Want to Change Patient Health Behavior? Change How You Talk To Your Patients

According to Marshall Becker, PhD, MPH, a one-time professor of mine and prime mover behind the Health Belief Model (HBM), four things must be in place for health behavior change to occur.  I am paraphrasing here:

1. A person has to know that they have a particular health condition
2. A person has to believe that having said health condition is bad
3. A person must perceive the benefits of behavior change to outweigh the difficulties of behavior change
4. There must be a “call to action” to spark the change

Absent any one of these steps the likelihood that behavior change will occur is diminished.

Now consider the problem of obesity and behavior change.

A series of recent Harris Polls looked at people’s perceptions and experiences regarding their weight. The polls, which confirm similar findings from numerous medical journals, found that:

• 39% of morbidly obese people (BMI >40) think they are overweight but not obese.
• 70% of obese people (BMI >30) believe they are merely overweight.
• 61% of “technically obese” adults had never been told by a health care professional that they were obese…or that they needed to do anything about their weight.

Following the logic of the Health Belief Model several critical behavior change “prerequisites” are missing.    First, many obese and overweight people do not believe they have a real problem with their weight.   Other people are obese – not them.   Sure they know they need to lose weight.   Many are probably trying on their own.

Second, since their physicians hasn’t told them they are obese, there is no reason for them to believe they have a problem or that carrying a few extra pounds poses a serious health risk.

At this point, according to the HBM, the likelihood of behavior change falters. There’s no reason for the patient to seriously consider the barriers or benefits to significant weight loss.

Poor physician-patient communication enables obesity…and probably many other chronic conditions

The evidence shows that patients who receive physician counseling about weight loss are up to 2 times more likely to report that they are currently trying to lose weight.  Yet such conversations reportedly do not occur in some two-thirds of physician visits by obese patients.

Why?

From the physician’s perspective, key barriers to weight loss counseling are self-perceived low competence in treating obesity, lack of treatment effectiveness, and poor patient motivation.   Don’t underestimate the importance of physician attitudes toward obese patients.   One study found that physician believed that 40% of their obese patients were capable of achieving a normal weight…but that most patients were not sufficiently motivated to lose the weight.

The therapeutic value of talking to patients

Physicians have more a lot more influence with patients than they seem to give themselves credit for.  If patients have a health problem, they expect their physician to tell them.

One has to wonder how many patients suffer needlessly from obesity, diabetes, heart disease and so on simply because their physicians did not take the time to impress upon them:

1. the fact that they have a condition
2. that having the condition is serious
3. that there are treatment options
4. here are the benefits and challenges
5. together we can solve the problem

It certainly makes me wonder.

Sources:

Befort, C., et. al., Weight-Related Perceptions Among Patients and Physicians.  How Well do Physicians Judge Patients’ Motivation to Lose Weight?  Journal of General Internal Medicine. 2006 October; 21(10): 1086–1090.

Greiner, K., et. al., Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions.  Journal of General Internal Medicine. 2008 May; 23(5): 581–587.

Overweight? Obese? Or Normal Weight? Americans Have A Hard Time Gauging Their Weight  http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/558/ctl/ReadCustom%20Default/Default.aspx.

Patients Often Don’t Hear What Doctors Think They Told Them

Physician-patient communications today are riddled with communication gaps according to researchers.  These communication gaps often have significant implications, i.e., misdiagnosis, patient confusion and overuse of costly diagnostic and treatment services.

Such are the findings from a study published in the September Annals of Internal Medicine.  The study examines the beliefs of patients with stable coronary artery disease who agreed to undergo elective angioplasty (PCI). Specifically, the study contrasts the patients’ understanding of the benefits of the procedure with those that the patient’s referring cardiologist or the Interventional Cardiologist believed they had told the patients.

