Slatt, Lisa M. MEd; Frasier, Pamela York PhD; Strayhorn, Gregory MD, PhD; Kowlowitz, Vicki PhD
Many chronic and costly diseases prevalent in society result from lifestyle behaviors (violence, accidents, smoking, obesity, lack of exercise, excessive use of alcohol) that can be modified.1 Studies show that physicians who intervene can have a positive impact on their patients' health and health-related behaviors.2–5 Yet, despite the emphasis specialty organizations have placed on prevention over the last decade, many physicians still do not counsel patients about risk-factor modification.6–8 Physicians often mention lack of adequate training, concern about the time needed for counseling, and the belief that patients' behaviors will not change9 as barriers to their counseling patients.
To help prepare physicians-in-training to practice prevention skills, the Department of Family Medicine at the University of North Carolina at Chapel Hill developed a prevention curriculum for its required third-year clerkship. Like other primary care departments, we use community practices to provide the clinical training for our clerkship students. From a 1996 study by Kowlowitz et al. that documented clerkship students' clinical activities,10 we knew that students in community-based clerkships were exposed to the health maintenance aspect of prevention because it was among the study's top three most frequently cited medical activities.
Since the offices of the community physicians across North Carolina serve as the clinical laboratory in which students apply their knowledge and skills in the care of patients, it was important for us to know in greater depth the prevailing clinical climate regarding prevention activities. More important, community family physicians, in their role as clerkship preceptors, are role models for students and are presumed to directly influence students' opportunities to incorporate prevention into patient care. For these two reasons, we surveyed preceptors about their practices of and attitudes towards prevention. We anticipated that findings from the survey would serve as a needs assessment, and would help us plan interventions with preceptors to improve the educational environments at the respective sites. We also thought that the findings might be useful to other departments that use community-based physicians to teach prevention skills to medical students.
During the 1995-96 academic year, 165 family physicians in 81 private practices and community health centers across North Carolina taught in our clerkship. No academic family practice center or solo practice served as a teaching site. One preceptor at each site was assigned a student during a six-week rotation. The preceptor supervised the student for four days each week, and the student spent the remaining weekday in seminars away from the office.
An 18-item questionnaire, developed by three of the authors (LS, PF, and VK), was based on items from similar practice-based surveys and covered a range of issues.11–13 Only the items analyzed for this paper are addressed.
At the beginning of the questionnaire, we defined health promotion or prevention as “offering advice or counseling about health habits or health-related behaviors that are intended to encourage patients to reduce health risks or improve health status.” Using Likert-type scales, the preceptors were asked to rate their (1) knowledge about prevention and skills in counseling patients, (2) preparation to counsel patients in general as well as in specific areas, (3) effectiveness in giving health promotion advice, and (4) success in getting patients to modify behaviors, as well as (5) the frequency with which services were offered, and (6) the type of services offered (i.e., smoking cessation, alcohol use, etc.). Finally, the questionnaire contained three items pertaining to sociodemographic data.
The questionnaire was pilot-tested with family physicians in an academic family practice center and with one community practice. Revisions were incorporated based on feedback received from the pilot study. The questionnaire was then mailed to the 165 family physicians teaching during the fall of the 1995-96 academic year. After two weeks, reminder telephone calls were made to non-responders. After a month, the questionnaire was re-mailed to non-responders and a reminder telephone call made.
Besides the descriptive statistics, we compared the preceptors in terms of gender, year of graduation from residency, and geographic location.
Of the 112 (70%) preceptors who responded to the survey, 75% were men and 55% had graduated from residency after 1987. Fifty-seven percent of the preceptors felt they were very knowledgeable about prevention and health promotion recommendations. As shown in Table 1, 64% of the preceptors indicated that they had “adequate” skills to counsel patients about prevention and health risk, and 32% felt they had a “great deal” of skills. Moreover, 99% of the preceptors reported that they routinely counseled all or most patients with health risks (see Table 2). While almost all preceptors reported counseling patients regarding prevention and health promotion, Table 2 shows that only 29% believed patient education to be very effective.
