Provider and patient intervention to improve weight loss: a pilot study in a public hospital clinic

OBJECTIVE: To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy. METHODS: The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy. RESULTS: 64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p<0.01). CONCLUSIONS: This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital. PRACTICE IMPLICATIONS: Hospital-based weight loss interventions need to target both physicians and patients.     

University hospital physicians' attitudes and practices for smoking cessation counseling in Malatya, Turkey

The aim of the study is to determine attitudes and self-reported practices performance for smoking cessation counseling of the physicians working at a university hospital in Malatya, Turkey. All physicians who were providing health care to adult patients in 19 outpatient clinics at the hospital were administered a self-reported questionnaire. Of the physicians, 26.5% reported that they were always asking about their patients' smoking history and 22.6% were always advising their smoker patients to quit. Men non-smoker physicians more often practiced counseling than men smoker physicians. Negative attitudes of physicians about smoking cessation counseling negatively effected their practices. Negative attitudes were significantly higher among men smoker physicians than non-smokers but attitudes did not differ among female smoker and non-smoker physicians. The findings showed that smoking cessation counseling was rarely practiced by physicians and physicians' practices differed by their smoking behavior, departments and attitudes towards smoking cessation.     

Challenges in making therapeutic lifestyle changes among hypercholesterolemic African-American patients and their physicians

OBJECTIVE: We explored challenges faced by hypercholesterolemic African-American primary care patients and their physicians regarding therapeutic lifestyle changes (TLC) and provide patient-influenced recommendations to physicians. METHODS: In this qualitative study, 23 urban family medicine patients and their physicians (N=12) participated in separate focus groups, where they were asked semistructured, open-ended questions about knowledge and barriers to lifestyle treatment of high cholesterol. RESULTS: During the focus groups, barriers mentioned by physicians were: lack of time for TLC counseling, inadequate knowledge about counseling patients, and patient readiness and responsibility to change. Patient-revealed barriers included difficulty adhering to a diet/exercise regimen and a lack of knowledge about high cholesterol. Patients who were successful with adopting a healthy lifestyle identified personal experiences or those of family and friends as motivating. CONCLUSION: Physicians desire training and resources to better help patients adopt diet and exercise regimens specific to their general and health literacy and their access to healthy foods, along with their readiness to change. Patients desire that physicians tailor their TLC advice to be specific to their context and they want help from physicians in setting realistic goals. Such a patient-centered counseling approach may improve adherence to lifestyle guidelines and, thus, clinical outcomes.     

Teaching resident physicians to provide exercise counseling: a needs assessment.

PURPOSE: To determine the behaviors, knowledge, and attitudes of resident physicians regarding exercise counseling. METHOD: In 1997, a self-administered questionnaire was sent to 313 internal medicine resident physicians at six U.S. training programs. Pearson correlation coefficients examined associations between the resident physicians' practices, attitudes, and personal habits. Stepwise multiple linear regression identified predictors of exercise counseling by the resident physicians. RESULTS: A total of 251 resident physicians responded. Only 15.5% reported counseling more than 80% of the clinic patients about exercise. Over 93% understood the benefits of exercise, and almost all (96%) felt that it was a physician's responsibility to counsel patients about exercise. Only 29% felt successful at getting their patients to start exercising, and only 28% felt confident in their skills to prescribe exercise for patients. Ninety-one percent felt that training in exercise counseling would be worthwhile. The significant predictors of physician exercise counseling were perception of exercise counseling as a priority (p <.001), confidence in exercise-counseling skills (p <.001), and postgraduate year of training (p <.05) (R(2) =.18). The significant predictors of physicians' confidence in exercise-counseling skills included physician's gender (i.e., men) (p <.001), perception that exercise is important for a healthy 35-year-old (p <.01), feeling successful at exercise counseling (p <.001), perceiving less interference with counseling by barriers (p <.001), and prior training in exercise counseling (p <.05) (R(2) =.44). CONCLUSIONS: Resident physicians' perceptions of exercise counseling as a priority, confidence in counseling skills, and postgraduate year of training are important predictors of their providing exercise counseling. These factors should be addressed in future educational programs.     

