Negative reactions by patients to recommendations for behavioral change may be one reason that such changes are not recommended more often by clinicians. Patients may also resist getting recommendations for behavioral change by not raising the subject with the clinician or by avoiding visits where such recommendations would be likely to occur (such as physical examinations). Physicians may avoid recommending changes to reduce potential conflict with the patient.
Declines in functioning were greatest when the physician recommended that the patient stop smoking, and potential declines were seen for patients with diet or exercise recommendations. No detectable functional decline occurred for those patients who had been given recommendations to make medication-related or dietary changes. This suggests that behavioral changes are perceived as being more difficult for patients than simple medication changes and that being faced with a recommendation to make a behavioral change is associated with lower levels of functioning. The patients who reported being told to quit smoking had marked increases in depression and anxiety and overall disability at 3 months after the visit. These results are consistent with the literature that smoking and depression are interlinked.16 Our study also supports the use of antidepressants such as buproprion21 for helping patients to quit smoking, but our study was done before the drug was approved and commonly used for this indication.
Limitations
The results from our study are subject to limitations and should be interpreted cautiously. First, we did not include sufficient numbers to allow testing of the association between success in the specific behavioral changes and functional decline. It is possible that the decline in functional status is limited to patients who were not successful in changing behavior. It is also possible that the declines are focused on a select group of behavioral changes, such as smoking. Further study is needed to test such associations. Second, data were collected at only 1 family practice center. The patient population is diverse but not necessarily representative of the community at large. Our study was also completed in North Carolina, a state known for tobacco consumption, which may have affected the results pertaining to smoking-related behavioral changes and functional decline. Further studies should emphasize whether functional declines reverse with a longer time frame and whether there is a relationship with successful behavioral change. Research should also consider whether physician behaviors can have a positive impact on a patient’s functional status.
Acknowledgments
Our research was supported by a grant from the American Academy of Family Physicians Foundation (#G9609). We would like to thank Dottie Greek for excellence in project management.