on providing preventive services than they were to expect their residency programs to prepare most or all to provide the services. Findings document the need to prepare physicians better to provide preventive services.     

Preventive care attitudes of medical students

Presently developing attitudes of future physicians towards preventive medicine will likely provide either a major impetus for or barriers to the inclusion of preventive medicine content in medical school curricula and in other formats of physician education. In turn, attitudes about preventive care and its role in medical practice will continue to have a large influence on how much disease prevention and health promotion emphasis physicians provide in their practices. Consequently, it becomes important to study how medical students' attitudes evolve during the process of medical education. Furthermore, to the extent that we can better understand how desired attitudes can be developed and nurtured, the practice of preventive medicine may become more purposeful. Beginning and third-year medical students were surveyed with a 100-item questionnaire designed to assess their attitudes regarding: the relative importance of 20 specific preventive services to the practice of medicine and the adequacy of preclinical coursework for preparing them to offer preventive care in medical practice. The confidence of third year students' in the ability of primary care physicians to provide these specific services was also assessed. Preventive care service areas about which third-year students expressed high confidence in the ability of physicians to provide were: immunizations, health screening physicals, blood pressure control, cancer detection education, family planning, health counseling/education, and sexually transmitted disease prevention. Services that students had low confidence in the ability of physicians to provide were: smoking cessation, nutrition counseling/education and weight reduction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prevention and health promotion in primary care: baseline results on physicians from the INSURE Project on Lifecycle Preventive Health Services

The INSURE Project on Lifecycle Preventive Health Services is a 3-year feasibility study to develop and test a clinical model of preventive health services, including patient education, in primary medical care as an insurance benefit. Seventy-four primary care physicians in group practices were surveyed regarding their baseline attitudes toward, and practice of, preventive services. Physicians report that they tend to be conscientious in educating their patients about their health risks, although they spend little time in patient education. Physicians are not sanguine about their success in getting their patients to follow their recommendations and tend to harbor doubts about their own efficacy in these areas. Specialty differences exist in these parameters. Physicians evidence contradictory attitudes about prevention. They believe doctors should spend more time providing preventive services but also believe that the lack of insurance reimbursement is an obstacle to providing these services. The concept of structural or sociological ambivalence is advanced to explain this pattern.     

Educating doctors to provide counseling and preventive care: turning 20th century professional values head over heels

Internationally, 20th century medical education concentrated on equipping new graduates with technical skills and pushing the frontiers of technological sciences to extend and enhance life in ways unimaginable in previous decades. In the 21st century, health services are expected to be characterized not by the "fix-up-when-things-go-wrong" type of care that 20th century physicians have become so good at, but by preventive care that can obviate much of the need for these fix-up services. Enabling doctors to deal with the different health care needs of future patients will require a values shift in medical education. The United States leads the world in per capita health care expenditure yet trails in many important measures of health status. It epitomizes many elements of both the good and the bad in current medical education that may be less obvious in other countries that are less wealthy, less technologically oriented, and less committed to individual freedoms. In this paper we use the US as a case study to argue the need for a fundamental shift in values away from the 20th century emphasis on disease, specialization and treatment, and towards health, generalization and prevention. We draw on data from the National Ambulatory Medical Care Survey to compare roles of primary care physicians and other office-based medical specialties in delivering preventive health care. We also estimate the cost of providing preventive care in terms of physician time. Finally, we contemplate how medical education values must change in the US and other countries if 21st century physicians are to be prepared to meet the health care needs of their communities.     

Training physicians for community-oriented primary care in Latin America: model programs in Mexico, Nicaragua, and Costa Rica.

Under the rubrics of preventive and social medicine, public health, and family and community medicine, medical educators in Latin America have developed programs to train physicians for community-oriented health care (COPC). The historical background for such programs in Latin America is reviewed. Three relevant examples of programs in Mexico, Nicaragua, and Costa Rica are highlighted, drawing on the author's direct experience with and in these faculties. The paper addresses the relation between these programs and national and regional trends in education and services.     

