Health Behavior vs. Doctor-Patient Communications – Are We Focused On Modifying The Wrong Thing?

It seem like everyone these days is focused on changing some aspect of patient health behavior. You know, getting patients to get a mammogram or PSA test, exercise more, take medications as prescribed, or simply becoming more engaged in their health care. If only we could change unhealthy patient health behaviors….the world would be a better place.
 
I agree with the sentiment, but I think that patients and their health behavior often get a “bad rap” from health care professionals. I would even go so far as to say that much (not all) of what we attribute to poor patient behavior is more correctly attributable to ineffective doctor communications with patients.
 

In my last post I talked about the link between strong physician advocacy, e.g., I recommend, and desirable health outcomes, i.e., patients getting more preventive screening.
 
Here’s what I mean. Mammography studies have consistently shown that screening mammograms rates would be much high if more physicians “strongly recommended” that women get screened, e.g., “I recommend” you get a mammogram. In studies where physicians advocated for screening, mammography screening rates were always higher compared to physicians that did not advocate for them.
 
The same phenomenon can be found in studies dealing with exercise, weight loss, colorectal cancer screening, HVP immunization, and patient participation in clinical trials. In cases where physicians unequivocally recommended to patients that they do XYZ, patients were much more likely to do it…or at least they were much more likely to try. I am not naive enough to believe that an unequivocal recommendation from a physician is a “cure all” for the most recalcitrant patients. Factors such as level of patient trust in the physician and patient’s agreement with the physician’s diagnosis are mediating factors. Depression and fatigue from dealing with chronic conditions also play a role. But the evidence clearly suggests that a good many patients probably would respond positively to a strong recommendation from their physician.
 
Here’s an anecdotal experience describe by a physician comment on my last blog post:
 

“I agree that doctor-patient communication is critically important. My 50 year-old best friend shuns doctors, but told me he is getting a colonoscopy because his doctor strongly recommended it. “

Here’s the basis for my thinking. Many patients operate on the principle that if my doctor thinks something is important they will tell me. On this point patients can be quite literal. I have seen studies in which obese patients do not see themselves as “obese.” Their self perception is validated every time their doctor fails to tell the patient that they have a serious weight problem and that they need to lose 20 pounds in no uncertain terms. If I have such a big weight problems why hasn’t my doctor said anything?
 

Think back to your recent trips to the doctor. If you are like me, you may be hard pressed to think of a single instance in which your physicians ever said the words “I recommend” to you.

 
The only such instance I can recall was when my wife’s oncologist (Stage 4 Lung Cancer) said “I recommend that you start the chemo treatment immediately….tomorrow wouldn’t be too soon.” My wife did what her doctor recommended and she is alive today some 6 years later.

Sources:

Carroll, J., et al. Clinician-Patient Communication About Physical Activity in an Underserved Population. Journal of the American Board of Family Medicine. 2008;21:118–127.

Taylor, V., et al. Colorectal Cancer Screening Among African Americans: The Importance of Physician Recommendation. Journal National Medical Association. 2003;95:806-812.

Brown, T., et al. Predictors of Cardiac Rehabilitation Referral in Coronary Artery Disease Patients. Journal of the American College of Cardiology. Vo. 54, 2009.

Albrecht, T., et al. Influence of Clinical Communication on Patients’ Decision. Clinical Oncology 26:2666-2673. 2008.

Two Words That Could Increase Your Preventive Screening Rates

“I recommend.” These are two word which, when spoken by a physician to a patient have tremendous power to change behavior.   That assumes of course a trusting relationship between patient and physician (but that’s a topic for another day).
 
Take the colonoscopy.   The U.S. Preventive Services Task Force (USPSTF) recommends that adults aged ≥50 years get a colonoscopy every 10 years. In 2005, 50% of adults aged ≥50 years in the U.S. had been screened according to these recommendations.  Not surprisingly, the rate of colonoscopy screening is much lower than that of other recommended adult preventive services.    I was curious why?
 
Here are two interesting facts.

 
1. Studies show that patients cite “physician recommendation” as the most important motivator of colorectal screening. In one study, 75–90% of patients who had not had a colonoscopy, said that their doctor’s recommendation would motivate them to undergo screening.

 

2. In that same study, in 50% of patients where a colonoscopy was appropriate but not done, the reason given was that the physician simply did not “bring up” the subject during the visit. Reasons included lack of time, visit was for acute problem, patient had previously declined or forget.

 
What the Doctor Says Makes A Difference
 
Turns out that the highest colonoscopy screening rates were highest among physicians who were more adamant about the need for screening. These doctors framed the recommendation (message) to the patient as coming from them self, e.g., “I recommend” or “we recommend.”   Doctors who framed the recommendation as coming from someone else, e.g., “they recommend” or “organization X recommends” had lower screening rates.
 
The following table provides examples of the differ ways that physicians in this study framed their recommendation to patients for colorectal cancer screening.

 
A Word of Clarification
 
In these days of patient-centered care and shared decision-making, some may question the use of physician-centric directives like “I recommended.” For one thing, a strong physician recommendation is what some patients want. For patients who want more than just the physician’s recommendation, the physician can provide them with information to help them make their own informed decision about getting a colonoscopy.
 
I recommend that you give this approach a try!
 
Sources:
Levy, B., et al. Why Hasn’t This Patient Been Screened for Colon Cancer? An Iowa Research Network Study. Journal of the American Board of Family Medicine. 2007;20:458–468

Guerra, C., et al. Barriers of and Facilitators to Physician Recommendation of Colorectal Cancer Screening. Journal of General Internal Medicine. 2007; 22(12):1681–8