Cardiovascular disease prevention counseling in residency: resident and attending physician attitudes and practices

PURPOSE: This study seeks to establish resident and attending physician attitudes and practice patterns with regard to cardiovascular disease (CVD) preventive counseling within a teaching hospital setting. METHODS: A 75-question survey was administered to residents and their attending physicians within a single academic medical residency program at a large, urban public hospital. RESULTS: Physician CVD risk factor counseling rates were lowest for exercise and diet (16% and 20%, respectively) and somewhat higher, although not ideal, for medication compliance and smoking (52% and 88%, respectively). Physicians did not often recommend behavior change strategies, and few physicians felt very effective in their counseling of smoking, exercise, diet, and weight reduction (25%, 24%, 27%, and 23%, respectively). Physicians acknowledged the existence of many patient, physician, and system barriers that interfered with providing more preventive counseling. There were few differences in counseling practices and attitudes between residents and attending physicians, and no significant gender differences. CONCLUSIONS: Our study found low counseling rates for CVD prevention, particularly in the areas of diet, exercise, and weight loss. Future interventions should highlight the importance of diet, exercise, and weight control in preventing CVD, and efforts should be directed toward training both resident and attending physicians, as counseling rates are low in both groups.     

Family physicians' perspectives on genetics and the human genome project

The objective of the study was to determine family physicians' attitudes and beliefs about human genetics research and the human genome project (HGP). The design of the study involved qualitative, semi-structured interviews. Primary variables of interest included family physicians' training; their attitudes about the HGP; requests for genetics counseling; and their approaches to counseling requests. The setting was a medium-sized, Midwest, US city. The participants were 16 university-affiliated, community-based family physicians. For contents analysis, we used a coding scheme to identify illustrative themes and subthemes. While most of the family physicians reported familiarity with genetics and the HGP, and experiences with counseling requests, nearly all (15) reported little training in genetics counseling. Four major themes were identified: 1) impact on clinical care; 2) educational issues relevant to genetics and the HGP; 3) ethical concerns; and 4) family medicine responsibilities. These family physicians do not perceive genetics as having a substantial impact on their practice, but do expect major clinical changes in the future. Many feel there have been inadequate educational opportunities to learn about genetics, and some indicate reluctance to invest in self-education until genetic problems become more clinically relevant. These practitioners envision a role for family medicine the specialty to shape priorities in genetics research.     

Physicians’ views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

ObjectiveTo systematically search and synthesise qualitative studies of physicians’ views and experiences of discussing weight management within a routine consultation.MethodsA systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data.ResultsFour analytical themes were found: (1) physicians’ pessimism about patients’ weight loss success (2) physicians’ feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.ConclusionDespite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable.Practice implicationsImproving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships.     

Patients' and physicians' perceptions and experience of hypercholesterolaemia: a qualitative study.

BACKGROUND: A better understanding of patients' and physicians' perceptions and experience of hypercholesterolaemia will help to improve cardiovascular disease prevention and aid the development of appropriate educational strategies. AIM: To identify perceptions, experience, educational needs, and barriers to learning in hypercholesterolaemic patients at high risk of cardiovascular disease. DESIGN OF STUDY: A qualitative study involving interviews with 27 hypercholesterolaemic outpatients and 21 physicians. SETTING: 21 centres in Paris, Bordeaux and Lille. METHODS: Semi-structured interviews were conducted by a sociologist with the aid of two interview guides focusing on hypercholesterolaemia. Interviews were recorded and subsequently transcribed, and qualitative analysis was performed to identify emerging themes. RESULTS: Six main themes emerged: understanding hypercholesterolaemia--a 'virtual' disease; understanding cardiovascular risk--a vague concept; lifestyle measures; long-term effects of medication; medical language difficulties; and patients' expectations and needs. Patients and physicians disagreed over the terms used to describe hypercholesterolaemia and cardiovascular risk, and the complexities of medical language. In contrast, patients and physicians agreed on the difficulties associated with implementing lifestyle changes and adhering to long-term treatment. CONCLUSIONS: The differences in perception and experience between physicians and patients indicate that physician-patient communication is sub-optimal and highlights the need to improve educational material for cardiovascular disease prevention. This analysis helps to identify appropriate educational objectives and methods for patients at risk of cardiovascular disease, and develop a structured educational programme.     

