WASHINGTON — “The art and science of behavior change asks physicians to accept delayed gratification,” David Katz, M.D., said at the annual meeting of the American College of Preventive Medicine.
Promoting behavior change in a clinical setting is a multidisciplinary task. Time constraints are a major concern, and overworked physicians spend most of their time on problems with immediate solutions, such as treating the infection or managing an acute injury, said Dr. Katz, a nutrition and preventive medicine specialist at Yale University, New Haven.
That said, physicians can experiment with office-based strategies including exam room posters, preappointment questionnaires, and the use of a dedicated staff member to provide in-depth counseling on prevention, according to several physicians and behavioral experts who spoke at a workshop at the meeting.
Although primary care physicians can initiate conversations about preventive medicine, it isn't reasonable for them to be completely up to date on what communities offer as support programs for increasing physical activity, losing weight, or quitting smoking, said Karen Eden, Ph.D., of Oregon Health and Science University, Portland.
But a nurse or other staff member can be trained to keep track of local resources, and to provide information and encouragement to a patient who expresses interest in finding out about a local Weight Watchers or a walking club.
Alternatively, a patient may be referred to someone in the community or in the medical facility, who serves as a contact person for all the patients in a medical practice. For example, Dr. Eden mentioned a health system in Portland, Ore., that uses a dedicated health educator.
Larry Dickey, M.D., of the California Department of Health Services, shared the Staying Healthy Assessment, a 20-item questionnaire developed by his department that is now standard for Medicaid patients in California. (See box.) The questionnaire is either mailed to the patient prior to the visit or given in the waiting room.
Pilot studies with the questionnaires show that they were well received by patients. Use of the questionnaires triggered doctors to provide brief preventive medicine counseling, but formal evaluations are pending. To view the questionnaires for all age groups in PDF form, visit www.dhs.ca.gov/ps/ocpm/html/staying%20healthy.htm
Dr. Scott Gee, a pediatrician who serves as director of prevention and health information at Northern California Kaiser Permanente, reported success with exam room posters and computer-generated office visit reminders.
His exam room posters, designed by Kaiser Permanente, include such topics as “How ready are you to eat more vegetables?” on a scale of 1–10; how much TV children watch and where; and what types of activities equal moderate exercise.
“I was initially skeptical of the exam room posters,” he said. “But the patients actually look at them, and they are arguing about it when you come into the exam room, especially about getting the TV out of the bedroom.”
In addition, Dr. Gee's Kaiser facility, the Pleasanton Pediatrics Group in Livermore, Calif., uses computer-generated office visit reminders that include “preventive health prompts” for tests that are due, such as blood pressure checks and childhood immunizations.
When a Kaiser patient comes in, he or she receives a printout that shows what services, if any, they need at that time, Dr. Gee explained. The printout is risk adjusted, with the immediate items at the top of the list, and upcoming tests or immunizations listed further down. “This has had a huge impact on compliance,” he said. Mothers have reaped the greatest benefits, since they have to manage their children's care as well as their own, he noted.
In the end, preventive medicine must still battle for time in an office visit, despite the best laid plans of primary care physicians, Dr. Gee acknowledged. “We want physicians to focus on behavior, but we don't want them to forget about the other things.”
Play 20 Questions About Health
The following questions are excerpted from a questionnaire given to all Medicaid patients in California, with answer choices of “yes,” “no,” or “skip.”
Do you receive health care from anyone besides a medical doctor, such as an acupuncturist, herbalist, curandero, or other healer?
Do you see the dentist at least once a year?
Do you drink milk or eat yogurt or cheese at least three times each day?
Do you eat at least five servings of fruits or vegetables each day?
Do you try to limit the amount of fried or fast foods that you eat?
Do you exercise or do moderate physical activity such as walking or gardening 5 days a week?