When considering preceptors' attitudes toward their preparation for offering preventive services and the types of preventive services they offered, 74% of the preceptors reported they were “very prepared” to counsel and 86% “almost always” offered services regarding smoking cessation (see Table 3). Over half of the preceptors offered services and felt “very prepared” to counsel patients regarding exercise, alcohol use, and age-specific preventive services. Only 39% of the preceptors felt “very prepared” to offer diet and nutrition services, yet two thirds reported that they “almost always” offered these services. In contrast, two thirds of the preceptors indicated they were “very prepared” to counsel patients about sexually transmitted diseases, yet only 38% “almost always” offered this service. Similarly, preceptors were more likely to feel prepared to counsel patients about HIV and AIDS (45%) than to offer this service (29%). Although the preceptors were family physicians, only 21% felt “very prepared” to counsel their patients regarding family and social relationships, and only 8% of preceptors felt “very prepared” to counsel or to offer services regarding family violence.
These preceptors were generally pessimistic about their levels of success in helping patients modify their behaviors. The two areas where the preceptors reported feeling “very successful” in helping patients were age-specific services (26%) and depression (21%) (see Table 3).
Because of the increase in the clinical focus on preventive services and the new emphasis on prevention training during residency in the 1980s, we compared the responses of preceptors who had completed residency before 1987 (earlier graduates) with those of preceptors who had finished their residencies during or after 1987 (recent graduates). Although 63% of recent and 55% of earlier graduates felt “very knowledgeable” about prevention and health promotion, only one third of each group felt that they had “a great deal” of skills to counsel patients. However, there was no significant difference between recent and earlier graduates in offering advice or counseling patients about preventive services.
We did find differences among graduation groups when comparing specific services. For example, 93% of the recent graduates “almost always” offered preventive services for smoking cessation, compared with 77% of those graduating before 1987 (p =.02), and 64% of the recent graduates “almost always” offered preventive services for alcohol use, compared with 44% of the earlier graduates (p =.08). Whereas 96% of the recent graduates “almost always” offered preventive services for illicit drug use, only 24% of those graduating before 1987 did so (p =.007). Although the difference was not statistically significant, recent graduates were more likely to “almost always” offer preventive services for family or social relationships and for HIV and AIDS. The two groups had similar distributions of offering preventive services for diet and nutrition, exercise, depression, sexually transmitted diseases, age-specific preventive services, and family violence. The more recent graduates were more likely to feel “very prepared” and “almost always” offered preventive services for diet and nutrition (p =.01) and HIV and AIDS (p =.02). There was no significant difference between the graduates' views of how successful they felt in helping patients modify their behaviors based on time since graduation from residency.
There was no significant difference between men and women preceptors regarding the frequency of offering advice or counseling patients about preventive services for health-risk and health-promoting behaviors. Even though 57% of all the preceptors felt they were “very knowledgeable” about prevention and health promotion, when compared with the men preceptors, the women preceptors were more likely to report “a great deal” of skills to counsel patients in these areas.
The women preceptors felt significantly more prepared to counsel patients regarding HIV and AIDS (p =.02) and sexually transmitted diseases (p =.04), “almost always” offered preventive services for HIV and AIDS (p =.007), and reported being more successful in helping patients modify their behavioral risks for HIV and AIDS (p =.03) than did men preceptors. Since the women preceptors were likely to be more recent graduates of residency (78% of the women preceptors had graduated between 1987 and 1995, compared with 47% of the men preceptors) than were the men, the women may have had more formal training regarding HIV and AIDS preventive services. Finally, although the levels of preparedness to counsel patients regarding smoking cessation, depression, and family violence were similar for men and women preceptors, the women were more likely than were the men to offer preventive services in these areas.
Since our preceptors are affiliated with six distinct regions across the state, we examined geographic variations in reported preceptors' behaviors and attitudes regarding preventive health services. The following five issues varied significantly by geographic region: offering diet and nutrition services (p =.001), offering preventive services (p =.02), feeling prepared to counsel about smoking cessation (p =.01), success in helping patients modify behavior related to alcohol use (p =.02), and HIV and AIDS (p =.006). Although the differences were not statistically significant, the preceptors' attitudes regarding their success helping patients modify behaviors related to exercise, sexually transmitted diseases, and age-specific preventive services also varied by region.