Knowledge, attitudes, and behaviors of Alabama's primary care physicians regarding cancer genetics.

PURPOSE: To determine Alabama's primary care physicians' knowledge, attitudes, and behaviors regarding cancer genetics. METHOD: A questionnaire was mailed to a random sample of 1,148 physicians: family and general practitioners, internists, and obstetrician-gynecologists. RESULTS: Of the surveyed physicians, 22.1% responded. Of the respondents, 63% to 85% obtained family histories of cancer from 76% to 100% of their patients. Obstetrician-gynecologists referred more patients for cancer genetic testing (p = .008) and were more confident in their abilities to tailor preventive recommendations based on the results (p = .05) than were the other physicians. Primary care physicians were more likely than were obstetrician-gynecologists to identify lack of time during the patient visit as hindering efforts to do genetic counseling (p = .01). Physicians in practice for ten years or less were more confident in explaining genetic test results than were those in practice for more than 20 years (p = .01). CONCLUSION: These data validate gaps in primary care practices in obtaining family history of cancer, as well as lack of confidence in explaining genetic test results and in tailoring recommendations based on the tests.     

Intraurban influences on physician colorectal cancer screening practices

BACKGROUND: Community social and economic resources influence colorectal (CRC) screening decisions by physicians and patients. The aim of this study is to systematically assess the differences in screening recommendations of primary care physicians within two urban communities that are distinct in socioeconomic characteristics. METHODS: Two-hundred-sixty-four primary care community (i.e., not hospital-based) physicians were stratified by community. Using self-report questionnaires, we examined primary care physicians' CRC screening practices, knowledge of risk factors and perceived physician and patient barriers to screening, Physicians practicing in upper-socioeconomic status (SES) communities were compared with those of participants practicing in lower SES communities. RESULTS: Physicians practicing in low-SES urban communities were significantly more likely to screen with fecal occult blood test than were physicians in upper-SES areas. Alternatively, upper-SES physicians were significantly more likely to recommend screening colonoscopy than were lower-SES physicians. The number of physicians (N=11) who screened for CRC using the double-contrast barium enema were few. CONCLUSIONS: Community-level SES influences physician cancer screening practices. Further understanding of these relationships may guide the development of interventions targeted to specific neighborhoods within urban areas.     

An intervention to increase physicians' use of adherence-enhancing strategies in managing hypercholesterolemic patients.

PURPOSE: Patients' lack of adherence to medical regimens frustrates many practicing physicians. This study was conducted to determine the effectiveness of a combined continuing medical education intervention in increasing physicians' adherence-enhancing skills and improving hypercholesterolemic patients' health. METHOD: A prospective, randomized, controlled trial was designed using a nested cohort of 28 community physicians throughout Alabama and 222 of their hypercholesterolemic outpatients. The intervention, carried out in 1998, consisted of three interactive case audio-conferences plus chart reminders. Physicians' learning was measured by unannounced standardized patients, and patients' health by serum cholesterol levels, weight, knowledge of hypercholesterolemia, self-reported dietary habits, and health status. RESULTS: No significant difference was found in the numbers of physician adherence-enhancing strategies, although the number did increase within the treatment group. There were significant differences in the intervention group's patients' knowledge of cholesterol management (p = .008) and significant reductions in their self-reported consumption of dietary fats (p = .002). A significant difference was found in the serum cholesterol level of men in the intervention group nine months after the intervention (p = .02). CONCLUSION: Combining a series of interactive case audio-conferences with chart reminders shows promise in increasing physicians' adherence-enhancing strategies. In chronic disease management, the problem of enhancing adherence remains complex.     

Newborn blood spot screening and genetic services: a survey of Minnesota primary care physicians.

