Health promotion counseling in residency training

This report describes health promotion counseling attitudes and practices in a family medicine residency that attempted to encourage such counseling. A patient “Health Habits Questionnaire” and matching patient education booklets were developed and distributed. Six grand rounds presentations on counseling were given. On three occasions, residency physicians completed questionnaires about counseling. Despite good personal health habits and positive attitudes toward counseling, the residency physicians had only moderate confidence in their counseling ability and infrequently documented counseling. The residents reported significant improvement in their ability to counsel patients about smoking cessation. Overall, the curriculum appeared to have a limited effect on health promotion. Received from the Department of Family Medicine, St. Paul-Ramsey Medical Center, St. Paul, Minnesota.     

The use of formal prior directives among patients with HIV-related diseases

Objective:To examine the knowledge of, counseling about, and use of prior directives among patients with HIV-related disease. Design:Cross-sectional survey with personal interviews that was part of the evaluation of a multi-site AIDS Health Services Program. Setting:Outpatient clinics and AIDS community-based organizations. Patients/participants:To be eligible for the survey, subjects had to be at least 18 years of age and enrolled in the AIDS Health Services Program for at least one month. 1,031 clients were interviewed in nine communities. Measurements and main results:Of those surveyed, 61% had thought a moderate or great amount about naming a proxy for health care decisions. The majority (68%) of the patients knew about prior directives, yet only 35% had been counseled and only 28% had a prior directive. Of those counseled, physicians had counseled only 11% (38/359). Gay/bisexual men were more likely to have been counseled and to have executed a prior directive than were others. Counseling was associated with having obtained a prior directive. Counseled subjects were 3.5 times more likely to have obtained a prior directive than were those not counseled. Conclusions:A gap exists between subjects’ knowledge and implementation of prior directives. To help bridge this gap, the authors recommend that physicians not only attend to the technical aspects of patient care, but also determine patient values concerning life-sustaining therapy and counsel patients on prior directives. Supported by National Institute of Aging Post Doctoral Health Care Research Training Grant AG00160 (JT) and supported in part by a grant from the Robert Wood Johnson Foundation.     

Training physicians about smoking cessation

Study objective:To test the hypotheses that physicians in private practice who receive a continuing education program (entitled “Quit for Life”) about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients. Design:Randomized trial with blinded assessment of principal outcomes. Setting:Private practices of internal medicine and family practice. Subjects:Forty-four physicians randomly assigned to receive training (24) or serve as controls (20) and consecutive samples of smokers visiting each physician (19.6 patients per experimental and 22.3 per control physician). Interventions:Physicians received three hours of training about how to help smokers quit. Physicians and their office staffs were also given self-help booklets to distribute to smokers and were urged to use a system of stickers on charts as reminders to counsel smokers about quitting. Measurements and main results:Based on telephone interviews with patients, physicians in the experimental group were more likely to discuss smoking with patients who smoked (64% vs. 44%), spent more time counseling smokers about quitting (7.5 vs. 5.2 minutes), helped more smokers set dates to quit smoking (29% vs. 5% of smokers), gave out more self-help booklets (37% vs. 9%), and were more likely to make a follow-up appointment about quitting smoking (19% vs. 11% of those counseled) than physicians in the control group. One year later, the rates of biochemically confirmed, long-term (≥9 months) abstinence from smoking were similar among patients in the experimental (3.2%) and control (2.5%) groups (95% confidence interval for the 0.7% difference: −1.7 to +3.1%). Conclusions:The authors conclude that this continuing education program substantially changed the way physicians counseled smokers, but had little or no impact on rates of long-term smoking cessation among their patients. There is a need for more effective strategies to help physicians help their patients to quit smoking. Supported by Grant # CA38337 from the National Cancer Institute and by the Henry J. Kaiser Foundation Faculty Fellowship in General Internal Medicine (SRC).     

