Hauer and colleagues have made an important contribution to medical education by documenting how best to teach behavioral counseling skills to medical students. Although the authors of this commentary agree that these skills are important for physicians to learn, they argue that physicians must acknowledge realities regarding the role of physicians as behavioral counselors and the limited effectiveness of counseling during clinical encounters. Students and physicians need to understand the limited role that the medical care system plays in determining lifestyles and the more potent effect that community-wide interventions can have. The authors call for education about behavioral counseling that teaches necessary skills, yet develops realistic expectations of what physicians can and cannot do by themselves, understanding of when to refer patients for intensive counseling, and recognition of the importance of societal factors in effecting behavior change.
Dr. Campos-Outcalt is chair, Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine, Phoenix, Arizona.
Dr. Calonge is president and CEO, The Colorado Trust, Denver, Colorado.
Editor’s Note: This is a commentary on Hauer KE, Carney PA, Chang A, Satterfield J. Behavior change counseling curricula for medical trainees: A systematic review. Acad Med. 2012;87:956–968.
Correspondence should be addressed to Dr. Campos-Outcalt, 550 E. Van Buren, Phoenix, AZ 85004; telephone: (602) 827-2014; e-mail: firstname.lastname@example.org.
Unhealthy behaviors contribute significantly to the myriad chronic diseases that are the major causes of morbidity and mortality in the and are a main driving force behind escalating health care costs. Health care providers throughout our health care system need to address this problem by finding effective ways to manage chronic conditions as well as by assisting patients in making healthy lifestyle choices to reduce their risk of developing chronic disease. To facilitate this, medical students should be taught the fundamentals of effective behavioral counseling as well as what works and what does not with individual patients. The article by Hauer and colleagues,1 documenting how best to teach these skills, is a welcome addition to the medical education literature.
The next step is to ensure that physicians in training understand the realities of the practice environment in which they will be encountering patients who require behavioral counseling. We need to acknowledge that physicians are unlikely to be the best members of health care teams to be assigned the task of effectively counseling patients to achieve healthy behaviors. The current health care system almost ensures that this will be true for the foreseeable future: Physicians are not afforded the time needed, nor are they adequately reimbursed, to provide behavioral counseling.
We also need to recognize that behavioral counseling in a clinical setting has limited success. Even for smoking, for which there is good evidence that cessation can be influenced by physician counseling, only a minority of patients will actually stop smoking, even if the physician uses all the best methods and ancillary assistance available, such as cessation support phone lines and nicotine replacement.2 Still, given the positive health outcomes for those who do quit, this is a worthy effort. Other behaviors can be affected by physician clinical encounters, such as breast-feeding and harmful alcohol use.3,4 However, societal factors typically have much more influence on population-wide behaviors. The price of tobacco products, smoke-free ordinances, and statewide quit lines all affect the proportion of the population that smokes5; alcohol taxes and limitation of purchasing access may have more influence on excess drinking6; and hospital practices regarding formula distribution can easily scuttle breast-feeding intentions.
Just as it is important that physicians learn behavioral counseling skills, they need to understand what they can affect and what they cannot when it comes to human behavior. Changing some unhealthy behaviors, such as poor diets, inactivity, and unsafe sex practices, requires much more intensive interventions than can be offered in a brief clinical encounter.7,8 For these behaviors, the evidence suggests that it is better to refer patients to professionals trained and able to provide these intensive interventions than to attempt unsuccessfully to change them with inadequate levels of physician counseling, limited by the realities of clinical practice. The health care system should include readily available sources of team-oriented services that can devote the time and energy needed to achieve long-term lifestyle changes. Likely, the best role for the physician is to identify a health issue through systematic screening, take advantage of the physician–patient relationship to recommend behavior change, and arrange referral to effective behavior change programs.
The role for academic medicine should be to research which behavioral counseling practices are and are not effective for use in the real-world clinical setting and what conditions can and cannot be affected by clinical encounters, as well as to find the most cost-effective and practical approaches to changing unhealthy behaviors. Although many adverse behaviors require intensive counseling, for some patient behaviors physician involvement is just as important, if not more so. Counseling for medication adherence, for example, is perhaps more closely related to medical practice, where physician involvement can make a significant difference.9
We should indeed teach behavioral counseling techniques to medical students while providing a realistic expectation of what they as physicians can and cannot do by themselves. We should ensure that physicians in training have the necessary knowledge of how they can best interact with those professionals who are likely to achieve better outcomes through intensive behavioral counseling with patients. And, we should teach our students about the social determinants of health, the value of public health, and the more significant contribution of the latter to health-related behaviors. Physicians need to understand the limited role that the medical care system plays in determining lifestyles and the more potent effect that community-wide interventions can have.
Other disclosures: None.
Ethical approval: Not applicable.
1. Hauer KE, Carney PA, Chang A, Satterfield J. Behavior change counseling curricula for medical trainees: A systematic review. Acad Med.. 2012;87:956–968
2. U.S. Preventive Services Task Force.. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med.. 2009;150:551–555
3. Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: An evidence review for the U.S. Preventive Services Task Force. Ann Intern Med.. 2008;149:565–582
4. Whitlock E, Polen M, Green C, Orleans CT, Klein J. Behavioral counseling in primary care to reduce risky/harmful alcohol use by adults, summary of the evidence. Ann Intern Med.. 2004;140:558–569
5. Hopkins D, Briss P, Ricard C, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med.. 2001;20(2 suppl):16–66
7. McTigue K, Harris R, Hemphill B, et al. Screening and interventions for obesity in adults: Summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med.. 2003;139:933–949
8. Lin J, Whitlock E, O’Conner E, Bauer V. Behavioral counseling to prevent sexually transmitted infections: A systematic review for the U.S. Preventive Services Task Force. Ann Intern Med.. 2008;149:497–508
9. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: A systematic review. Arch Intern Med.. 2007;167:540–549