PURPOSE: To (1) obtain guidance on the preferred content and format of quick reference newborn blood spot screening information from the Minnesota Department of Health; (2) determine primary care physicians' perceptions of the benefits of genetic services; and (3) determine primary care physicians' satisfaction with genetic counseling services. METHODS: A written survey was mailed to family physicians and pediatricians in Minnesota (n = 300). RESULTS: Eighty physicians responded (28% response rate). Whereas 70% of respondents felt previous information received from the newborn screening program was adequate, 83% were interested in quick reference information. The majority of physicians preferred this information as a laminated sheet (63%). Physician procedure for an abnormal screen, newborn screening program protocol for an abnormal screen, and disease treatment and follow-up information were recommended for inclusion on quick reference. Over half of physicians agreed with the following benefits of genetic services: provide testing options (88%); evaluate family members (88%); reduce parental anxiety (87%); provide resources (83%); provide diagnostic information (76%); determine medical needs (67%); and determine emotional needs (51%). Ninety-nine percent of physicians were satisfied with genetic counseling services. CONCLUSIONS: Physicians indicated that reference material for primary care physicians should include a quick reference card with specific categories of information. Newborn screening programs should attempt to increase physician awareness of genetic services, including the subsequent medical and psychosocial benefits for their patients.     

An intervention to increase patients' trust in their physicians. Stanford Trust Study Physician Group.

PURPOSE: To investigate the effect of a one-day workshop in which physicians were taught trust-building behaviors on their patients' levels of trust and on outcomes of care. METHOD: In 1994, the study recruited 20 community-based family physicians and enrolled 412 consecutive adult patients from those physicians' practices. Ten of the physicians (the intervention group) were randomly assigned to receive a one-day training course in building and maintaining patients' trust. Outcomes were patients' trust in their physicians, patients' and physicians' satisfaction with the office visit, continuity in the patient-physician relationship, patients' adherence to their treatment plans, and the numbers of diagnostic tests and referrals. RESULTS: Physicians and patients in the intervention and control groups were similar in demographic and other data. There was no significant difference in any outcome. Although their overall ratings were not statistically significantly different, the patients of physicians in the intervention group reported more positive physician behaviors than did the patients of physicians in the control group. CONCLUSIONS: The trust-building workshop had no measurable effect on patients' trust or on outcomes hypothesized to be related to trust.     

Physicians' attitudes and practices regarding complementary and alternative medicine

This article offers a review of the research literature on complementary and alternative medicine (CAM) and presents the findings from an exploratory survey of the beliefs, attitudes, intentions, and behaviors of conventionally trained physicians toward CAM. Earlier studies of CAM focused primarily on patients' attitudes and behaviors rather than those of physicians. Physicians play a crucial role in moderating patients' beliefs about and use of CAM treatments. Accordingly, this study focused on physicians' knowledge of medical efficacy and their impressions of CAM treatments. The findings from a survey mailed to a random sample of California physicians revealed that physicians' use or recommendations of CAM in their practices are limited by concerns about medical professional norms, yet are positively associated with their use of computer technology for self-education and communication with peers. Sixty-one percent of physicians do not feel sufficiently knowledgeable about CAM safety or efficacy, and 81% would like to receive more education on CAM modalities. The findings raise important issues for medical education and patient care.     

Patients' perspectives on sexual history taking in Korea

OBJECTIVE: This study was conducted to assess patients' beliefs and attitudes towards physicians taking their sexual history during routine medical visits in Korea, where Confucianism is the core societal value. METHODS: A survey questionnaire was administered to determine the patients' perspectives to sexual history taking, their actual experience of being asked about sexual issues by physicians, their belief in the importance of sexual history taking, their attitudes and cooperativeness towards each component of sexual history, and the effect of the physicians' age and gender on their comfort level during interview. RESULTS: 74.6% of respondents had never been asked about their sexual issues by physicians. Most patients showed a positive attitude and cooperativeness in general, although more than 25% had a negative attitude and were uncooperative with regards to certain components of sexual issues. Their comfort level to sexual history taking was not influenced by the physicians' age. However, female patients felt more comfortable discussing sexual issues with female physicians. CONCLUSION: Sexual history taking was often overlooked during routine medical visits in Korea, although patients showed a relatively positive and cooperative attitude. Women showed a greater preference for female physicians. PRACTICE IMPLICATIONS: Sexual history taking should be more facilitated in clinical practice and requires a deliberate approach and skill.     