Missed opportunities for prevention of osteoporotic fracture

BACKGROUND: Osteoporotic fracture is a growing public health problem burden to society. Despite the importance of physician practices in preventing it, relatively little is known about the osteoporosis-related practices of US physicians. METHODS: A total of 1500 female members of a Connecticut independent practice association model health plan (aged 40-69 years) were surveyed to identify women's receipt of osteoporosis-related services (eg, prevention counseling, bone mineral density [BMD] testing, and communication about treatment options). These findings were compared with recommendations of the US Preventive Services Task Force and the National Osteoporosis Foundation. We received 1007 completed questionnaires, for a response rate of 69%. RESULTS: Only 49% of the sample reported that a health care provider ever discussed osteoporosis with them. In multivariate analyses, women with multiple risk factors were not more likely than other women to have been counseled about osteoporosis and its prevention, although those with an osteopenia/osteoporosis diagnosis were. In contrast to National Osteoporosis Foundation recommendations, only a small minority of high-risk women (12%-34%) had their BMD tested. Although most women with an osteopenia/osteoporosis diagnosis reported receiving information on estrogen replacement therapy, calcium, and weight-bearing exercise, fewer reported receiving information on pharmaceutical alternatives to estrogen (33%) and vitamin D (20%). CONCLUSIONS: The main trigger to physician counseling of women about osteoporosis and its prevention is an osteopenia/osteoporosis diagnosis. Women with multiple risk factors for osteoporosis are not being identified for preventive counseling interventions or BMD testing.     

Dietary counseling of hypercholesterolemic patients by internal medicine residents

Objective:To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. Design:Cross-sectional, self-administered questionnaire survey. Setting:Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states. Participants:All 130 internal medicine residents who were actively participating in outpatient continuity clinic. Interventions:None. Measurements and main results:Only 32% of the residents felt prepared to provide effective dietary counseling, and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree of practical knowledge about dietary facts varied. Residents reported giving dietary counseling to 58% of their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use of effective behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency. Conclusion:Internal medicine residents know much more about the rationale for treatment for hypercholesterolemia than about the practical aspects of dietary therapy, and they feel ineffective and ill-prepared to provide dietary counseling to patients. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, May 2–4, 1990. Supported by the University of North Carolina Faculty Development Fellowship Program in General Medicine and General Pediatrics (54004-05, Bureau of Health Professions, Washington, DC) and by grants from the Medical Foundation of North Carolina, the Georgia Affiliate of the American Heart Association, and the Geisinger Foundation.     

The reasons patients request “checkups”

When patients request checkups, physicians may assume it is for detection of asymptomatic disease. However, such patients may have other, covert reasons for seeking medical care which might not be addressed by a periodic health examination. The authors interviewed 38 consecutive patients who requested a new appointment at an academic, hospital-based general medical practice, and said the appointment was for a checkup and not an acute problem. Health screening was the principal reason for requesting evaluation of only 24% of patients. Fifty-two per cent had two or more reasons: psychosocial problems, health concerns, or symptoms. Psychosocial problems, with and without other problems, were the reason 45% of patients requested checkups. Physicians should be alert to the various reasons why patients request checkups, and not assume that a periodic health examination alone is an appropriate response. Received from the Division of General Medicine, University of Virginia, Charlottesville, Virginia, and the General Medicine Unit, University of Rochester Medical Center, Rochester, New York. This study was conducted while Dr. Connelly was a Henry J. Kaiser Family Foundation Fellow in the General Internal Medicine Unit at the University of Rochester.     

Exercise counseling

Objective: To assess how often physicians counsel patients about exercise and to identify which primary care internists infrequently counsel about it. Design: Cross-sectional survey of a random sample of primary care internists in Massachusetts. Questions covered physicians’ attitudes, beliefs, and practices with respect to counseling about exercise; physicians’ perceived barriers to counseling about exercise; physicians’ personal exercise frequency; and physician demographics.Participants: Of 1,000 physicians, 687 were eligible and 422 returned usable questionnaires (response rate 61%). Results: Data describing physician demographics, practice setting, measures of personal fitness, and beliefs regarding exercise were entered into a logistic regression model. The characteristic that best identified physicians who infrequently counsel about exercise was their perceived lack of success at counseling (OR 22.83, 95% CI 8.36–62.31). Other independent predictors of infrequent counseling were physicians’ lack of conviction that exercise is very important (OR4.86,95% CI 1.70–13.91), physician ages 40years (OR 308, 95% CI 1.33–7.15), and higher physician resting heart rate (OR 345, 95% CI 1.46–8.18). Conclusions: Several factors were found to be independently associated with the likelihood of a physician’ counseling about exercise. These included physician perceived success at counseling, physician belief that exercise is important, physician age, and physician resting heart rate. These results suggest possible strategies to improve physicians’ counseling efforts. Received from the Section of General Internal Medicine, Evans Memorial Department of Clinical Research, Department of Medicine, the University Hospital, Boston University Medical Center, Boston, Massachusetts.     

Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program

STUDY OBJECTIVE: To test whether physicians who receive a continuing education program ("Quit for Life") about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients who smoke. DESIGN: Randomized trial with blinded assessment of principal outcomes. SETTING: Four health maintenance organization medical centers in northern California. SUBJECTS: Eighty-one internists assigned by blinded randomization to receive training (40) or serve as controls (41). Consecutive samples of smokers visiting each physician (mean, 25.6 patients per experimental and 25.2 per control physician). INTERVENTIONS: Internists received 3 hours of training about how to help smokers quit. Physicians and their office staff also were given self-help booklets to distribute free to smokers and were urged to use a system of stickers on charts to remind physicians to counsel smokers about quitting. MEASUREMENTS AND MAIN RESULTS: On the basis of telephone interviews with patients after visiting the physician, we determined that internists who attended the Quit for Life program discussed smoking with more patients who smoked, spent more time counseling them about smoking, helped more patients set dates to quit smoking, gave out more self-help booklets, and made more follow-up appointments to discuss smoking than did internists in the control group. One year later, the rate of biochemically confirmed, long-term (greater than or equal to 9 months) abstinence from smoking was 1% higher among all patients of trained internists than among patients of controls (95% CI, -0.1% to +2.3%), and 2.2% (+0.2% to +4.3%) higher among the patients who most wanted to quit smoking. CONCLUSIONS: This continuing education program substantially changed the way physicians counseled smokers. As a result, a few more patients who wanted to quit smoking achieved long-term abstinence.     

Physician Training:

The authors surveyed former medical resident physicians who participated in long-term home health care program services during training. Forty-four physicians who had served in a home visit program were surveyed after an average of ten years since completion of medical training (range: 1 to 18 years). The majority of the 43 respondents (56%) make house calls in their current medical practices and most of the 36 now involved in medical house staff training (83%) incorporate their home care experience into their teaching today. Working at a home health care program can have educational value for medical residents, influence later practice, and result in personal and professional rewards.     

Financial barriers to medical care: a prospective study in a university-affiliated community clinic

Access to medical care in the United States is deteriorating, particularly for the poor. The authors evaluated patients who could not afford medical care recommended by physicians in a university-affiliated clinic that serves a predominantly indigent population. The authors determined the patients' demographic characteristics, their medical problems, and the types of care for which financial barriers existed. In addition, the authors compared the patients' demographic characteristics and medical illnesses with those of a control group of patients from the clinic who did not experience financial barriers to medical care. Of the 1,950 patients evaluated, 94 (4.8%) were unable to afford care recommended by their physicians. Sixty-seven percent were US citizens, 73% were unemployed, 63% had monthly family incomes of less than $500, and only 33% had health insurance. The patients had a variety of medical problems, ranging from hearing loss, for which they could not obtain hearing aids, to breast masses, for which they could not obtain mammographies or biopsies. When compared to patients who did not experience financial barriers to recommended care, the study patients tended to be poorer, more likely to be undocumented, more likely to be uninsured, and less likely to have acute, self-limited illnesses. Our findings support the argument that the nation's current piecemeal approach to providing indigent health care may lead to serious financial barriers to access in some localities.     

Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina

CONTEXT: National guidelines recommend that practitioners assess and reinforce patient adherence when prescribing antiretroviral (ART) medications, but the extent to which physicians do this routinely is unknown. OBJECTIVE: To assess the adherence counseling practices of physicians caring for patients with HIV/AIDS in North Carolina and to determine characteristics associated with providing routine adherence counseling. DESIGN: A statewide self-administered survey. SETTING AND PARTICIPANTS: All physicians in North Carolina who prescribed a protease inhibitor (PI) during 1999. Among the 589 surveys sent, 369 were returned for a response rate of 63%. The 190 respondents who reported prescribing a PI in the last year comprised the study sample. MAIN OUTCOME MEASURES: Physicians reported how often they carried out each of 16 adherence counseling behaviors as well as demographics, practice characteristics, and attitudes. RESULTS: On average, physicians reported spending 13 minutes counseling patients when starting a new 3-drug ART regimen. The vast majority performed basic but not more extensive adherence counseling; half reported carrying out 7 or fewer of 16 adherence counseling behaviors "most" or "all of the time." Physicians who reported conducting more adherence counseling were more likely to be infectious disease specialists, care for more HIV-positive patients, have more time allocated for an HIV visit, and to perceive that they had enough time, reimbursement, skill, and office space to counsel. After also controlling for the amount of reimbursement and availability of space for counseling, physicians who were significantly more likely to perform a greater number of adherence counseling practices were those who 1). cared for a greater number of HIV/AIDS patients; 2). had more time allocated for an HIV physical; 3). felt more adequately skilled; and 4). had more positive attitudes toward ART. CONCLUSIONS: This first investigation of adherence counseling practices in HIV/AIDS suggests that physicians caring for patients with HIV/AIDS need more training and time allocated to provide antiretroviral adherence counseling services.     