The teaching of preventive medicine in American medical schools, 1940–1980

The concept of incorporating prevention into clinical medicine has been addressed by academic medicine since the 1940s. Results reflect the dominant interests of academic medicine over time. This paper reviews this experience, as reflected in national conferences and related activities largely sponsored by the Association of Teachers of Preventive Medicine, and assesses implications for the 1980s. The consensus of the 1940s was that medical education should focus upon quantitative disciplines. Clinical applicability was considered important, but little was developed. Convening in 1952, deans, clinicians, and preventive medicine faculty strongly recommended teaching clinical prevention in “comprehensive care” programs. This movement was eclipsed by research and specialization. Academic preventive medicine focused on residency training and research, culminating in a major conference in 1963. Epidemiology and biostatistics flourished, while teaching clinical prevention received little attention. By 1970, dominant interest shifted to health services policy and research. Currently, some preventive medicine departments have affiliated with primary care training programs, and policy makers are focusing upon prevention. A number of nationally sponsored curriculum development projects deal with preventive aspects of primary care. Under these circumstances, incorporation of prevention into medical practice seems likely to succeed at the academic level. This may in turn stimulate similar occurrences in the medical care system.     

Policy tools for building health education and preventive counseling into managed care

CONTENT: Six policy tools for building health education and preventive counseling into managed care are presented, and the opportunities and barriers to implementing each are described based largely on managed care plans operating in California in 1998. The six policy tools include (1) covering health education and preventive counseling as defined benefits, (2) increasing access to and use of health promotion programs, (3) incorporating health education into disease-management programs, (4) defining quality performance measures for health education and preventive counseling, (5) defining performance targets and guarantees for health education and preventive counseling to hold health plans accountable for providing these services, and (6) building collaboration between public health agencies and managed care on public health education and health promotion. For each of these, the policy option is described, examples of current practice are provided, and the problems and limitations associated with each are discussed.     

Cancer screening and prevention practices of inner-city physicians

INTRODUCTION: Effective preventive services are needed most in underserved, inner-city settings that suffer disproportionately from morbidity and mortality. Primary care physicians can play an important role in the provision of efficacious cancer prevention and screening services to patients in these communities. METHOD: We surveyed 122 primary care physicians about their cancer prevention and screening knowledge, attitudes, and practices. RESULTS: Relative to the findings from national and local surveys, sample physicians were not as knowledgeable about national guidelines for preventive care, were less likely to counsel on smoking cessation, and were less likely to advise diet modification. Although physician practices reflected national cancer prevention and screening guidelines in general, a significant proportion of physicians suggested lung and prostate cancer screening tests that were inconsistent with national recommendations. CONCLUSIONS: Systematic efforts are needed to increase the knowledge and practices of inner-city physicians concerning cancer prevention and screening.     

Meeting an expanding educational role for ambulatory care services

The mid-1980s have been marked by a growing shift in the locus of health care delivery: from the in-patient setting to ambulatory care programs. As a result of cost containment strategies--exemplified by the diagnosis related group method for hospital reimbursement--the ambulatory care network has assumed responsibility for many patients with advanced or complicated diseases. This increased responsibility is in addition to preventive services, health maintenance, and routine care of acute and chronic conditions. This shift not only requires expansion of the current system for delivery of primary care services, but will also increase the role that organized ambulatory care programs will have to play in the education of health professionals. On the basis of a ten-year experience in utilizing two county funded neighborhood health centers for primary care training of family practice residents and medical students, undergraduate and postgraduate medical education programs are discussed in terms of the changes they impose on ambulatory care program organization (e.g., staffing, space, patient assignment and consent), proposed financing, and agreements with educational institutions. The increased administrative burden of training programs is offset by benefits which include staff satisfaction, enhanced quality of care, and an increase in the pool of appropriately trained physicians.     

Forensic training in family practice residencies

Knowledge and skill in forensic medicine are important in primary care not only for defensive purposes but also because of potential therapeutic value in patient care. The major role in future mental health services envisioned for primary care physicians makes such training especially important. A national survey of family practice residency programs reveals that 47 percent of programs do not address forensic aspects of medical practice. A model forensic medicine curriculum is described that would require minimal adjustment of existing programs. The need for inclusion of forensically qualified clinicians in training programs for primary care physicians is evident.     

