Physicians’ CVD Counseling Practices

Prevention counseling rates were significantly lower for exercise and diet than for smoking and medication compliance (Table 2). Only 16% and 20% of physicians reported that they “always” counseled about exercise and diet, respectively, whereas 88% and 52% reported counseling smoking cessation and medication adherence, respectively (p<0.0001). Attending physicians were significantly more likely than residents (79% vs. 45%) to “always” counsel new patients about medication compliance (p=0.025). No other statistically significant differences between attending physicians and residents were found. Additionally, no significant differences were found in CVD counseling practices for new patients based on physician gender (data not shown).

With respect to specific CVD risk factors, the level of physician training was generally not a determining factor in the patterns of counseling (Table 3). However, attending physicians were more likely than residents to “always” counsel patients with high blood cholesterol about specific dietary recommendations. Attending physicians were significantly more likely than residents to “always” counsel patients with high blood cholesterol about decreased saturated fat intake, decreased dietary cholesterol intake, and weight loss (Table 3). There were no other significant differences in CVD counseling based on physician gender (data not shown).

Table 2. Percentage of Physicians Who “Always” Provide CVD Risk-Factor Counseling Practices for New Patients

Physician Training Level
Health Issue

Total (N=82)

Attending (N=15)

Resident (N=67) P Value
Percentage (%)
Exercise

16

21

15 0.55
Diet

20

36

18 0.14
Smoking

88

86

88 0.81
Medication compliance

52

79

45 0.025*
* p<0.05

Physicians were significantly more likely to provide CVD preventive care on exercise to patients with risk factors, such as obesity, hypertension, high blood cholesterol, sedentary lifestyle, and/or smoking, than to patients without such risk factors (Tables 2 and 3). Exercise counseling was “always” recommended in only 16% of patients without other CVD risk factors. For patients with obesity, hypertension, and high blood cholesterol, physicians always addressed counseling 61%, 40%, and 39% of the time, respectively (Table 3). The difference in exercise counseling frequency for patients with CVD risk factors compared to those without was significant (p<0.001).
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Table 3. Counseling Practice Patterns: Percentage of Physicians Who “Always” Engage in Specific Counseling Techniques

CHD Risk Factor Physician Training Level
Counseling Practices Total

Attending

Resident P Value
(N=82)

(N=15)

(N=67)
Percentage (%)
Obesity
Discuss weight reduction 42

47

40

0.65
Review health risks ot obesity 60

53

61

0.58
Advise decreased caloric intake 48

60

45

0.29
Advise regular exercise 61

60

41

0.93
Set a goal tor weight loss 24

40

21

0.12
Hypertension
Review health risks ot high blood pressures 34

43

33

0.48
Advise weight loss, if patient is overweight 48

60

45

0.29
Advise regular exercise 40

47

39

0.58
Review medication adherence 69

73

67

0.64
Advise stress reduction 6

13

4

0.20
High Blood Cholesterol
Review health risks of high blood cholesterol 43

64

39

0.09
Advise weight loss, if patient is overweight 48

71

42

0.049*
Advise regular exercise 39

50

36

0.34
Advise decreased saturated fat 41

79

33

0.002*
Advise decreased dietary cholesterol 52

79

47

0.03*
Sedentary Lifestyle
Review health benefits of exercise 58

47

61

0.30
Suggest appropriate exercise for patient 29

20

30

0.45
Give specific instructions on how to exercise safely 13

13

141

0.98
Set a specific exercise goal including frequency and duration 17

13

18

0.66
Smoking
Discuss stopping smoking 74

87

72

0.23
Review economic benefits of quitting 19

15

20

0.72
Recommend quit-smoking program 54

30

58

0.08
Review health risks 75

67

77

0.39
Set a specific quit date 16

29

14

0.17
Prepare the patient for withdrawal symptoms 20

21

21

0.96

Physicians did a poor job helping patients set a plan to make behavioral changes. Only 16% of physicians encouraged patients that smoke to set a quit date. Few physicians set an exercise goal (17%), suggested specific exercises (29%), or gave specific instructions about exercise safety (13%) when counseling their sedentary patients (Table 3).