The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient.

BACKGROUND--Simulated patients are used with increased frequency for medical students and residents, but have not been used very often with practicing physicians. We hypothesized that educational materials could improve primary care physicians sexual practices history taking and counseling as assessed by a simulated patient in the physician's office. METHODS--Simulated patient (SP) visits were made to 232 (75% of eligible) primary care physicians. The patient simulated was a sexually active young woman with vaginitis and sexually transmitted disease/human immunodeficiency virus risk behaviors. In advance of the visit, physicians were provided educational materials (monograph, pamphlet, and audiotape) developed for the study, including a risk assessment questionnaire that could be used with patients. RESULTS--Most physicians randomly allocated to the intervention participated. Twenty-one percent of physicians refused to schedule an SP visit. Physicians who received an SP rated the experience highly. Physicians who prepared for the visit with the educational materials performed significantly better than those who did not. About two thirds of physicians reviewed the materials, many for the second time, after the SP visit. Physicians who used the study risk assessment questionnaire performed better. Many physicians (24.9% to 39.8%) did not meet each of the four goals for the visit, as assessed subjectively by the SP. Physician performance was better for measures of general patient interaction than for measures of sexual practices history taking and counseling techniques. CONCLUSION--The SP visit was acceptable to most physicians practicing in a community and was evaluated by them as an appealing and an effective educational experience. The SP, however, has limited feasibility because of cost. The SP led to review of materials by nearly all physicians either before or after the visit. Physicians who prepared before the visit performed better on every dimension, eliciting more information, displaying better patient interaction skills, and meeting more of the educational goals. Even with educational preparation, however, many physicians were not perceived as being effective counselors.     

Physicians’ psychosocial beliefs correlate with their patient communication skills

OBJECTIVE: To assess the relationship between physicians’ beliefs about the psychosocial aspects of patient care and their routine communication with patients. PARTICIPANTS AND SETTING: Fifty community primary care physicians participating in a continuing medical education program and 473 of their patients in Portland, Oregon. METHODS: Routine office visits were audiotaped and analyzed for communication behaviors and emotional tone using the Roter Interactional Analysis System (RIAS). Physician beliefs about psychosocial aspects of care were measured using a self-report questionnaire with a five-point Likert scale. Attitudes were correlated with communication behaviors using the Pearson correlation coefficient. RESULTS: Physicians’ attitudes toward psychosocial aspects of care were associated with both physician and patient dialogue in visits. The physicians who had positive attitudes used more statements of emotion (i.e., empathy, reassurance) (p<0.05) and fewer closed-ended questions (p<0.01) than did their colleagues who had less positive attitudes. The patients of the physicians who had positive attitudes more actively participated in care (i.e., expressing opinions, asking questions), and these physicians provided relatively more psychosocial and less biomedical information (p<0.05). CONCLUSION: Physician beliefs about psychosocial aspects of patient care are associated with their communication with patients in routine office visits. Patients of physicians with more positive attitudes have more psychosocial discussions in visits than do patients of physicians with less positive attitudes. They also appear more involved as partners in their care. These findings have implications for medical educators, teachers, and practicing physicians. Supported in part by the Zlinkoff Foundation, Oregon Foundation for Medical Excellence, and the Miles Institute for Health Care Communication. The views expressed are those of the authors and not of the sponsoring institutions.     

Physicians' transmission prevention assessment and counseling practices with their HIV positive patients.

Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexual and needle-sharing behaviors, and by providing risk reduction counseling. From 1995 to 1997, we gathered data on the HIV transmission prevention assessment and counseling practices of 44 San Francisco Bay area physicians in face-to-face, semistructured interviews. A refined coding scheme and constant comparative analytic method were used. Although physicians varied in their responses to coded items, two styles of engagement, at the extremes, emerged from the data: "consultant" and "collaborator." Consultants conducted transmission prevention assessment and counseling during initial visits or upon medical cues (e.g., presence of sexually transmitted diseases) and viewed themselves primarily as information sources, whereas collaborators regularly conducted transmission prevention counseling and viewed themselves as actively helping patients reduce transmission risk. Physicians who fell between the two styles generally did not conduct regular counseling themselves, but many used referrals to health educators. The findings suggest that consultant and collaborator styles may influence patients differently, and offer insight into the role that physicians can play in transmission prevention with HIV positive patients.     

