Crux of the Lifestyle Dilemma Do Physicians Believe in Primary Prevention

Key Points

• Good, even great, evidence is not enough to lead to substantial lifestyle changes among patients.

• Traditional medical training has not prepared the majority of practice physicians in the science (evidence) of primary prevention or in the tools necessary to make it happen, such as motivational interviewing.

• Although many physicians say they believe in primary prevention, their behavior often belies this. Belief in the power and effectiveness of primary intervention strategies among primary care physicians cannot be assumed and must be explored individually with each physician.

• Physicians need to go through a series of steps, much as any patient who desires to change a behavior, to become proficient at primary prevention.

• The predicted results will reward the efforts for physicians who can take a day-by-day, long-term perspective on health.

Why not primary prevention now? Whether this means systematically performing CAD risk assessments on all adult patients, or whether the physician wants the broadest possible impact on multiple major chronic diseases through primary prevention, the rate-limiting step is the same: motivation. As with patients, too few physicians actively engage in either strategy. What would be required for lifestyle work to become a critical part of every patient encounter? Motivational interviewing theory suggests that the behavior is not important to physicians, or they lack skill in this technique.

The data cited have now been long available. Physicians do not lack an evidence base to justify such a behavior change; they lack the will. They should examine this phenomenon as a perfect problem to approach with MI skills.

The problem is usually couched in terms of patient compliance and patient resistance as the source of failure to adopt a healthy lifestyle. This may be true in part, but the physician also plays a role. The principles of MI, applied to patients, suggest that physicians need to understand patients' perspective better and, whatever their resistance, why they do want to take care of themselves (Rollinik et al., 2008; Ruback et al., 2005). One can never positively influence the behavior of another person without continuous, positive, empathic, nonjudgmental support.

Another barrier in providing primary prevention is that no one has directly observed a primary prevention "miracle." Although so important to the religious conversion experience, miracles just don't happen in primary prevention. Prevention of poor outcomes is not an observable event.

In usual practice, physicians derive the most satisfaction by testing or treating and seeing a prompt result. The relatively simple "instant gratification" of this approach is addictive. Give sublingual nifedipine, and the patient's blood pressure decreases; give insulin, and the sugar level is reduced. Tap on a reflex, and the tendon jumps; order a CT scan, and unseen abnormalities become apparent. Primary prevention offers no such satisfaction, even though it may be a favorite subject of interest, with a gratifying sense of sharing a deep belief.

Motivating physicians to move toward a primary prevention lifestyle and practice (these must go together) is similar to moving a smoker toward smoking cessation. All patients who are smokers should receive at every physician visit a straightforward, simple, clear, nonjudgmental message that giving up smoking is the single most important thing they could do for their health. This message should be accompanied by a simple question, "Would you like to talk about it?" Although average results from simple, brief counseling are 2.8% quit rates (Lancaster and Stead, 2004), because of the large patient populations, this rate is actually quite important. Physicians must be willing to accept intermediate behavioral outcomes in this range: 3% to 5% increases in smoking cessation (Butler et al., 1999), exercise (Hillsdon et al., 2007; Lawlor and Hanratty, 2001; Ogilvie et al., 2007; Peterson, 2007; Sherman et al., 2007), eating 5 servings of fruits and vegetables (Steptoe et al., 2003), other healthy nutrition practices (Hunt et al., 1995), reducing problem drinking (Fleming, 2005; Ockene et al., 1999), accident prevention (Miller and Galbraith, 1995), and general healthy lifestyle advice (Christian et al., 2008; Steptoe et al., 2001).

Each physician should reflect on the following questions:

1. "Do I believe that primary prevention can really work, and that it can substantially outperform other strategies to promote health?" As noted, belief is required. Exposure to high-quality primary prevention information can help, especially with urging from a colleague or mentor. We cannot assume that physicians believe; we have to ask. Belief is a journey, and the physician must explore personal history and professional socialization, first asking, "On a scale of 1 to 10, how great is my belief that primary prevention is the right thing to do and the key to the best results in medicine?"

2. "If I do believe in primary prevention, do I think it is important?" The physician must be convinced that this is a worthwhile focus. The physician's belief in the relative importance of preventive interventions is influenced by example, information, patient satisfaction, and organizational support. If primary prevention is not important, it does not deserve to be practiced. If the physician thinks it is even somewhat important, however, primary prevention warrants further consideration.

3. "If I believe in primary prevention, and I believe it is of paramount importance, am I convinced that I can do it?" Confidence is also relative and susceptible to both information and example. The physician needs to ask,

"On a scale of 1 to 10, how confident am I that I can integrate the behaviors necessary for primary prevention into my life and work flow?"

The evidentiary basis, practice, and strategies of motivational interviewing are new enough that many physicians are not even familiar with the term. Many of these physicians, however, intuitively respond to the process and may think,— "I've done that; I just didn't know what it was called." Usually, however, MI is only targeted at patients with high-risk medical conditions. As a strategy, it has succeeded dramatically for certain patients, but MI has not penetrated far into the U.S. health care environment since it was introduced to a wide audience in 1992. MI simply is not a formal part of most practices, mainly because the power of the intervention has been aimed at the wrong strata of system participants.

Insufficient data and insight surround the major question, "How do we nurture physicians in their career development to have firsthand knowledge of the power to change and evolve personally?" If the United States is to become a healthier country, current health care reform policies should address this question directly. Primary prevention can then become a natural, integral part of the health care process, an act as simple as breathing.

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