The patient population consisted of 158 patients with stable heart disease. Of these patients, 68% had angina, 42% had activity-limiting angina, 77% had a positive stress test result, and 29% had had previous heart attack (MI). Almost three quarters of patients thought that without the procedure (PCI), they would probably have MI within 5 years, and 88% believed that PCI would reduce risk for an MI.

In contrast, 63% of cardiologists believed that the benefits of PCI were limited to symptom relief of angina-related pain. Opening up blocked coronary arteries can be life-saving in emergencies, but there is no evidence that increasing blood flow to the heart in stable patients prevents future heart attacks as patient believed.

The study did not looking at the appropriateness of care. It simply considered whether patients heard what physicians think they told them in the office when discussing the risks and benefits of have the procedure.

The Upshot of the Study?

The study, and others like it, point to the need for:

• More Informed Decision Making – this study suggests that patients are not getting (from their physicians) or do not understand the information they need to make informed decisions about potentially hazardous procedures.
• Better Understanding of the Patient Beliefs – Patients may stop taking medications in the mistaken belief that they are no longer at risk due to having had angioplasty.
• The Need Engage in “Teach Back” Methods with Patients – Physicians need to get patients to repeat what they to believe their physician told them to insure greater accuracy.

Authors cautioned that the “communication gap” identified in the study is probably not limited to angioplasty and may apply to many potentially dangerous and costly treatments and procedures.

Source:

Rothberg, M., et al.  Patients’ and Cardiologists’ Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease.  Annals of Internal Medicine.   September 7, 2010 vol. 153 no. 5 307-313

Five Reasons Why People Do Not Ask Their Doctor Questions

A neighbor of mine was diagnosed with breast cancer about the same time was wife was being treated for lung cancer.  I saw my neighbor the other day for the first time in several years.  I asked her how she was doing.  She said great.  In turn I asked her how her PET/CT exam looked.  PET/CT scans are often done to make sure that one’s cancer hasn’t spread.  My wife gets one every year.  My neighbor told me her doctor never told her she needed one…that mammograms would suffice.   She went on to say a friend had also recently asked her if she had a PET/CT as well.  “Maybe I should ask my doctor” she told me.  That was the same response she gave me the last time I raised the subject two years earlier, “I should ask my doctor.”
 
So Why Don’t People Ask More Questions?
 
My neighbor is not alone when it comes to asking their doctor questions.  In an earlier post, I cited research which found that patients ask their doctor an average of 2 important questions during the office visit.

According to researchers, there are five reasons why people don’t ask their doctor questions.  These reasons include:

1. Fear – fear of what the doctor may think of them, fear of what the doctor may say, fear of looking or sounding stupid in front of the doctor, fear of getting the wrong answer.
2. The Doctor Knows Best – if something is important the doctor will mention it, if I need the test the doctor will order it, and so on.
3. Not wanting to interrupt – office visits follow a clear pattern opening statement, medical interview and exam, diagnosis, treatment and closing.  Other than during their opening statement, most patients realize that the doctor does most of the talking.
4. Not being asked by the doctor if they have any questions – studies show that physicians do not ask patients if they have any questions in more than 50% of office visits.
5. Patient feels rushed – feeling that their question isn’t really all that important after all.

In my neighbor’s case, I suspect that “fear of knowing” the results of a PET/CT scan may be the overriding reason why she has not asked her doctor about having the exam.   Why invite bad news if you don’t need to.   Fear is a pretty strong motivator.  Strong enough in many instances to trump another strong motivator – one’s survival instinct.
 
Check out Why Patients Don’t Ask More Questions Part 2
 
If You Have A Question Write It Down And Give It To Your Doctor

One way for patients to ask their doctor questions is to write them down before the visit and give them to the doctor at the start of the visit.   That way patients can avoid having to worry about how or when to ask a question.  Physicians for their part should invite patient questions even at the risk of extending the office visit.

Sources:

Roter, D. L. Patient Question Asking in Physician- Patient Interaction.   Health Psychology. 1984; 3 (5) 395-409.

Cegala, D.  Personal notes. 3/12/2010.