Our study found that the majority of community physicians precepting for the Department of Family Medicine at the University of North Carolina at Chapel Hill during 1995-96 perceived themselves to be very knowledgeable about prevention and health promotion and to have skills to counsel patients in these areas. The gender of the preceptor did not affect knowledge of prevention, although women felt more skilled to counsel patients than did men. The overwhelming majority of the preceptors routinely offered prevention services and health promotion counseling to patients. Despite putting prevention into practice, however, the majority of the preceptors felt their counseling and patient education attempts were not very effective. The preceptors expressed this perception of lack of success regardless of gender and date of graduation from residency. We found variations based on geographic location within North Carolina for the types of services preceptors offered to patients and the degrees to which preceptors perceived success in helping patients modify behaviors.
When compared with a 1992 study11 of prevention practices among family physicians in North Carolina for four preventive clinical services (smoking cessation, alcohol use, illicit drug use, and diet and nutrition), we found our preceptors were more likely to offer services in three areas (smoking, alcohol use, and diet and nutrition) than were those in the earlier study. But, we also found that our preceptors were less likely to offer services for illicit drug use than were those in the earlier study.11
When compared with a 1996 study of Massachusetts family physicians,12 a greater proportion of our preceptors reported being “very prepared” to counsel patients about smoking cessation, alcohol use, exercise, diet, and family stress. However, our preceptors were less prepared to counsel about illicit drug use than were the Massachusetts family physicians. Although a larger proportion of our preceptors reported being “very successful” in modifying one behavior, patient stress, a smaller proportion felt “very successful” in modifying alcohol use, exercise, diet, and illicit drug use when compared with the Massachusetts family physicians. It should be noted that in both studies the percentages of physicians who felt “very successful” in helping patients change behaviors were low, ranging from 1% to 8%.
We used our study's findings to plan and implement a prevention curriculum. We had assumed that our preceptors served as real-world role models in the area of prevention and health promotion, and our findings indicated that preceptors carried out their job as role models. They felt knowledgeable and skilled in offering a variety of prevention and health promotion services, and they routinely offered services and counseled patients with health risks. We know too that this role modeling was not influenced by a preceptor's gender or year of graduation from residency.
We were surprised by the across-the-board pessimism the preceptors expressed regarding their success in modifying patients' behaviors. This presened us with an educational dilemma in planning our curriculum. We could continue placing students with preceptors who were knowledgeable and skilled at the practice of prevention and who practiced health promotion, but these preceptors would also likely share with students their frustration about the lack of success with patients. While exposing students to this aspect of the doctoring would reflect the real world of caring for people and underscore the complex dynamic of changing human behavior, we ran the risk of enabling students to become jaded about incorporating prevention skills into their clinical repertoires.
Addressing this issue through faculty development with 165 physicians in 81 practices was impractical, so we implemented the prevention curriculum with an additional requirement that the students to do an assignment that removed the patient as the denominator for measuring success and instead focused on the practice. We asked students to enlist their preceptors' help in identifying a prevention issue or dilemma within the practice. For example, the issue could address the practice's compliance with a recommended prevention guideline such as childhood immunizations. The students explored the rationale for the recommendation, the pros and cons of how it was practically implemented, and made recommendations to address any identified problems. The students presented their findings to the preceptors and their staffs. Thus, they contributed in a meaningful way to improving the practices' prevention activities. This assignment produced several benefits: it taught the students a process for approaching prevention from a systems standpoint, it gave them practice in developing practical solutions for busy practices, and it gave back to the practices a tangible product that would improve patient care. Feedback from preceptors revealed that in many cases students' projects had led to changes in the ways prevention services were implemented in the practices.
Implementing our prevention curriculum has provided more consistency of educational experiences across the diverse regions of North Carolina. Further exploration about why physicians continue to offer a variety of prevention services while feeling ineffectual in their efforts to help patients modify their behaviors is needed.
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