Nondrug treatment of hypertension: a survey of black physicians in New York State

A survey of 64 black physicians in New York State was completed in April 1988 concerning physicians' approach to the nondrug treatment of hypertension. The physicians clearly support the use of nonpharmacologic treatment of mild hypertension, particularly for patients with diastolic blood pressure of 90 to 94 mmHg. However, very little time appears to be spent counseling patients with respect to diet and weight reduction. There was considerable variability in the degree of confidence felt by physicians in recommending nondrug approaches to hypertension control. An overwhelming majority of physicians felt that their training did not adequately prepare them for counseling patients about diet specifically or for practicing preventive medicine generally. The findings of this survey suggest a need for significantly increased attention to training physicians during both medical school and residency in prevention, patient counseling, and health promotion.     

Patients' and physicians' understanding of health and biomedical concepts: relationship to the design of EMR systems

OBJECTIVE: The aim of this paper is to examine knowledge organization and reasoning strategies involved in physician-patient communication and to consider how these are affected by the use of computer tools, in particular, electronic medical record (EMR) systems. DESIGN: In the first part of the paper, we summarize results from a study in which patients were interviewed before their interactions with physicians and where physician-patient interactions were recorded and analyzed to evaluate patients' and physicians' understanding of the patient problem. We give a detailed presentation of one of such interaction, with characterizations of physician and patient models. In a second set of studies, the contents of both paper and EMRs were compared and in addition, physician-patient interactions (involving the use of EMR technology) were video recorded and analyzed to assess physicians' information gathering and knowledge organization for medical decision-making. RESULTS: Physicians explained the patient problems in terms of causal pathophysiological knowledge underlying the disease (disease model), whereas patients explained them in terms of narrative structures of illness (illness model). The data-driven nature of the traditional physician-patient interaction allows physicians to capture the temporal flow of events and to document key aspects of the patients' narratives. Use of electronic medical records was found to influence the way patient data were gathered, resulting in information loss and disruption of temporal sequence of events in assessing patient problem. CONCLUSIONS: The physician-patient interview allows physicians to capture crucial aspects of the patient's illness model, which are necessary for understanding the problem from the patients' perspective. Use of computer-based patient record technology may lead to a loss of this relevant information. As a consequence, designers of such systems should take into account information relevant to the patient comprehension of medical problems, which will influence their compliance.     

Influence of ethnicity and language concordance on physician-patient agreement about recommended changes in patient health behavior

The purpose of this study is to examine the association of ethnicity and language concordance with physician-patient agreement about physicians' recommendations for patient health behavior in the following areas: diet, exercise, medication, smoking, stress, and weight. Twenty-seven resident physicians at the University of New Mexico's internal medicine and family practice clinics and 427 of their patients participated. Random effects models were used to estimate the influence of ethnicity and language concordance on whether patients and physicians agreed about specific recommended changes in patient behavior. Ethnicity concordance was not significantly associated with physician-patient agreement. Language concordance positively influenced the likelihood of agreement about exercise but negatively influenced agreement about medications. The lowest percentage of agreement occurred in the area of medication regimens (60%). The results from this study indicate that language is an important barrier to physician-patient agreement, while ethnicity concordance has no effect. However, the influence of whether the physician and patient speak the same language on agreement is unclear and warrants further research.     

Communication to Pediatric Cancer Patients and their Families: A Cultural Perspective

Background:

Communication is a key component of palliative care. The area of pediatric palliative care is emotionally distressing for families and healthcare providers. Inadequate communication can increase the stress and lead to mistrust or miscommunication.

Materials and Methods:

Reviewing the literature on communication between physicians and patients, we identified several barriers to communication such as paternalism in medicine, inadequate training in communication skills, knowledge of the grieving process, special issues related to care of children and cultural barriers. In order to fill the void in area of cultural communication, a study questionnaire was administered to consecutive families of children receiving chemotherapy at a large, north Indian referral hospital to elicit parental views on communication.

Results:

Most parents had a protective attitude and favored collusion, however, appreciated truthfulness in prognostication and counseling by physicians; though parents expressed dissatisfaction on timing and lack of prior information by counseling team.

Conclusion:

Training programs in communication skills should teach doctors how to elicit patients’ preferences for information. Systematic training programs with feedback can decrease physicians stress and burnout. More research for understanding a culturally appropriate communication framework is needed.