Physicians' ethical beliefs about cost-control arrangements

BACKGROUND: Although much has been written about the ethics of new methods of health care financing, little is known about the extent to which physicians experience these cost-control arrangements as ethical problems. METHOD: A cross-sectional telephone survey of 1,549 physicians, 8 to 17 years after residency, randomly selected from 75 US metropolitan service areas (response rate, 74.0%). RESULTS: Only 17.0% believed that financial incentives to limit services are ethically acceptable. Although 52.9% thought that physicians should try to abide by guidelines discouraging the use of interventions with possible but unproven benefit, only 14.5% thought such guidelines should be enforced by payers. Only 5.7% thought that it was morally acceptable for payers to discourage physicians from telling patients about their personal financial incentives, and only 9.1% found compliance with such restrictions morally acceptable. Changes in the health care system in the past 5 years were believed to have had a negative impact on their own patients' trust in them by 50.6%, and 80.8% believed that changes in the health care system in the past decade have diminished physicians' commitment to an ethic of undivided loyalty to patients. In multiple regression analysis, physicians who reported that the overall personal financial incentives in their practices encouraged them to reduce services were significantly more likely to have ethical objections to such incentives, to believe their own patients' trust in them had diminished, and to believe that the ethic of undivided loyalty to patients had diminished. CONCLUSIONS: Many of the methods now commonly used to influence medical decision making are considered ethically objectionable by most midcareer physicians. Whether their ethical disquiet about these arrangements is justified cannot be answered from these data.     

Decision making and counseling around mammography screening for women aged 80 or older

BACKGROUND: Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography. OBJECTIVE: To explore decision-making and physician counseling of oldest-old women around mammography screening. DESIGN: Qualitative research using in-depth semi-structured interviews. PARTICIPANTS: Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center. APPROACH: We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old. RESULTS: Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient’s health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician’s recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions. CONCLUSIONS: Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography. The authors have no conflicts of interest to declare. This paper was presented in part at the 2005 National Meeting of the Society of General Internal Medicine, May 13, 2005, New Orleans, LA. Grant support was obtained from the National Research Service Award from the National Cancer Institute (1 F32 CA110424-01).     

Teaching residents to care for vulnerable populations in the outpatient setting

Residency programs have an obligation to teach house officers to care for vulnerable populations. Such populations consist of those whom physicians tend to consider undesirable as patients, and thus who often lack adequate care, because they cannot pay for medical services, because they have medical problems that are difficult to manage, or because they have characteristics giving them low social status. The authors identify and discuss key aspects of learning to care for such populations. These aspects include obtaining appropriate experience caring for disadvantaged patients, developing sensitivity to pertinent sociocultural issues, exploring biases, acquiring relevant special skills, studying epidemiology of diseases in specific vulnerable groups, and learning about health care financing and health policy. Measures to help residents obtain more satisfaction from caring for vulnerable patients are among additional topics discussed. Received from the Departments of Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota, and the University of Washington, Seattle, Washington.     

Study follows PEP for sexual exposures

A study of 151 patients, who began postexposure prophylaxis treatment (PEP) after having been exposed to HIV, attempted to examine the efficacy of PEP in preventing HIV seroconversion. Although PEP has been used in this context for some time, physicians who are prescribing it are not collecting the necessary data for understanding the implications of PEP. In this study patients were tested for HIV, counseled about risk, informed about the treatment, and treated with two drugs for 4 weeks. After 28 days of treatment, no patient tested positive for HIV. It also appears that the availability of PEP has not discouraged safe-sex practices.     

Nutrition assessment and counseling practices

This survey examined the nutrition-related practices and office services of primary care physicians, and their preferred nutrition topics and educational methods. Respondents were 960 physicians from across the United States who were members of the Society of General Internal Medicine. A four-page mailed questionnaire with 21 items queried background information, nutrition-related clinical practices and office support systems, perceived self-efficacy for nutrition assessment and counseling, and nutrition-related educational preferences. Two-thirds of the respondents said they personally provided nutrition counseling. They reported moderate selfefficacy for nutrition counseling and lower confidence for using specific relapse prevention strategies. Greatest interest in further education related to chronic disease prevention and nutrition for the elderly, provided in convenient formats for practicing physicians.