Wednesday, December 29, 2010
Is it bad patient behavior or poor doctor-patient communication?
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 healthcare. 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 six years later.
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.
This post by Steven Wilkins, MPH, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- Going against medicine: courageous or foolish?
- Remembering Gene
- QD: News Every Day--About that placebo effect. . ....
- Why morning exercise is best
- QD: News Every Day--Medicaid continues to stress s...
- QD: News Every Day--Echinacea won't cure the commo...
- Changing the business of anticoagulation
- iPhone diagnosis of Raynaud's disease
- QD: News Every Day--Speaking fee bans are being by...
- Taking chocolate to heart
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.