Self-report of delivery of clinical preventive services by U.S. physicians. Comparing specialty, gender, age, setting of practice, and area of practice.

OBJECTIVES: To summarize national survey results for key clinical preventive services provided by primary care physicians, characterize the results by demographic and practice attributes of the respondents, and compare the results to those obtained in other studies. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 3881 clinicians who provided primary care at least 50% of their time, randomly sampled from the professional associations representing family practitioners, pediatricians, internists, and OB-GYNs. MEASURES: The Primary Care Providers Survey instrument of 1992, administered through the Office of Disease Prevention and Health Promotion, designed to assess the provision of clinical preventive services by primary caregivers. MAIN RESULTS: Few of the physicians surveyed reported providing most indicated clinical preventive services more than 80% of the time. For the purposes of this paper, > 80% provision of preventive services is considered adequate. Female physicians reported providing more preventive services involving exercise, diet, alcohol/drugs, seatbelts, sexual activity, family planning, immunizations, and screening procedures. Physicians aged < 50 reported providing more preventive services involving smoking, alcohol/drugs, seatbelts, sexual activity, and family planning. Older physicians generally reported more delivery of vaccines and screening procedures. Practitioners from big metropolitan areas reported more preventive services involving alcohol/drugs and family planning while respondents in rural areas reported less immunizations and screening procedures. When analyzed by specialty, physicians reporting the most preventive care varied by type of preventive care. CONCLUSIONS: Small differences in the self-report of provision of clinical preventive services between specialties and demographic subgroups did exist. At the time of this survey, however, no group of primary care physicians reported providing clinical preventive services to their patients at adequate levels.     

Rural patients' interests in preventive medical care

A number of national studies have reported patients' interests in preventive medical care, but rural populations have not been well studied. We surveyed patients from a major clinic in rural central Minnesota to determine their interests in preventive medical care and their physicians' perceptions of those interests. Of 270 patients who responded to a questionnaire, 63-93 percent agreed that physicians should perform a wide variety of primary and secondary preventive medical services, such as periodic health examinations and counseling about smoking, exercise, and diet. Study physicians recommended most preventive medical services at least as often as did their patients, but physicians consistently underestimated patients' wishes for these services. Our results indicate that this rural clinic population is interested in a broad range of preventive medical services, which was not fully appreciated by the physicians.     

Tools, teamwork, and tenacity: an office system for cancer prevention.

BACKGROUND. Despite national priorities in cancer control, the number of people with established ongoing medical care who do not receive indicated preventive services is substantial. Proven strategies to optimize preventive care in community practice are limited. METHODS. In the Cancer Prevention in Community Practice Project (CPCP), 50 primary care providers were randomly assigned to receive an "office system" intervention. The intervention led to reorganization of office operations based on four functional core components: identifying patients' needs for services; monitoring their status over time; providing positive reinforcement to patients; and establishing an internal feedback component consisting of a brief audit to assess how the system is operating. Implementation of the CPCP system in each practice was accomplished using trained facilitators, and involved incorporating one or more tools developed to meet the functional components of the practice. RESULTS. One hundred percent of the practices were successful in implementing some changes in their office operations that met CPCP office system functional criteria. All study practices implemented customized flow sheets, while use of other office system tools were incorporated at between 32% to 75% of study sites. Identifying patients in need of preventive services was performed most often by the clinical staff (39%), whereas monitoring patients' receipt of preventive services over time and reinforcing positive patient behavior were performed most often by physicians (63% and 46%, respectively). Changes made in practices were maintained for at least 12 months. CONCLUSIONS. Primary care practices in community settings can implement significant and lasting changes in their practice environment that will improve their performance of preventive activities. The functional components of the CPCP office system design proposed and tested here are applicable to a wide variety of practice settings.     

The delivery of preventive services for patient symptoms

BACKGROUND: Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known. METHODS: Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms. RESULTS: One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services. CONCLUSIONS: Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.     

Defining Competencies and Performance Indicators for Physicians in Medical Management

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.     