Table 4. Percentage of Physicians Who Considered Counseling about the Following CVD Risk Factors “Very Important”

Physician Training Level
CVD Risk Factors

Total (N=82)

Attending (N=15) Resident (N=67) P Value
Percentage (%)
Cholesterol

85

93

82

0.28

Blood pressure

93

93

93

0.92

Exercise

76

80

76

0.75

Diet

76

87

75

0.32

Smoking

100

100

100
Weight reduction

79

73

81

0.53

Taking blood pressure medication      95

100

96

0.41

Physicians’ CVD Counseling Attitudes

The majority of respondents felt that it was “very important” to counsel patients about cholesterol, blood pressure, exercise, diet, smoking, weight reduction, and blood pressure medication compliance (Table 4). However, there were differences in the percentages of physicians who felt it was “very important” to counsel based on the type of risk factor. While 100% of physicians felt it was “very important” to counsel on smoking and 95% felt it was “very important” to counsel compliance with blood pressure medications, only 76% felt it was “very important” to counsel on exercise and diet, and only 79% felt it was “very important” to counsel on weight reduction.
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Table 5. Percentage of Physicians Reporting at Least “Moderate” Effectiveness in Preventive Patient Counseling

Physician Training Level
Health Issue

Total (N=82)

Attending (N=15)

Resident (N=67) P Value
Percentage (%)
Smoking cessation

25

27

26 0.94
Exercise

24

20

26 0.64
Healthy diet

27

27

26 0.97
Taking blood pressure medicine

69

80

67 0.32
Weight reduction

23

13

24 0.36

Physicians’ Perceived Lifestyle Counseling Effectiveness

Physicians felt significantly more effective when counseling on medication compliance than smoking cessation, diet, and weight (Table 5). Less than one-third of physicians felt “very” or “moderately” effective when counseling their patients about smoking cessation, exercise, healthy diet, or weight reduction, compared to 69% of physicians who felt at least “moderately” effective counseling on medication compliance (p<0.0001). There was no significant difference between attending and resident physicians in their perceived effectiveness in counseling.
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Table 6. Factors Affecting Physician Counseling (Percentage “Yes”)

Physician Training Level
Attitudinal Barriers

Total (N=82)

Attending (N=15) Resident (N=67) P Value
Percentage (%)
Recommendations on prevention are unclear

35

80

23 0.00002*
Physicians receive little training in prevention

83

100

78 0.051
Physicians are not interested in prevention

35

47

30 0.23
Physicians value acute care more than preventive care

67

80

61 0.19
Physicians are not very knowledgeable about prevention guidelines                                 55

80

48 0.028*
* p<0.05

Physicians’ Self-Reported Barriers to Prevention

The majority of physicians felt limited in their prevention practices by a lack of preventive care training (83%), and by a lack of knowledge about prevention guidelines (55%), and by general attitudes which value “acute” care more than preventive care (67%). Significant attitudinal differences were found between attending physicians and residents with regard to prevention recommendations and training. Attending physicians were significantly more likely than residents to state that “unclear” prevention recommendations were a limitation to providing preventive care. Significantly more attending physicians than residents felt that physicians were not very knowledgeable about current prevention guidelines and that physicians receive little training in prevention. Other barriers to prevention cited by physicians included lack of time, perceived lack of patient interest, missing or inadequate information in patient charts, communication difficulties with patients, and cultural differences between doctors and patients (Table 7).
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Table 7. Barriers to Counseling (Percentage “Yes”)

Physician Training Level
Attitudinal Barriers

Total (N=82)

Attending (N=15) Resident (N=67) P Value
Percentage (%)
Lack of time

94

87 96 0.79
Missing or inaccurate informationon patient charts                        71 79 70 0.45
Communication difficulties with patients

63

60 64 0.76
Cultural differences between doctors and patients

61

80 57 0.10
Lack of patient interest

81

64 85 0.13
Category: Diseases / Tags: attitudes, barriers, cardiovascular risk, counseling, diet, exercise, knowledge, practices, prevention, self-efficacy, smoking

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