Cardiovascular Disease

Physicians play a key role in providing both curative and preventive healthcare. Counseling may be an effective tool in reducing behavioral risk factors for CVD. Yet, physicians do not counsel their patients aggressively about lifestyle changes to prevent CVD. As hypothesized, the reported frequency of preventive counseling in this study was low, especially for diet, exercise, and weight loss. Rates of counseling for smoking cessation and medication adherence were much higher than for other CVD risk factors, a finding which has been reported by others. Counseling behaviors mirrored physicians’ beliefs about the importance of different risk factors: more physicians reported counseling for smoking cessation and medication adherence was “very important” than exercise, diet, and weight reduction. This suggests that messages about the importance of diet, exercise, and weight control for prevention of CVD are not reaching most physicians.

Rates of exercise promotion were higher for patients with risk factors for CVD than patients without risk factors. This finding is in agreement with previous research which indicates a lower prevalence of physician counseling for CVD risk factors among patients without risk factors or preexisting disease than without. While counseling only high-risk patients may be a time-efficient strategy, physicians miss an important opportunity to prevent CVD if they do not promote healthy lifestyles to patients without major risk factors.
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Physicians reported low rates of using proven behavioral techniques when counseling patients. They did not tell patients how much and what kind of exercise to do, did not encourage patients to set quit dates for smoking, or give specific goals for weight loss. Physicians’ failure to recommend key behavior strategies has been noted in prior studies. The poor quality of counseling skills may make physicians’ efforts less effective, which may, in turn, reinforce negative attitudes and low confidence in counseling skills.

Only approximately one-quarter of providers reported feeling “effective” when providing preventive patient counseling about smoking cessation, exercise, and weight reduction. This is of particular concern, because physician confidence levels have been correlated with their counseling practices. In this study, however, counseling rates for smoking cessation were high, despite the fact that few physicians felt their counseling on this topic was effective. This is perhaps because these physicians felt uniformly (100%) that it was important to counsel against smoking. Indeed, studies have also demonstrated the importance of attitude (believing that counseling is important) in determining physicians’ counseling practices. This demonstrates the need to intervene on multiple levels (provide skills, enhance self-efficacy, and improve attitudes) to effect physician behavior.
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In an attempt to understand reasons for low rates of preventive counseling, we queried physicians on potential limitations and physical barriers to counseling. Attending physicians and residents alike agreed with the existence of many practical barriers, such as lack of time and missing charts. In addition, the majority of physicians cited communication and cultural differences as possible barriers to preventive counseling. This may have been specific to the physicians surveyed, as the majority of them were Caucasians practicing in a clinic with a predominantly African-American, low-income patient population. This finding may support the need for “cultural competency” training for residents.

Our study explored whether physician training level was predictive of counseling behaviors and attitudes, a subject not previously addressed in the literature to our knowledge. Our data indicated that attending physicians were no more likely to counsel patients with CVD risk factors than were resident physicians. There are several possible explanations for this finding. Perhaps attending physicians felt that the literature supporting physician counseling was not compelling, or else they were unfamiliar with the American Heart Association recommendations. Attending physicians were much more likely than residents to state that recommendations on prevention were unclear or that physicians were not very knowledgeable about current prevention guidelines. Another explanation is that attending physicians may have been more aware of deficiencies in the literature supporting the efficacy of physician counseling.

Although previous studies have found physician gender differences in preventive counseling practices, our study did not. The attitudes and practices of male and female attending and resident physicians with regard to CVD risk factor counseling were alike in this study. This could be because our sample size of this study was not very large or because the differences based on gender are not as marked in an academic setting.

Limitations of our study were the relatively small sample size (N=84), the fact that the study was carried out among only one residency program, and reliance on physician self-report. The latter method of data collection may have resulted in an overestimation of actual prevention counseling attitudes and practices. However, since our findings indicate a low level of counseling practices, this adds weight to the concern that physicians are undercounseling for CVD prevention.

In summary, our study adds to the growing body of literature that primary care physicians do not adequately address CVD prevention, and, in particular, the importance of diet, exercise, and weight control. Most importantly, our study did not find any differences in counseling practices between attending physicians and residents, a finding that highlights the need to create interventions in residency for both residents and their attending physicians.
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Category: Diseases / Tags: attitudes, barriers, cardiovascular risk, counseling, diet, exercise, knowledge, practices, prevention, self-efficacy, smoking

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