Prevention in primary care: variability in physician practice patterns in New York City

We conducted a telephone survey of 120 randomly selected primary care physicians in New York City. This survey, which was completed in October 1984, concerned physicians' recommendations for health promotion and disease prevention. The recommendations by these physicians were often at variance with the recommendations of nationally recognized organizations such as the American Cancer Society and the American College of Physicians. Multivariate analysis revealed that board-certified physicians, U.S. medical graduates, and younger physicians agreed more frequently with the recommendations of national organizations. The physicians surveyed agreed upon the need to include health promotion and disease prevention in their practices. Eighty-seven percent agreed with the statement, "Physicians should probably practice more preventive medicine than they presently do." Reasons given for the failure to practice more prevention included lack of time (70 percent), inadequate reimbursement (60 percent), and "unclear recommendations" (58 percent). Approximately four out of five of the physicians felt a task force was needed to "clarify recommendations" for preventive medicine. The findings of this survey suggest a need for increased physician training and education in disease prevention and health promotion.     

Vers des nouvelles perspectives d'appui à la Prévention au Système National de la Santé, en Tunisie

"Prevention", a component of primary health care since Alma Atas declaration (1978), has been a strategic axis of health policy in Tunisia for four decades. If the Tunisian Revolutionary Constitution (2014) declared in its Article 38 that "the State guarantees prevention", the regulatory texts, organizing preventive structures and its operational programs, have today become ill-suited with the global burden of disease and current scientific evidence. The analysis of current preventive practices in Tunisia, based on the "health continuum", the taxonomy of "preventive strategies" and the identification of "vulnerable populations", has shown the need to implement prevention activities. "Primordial" and "quaternary" (for the management of cardiovascular diseases and cancers), extension of the fields of health education and epidemiological surveillance, towards Therapeutic Education of Patients / Health Promotion, and health monitoring, and coverage of new groups at risk: adolescents and the elderly. Faced with the multitude of prevention structures and the fragmentation of health programs, the reform of the national preventive policy and its practices should be based on the principles of integration, relevance and efficiency, through the establishment of a National Health Protection Agency (NHPA). This ANP is called upon to launch new prevention support projects including integrated preventive medicine centers (providing periodic health examinations), hospital patient therapeutic education services and home care units. Such a reform, announcing the birth of a new generation of preventive basic health care activities in Tunisia, should be reinforced by a legal, organizational and educational basis.     

The INSURE project on lifecycle preventive health services.

The INSURE Project on Lifecycle Preventive Health Services is a 3-year study to determine the feasibility of implementing preventive services in primary medical care as a health insurance benefit and to assess the short-term impact of this implementation on providers and consumers. Initiated by the life and health insurance companies, the project has received additional support from private philanthropic foundations. Preventive services, which will be provided under a lifecycle approach according to the age and sex of the patient and include education of patients on health-related behavior, will range from prenatal care through geriatrics. A quasi-experimental design will be used in which three study (experimental) group practice sites are matched with three control group practice sites. At the study sites, the primary care physicians will participate in orientation sessions on recommended preventive services and patient education procedure; they will also examine and counsel the study patients. The study and control physicians and patients will be surveyed before and after the program of intervention is conducted at the study sites to assess their knowledge, attitudes, and behavior toward health behavior practices.     

The impact of primary care resources on prevention practices

Organizational factors influence the quality of preventive care. Combining facility-level data from a national organizational survey and centrally available, externally abstracted chart review data on prevention performance, we assessed the relationship between structural features of primary care departments and the quality of preventive care delivered. Primary care practice resources were significantly and positively associated with the delivery of 6 of 9 preventive services. Adjusting for facility size and academic affiliation, these resource arrangements accounted for substantial variation in 8 of 9 services. Assuring high-quality prevention performance requires ongoing investment in primary care-based infrastructure.     

Computerized telephone reminder system facilitates wellness and prevention

In the near future, the most successful medical practices will have wellness and prevention as their primary objectives of care. Telephoned reminders have proved to be the most effective method of bringing patients in for immunizations, cancer screening, and other preventive measures. Using computer telephony integration (CTI) technology to automate wellness and recall messages makes possible a cost-effective, consistent program of personalized reminders. This technology allows a medical practice to generate revenue from patients overdue for an appointment, to promote wellness through regular checkups or education programs, and to improve patient satisfaction with services.