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Patients take lifestyle recommendations seriously, but not many physicians offer them. Why not? Do you?
The Nadolsky brothers break down the statement's 2020 goals
It is well recognized that lifestyle is medicine and that a significant proportion of ailments are directly caused by or adversely affected by aspects of lifestyle or behavior. Despite that, there remains discordance with appropriate lifestyle and behavioral counseling by physicians. Last month, the American Heart Association issued a scientific statement, "Medical Training to Achieve Competency in Lifestyle Counseling: An Essential Foundation for Prevention and Treatment of Cardiovascular Diseases and Other Chronic Medical Conditions," calling for a focus on training physicians to improve this critical aspect of patient care.
The statement cites their 2020 goals for cardiovascular health promotion and previously identified lifestyle characteristics to focus upon including nutrition, physical activity, smoking, and adiposity. Our column showcasing news and insights for practicing lifestyle medicine is an effort to advance the practice amongst clinicians. Lifestyle or behavioral therapy is always recommended as first line for prevention or treatment of related diseases as we pointed out in a review of clinical practice guidelines last year. It is noted, in the statement, that physicians should be the leaders in lifestyle and behavior counseling due to their being in the best position on the front lines with patients and that 80% of Americans visit their primary care physician annually. Patients place a high value on recommendations from their physicians but unfortunately, the rate of lifestyle counseling from physicians is poor. This is reportedly due to feeling a lack of knowledge on diet or exercise and low confidence in prescribing those modalities effectively.
In recommending integration of fundamentals to lifestyle counseling in medical school curricula, general education objectives related to behavioral sciences and lifestyle components were proposed. The proposed learning objectives are divided into categories of behavioral sciences and skills, nutritional assessment and counseling, physical activity and exercise assessment and counseling, and tobacco exposure assessment and smoking cessation counseling. Within each category, the statement lists multiple specific recommendations for providers.
Much of the statement revolves around education of the physician as lack of lifestyle medicine knowledge is thought to be the major reason why physicians do not discuss it in the clinic. We personally feel that medical school curricula wouldn't need to be completely overhauled. There would just need to be more of an emphasis on lifestyle as medicine in each lecture when applicable with some additional lectures and rotations teaching behavioral science, nutrition, physical activity, and smoking cessation.
The article does discuss how the education of "what" to do is likely less important than the "how." Actually implementing behavior change ("how") in the clinic may require more training than the knowledge ("what"). See a previous article where we discuss motivational interviewing.
A key component of motivating physicians to actually promote lifestyle as medicine may be sufficient reimbursement and time. Many physicians feel pressured to see more patients on a daily basis, which limits their time with each patient.
Becoming efficient in a patient encounter would be needed in our current system of less time per patient. In an optimal healthcare system, the physician would be allowed ample time to provide lifestyle behavioral change therapy along with sufficient reimbursement to give more incentive to the physician. These limitations are briefly mentioned in the article, but we believe these play a much larger role in getting physicians to push lifestyle as medicine.
Another barrier is the believed notion that patients do not want or care for the lifestyle counseling. Physicians believe their patients aren't receptive to lifestyle counseling so they omit it altogether in their encounters. This is despite the evidence that shows physician encouragement of lifestyle changes is effective. We have personally noticed this behavior among our colleagues and understand the frustration. However, there are patients out there who will most definitely be receptive to the lifestyle counseling when approached in a nonconfrontational manner. These patients would be missed if lifestyle counseling were omitted completely.
Karl Nadolsky, DO, is board-certified in endocrinology and in internal and obesity medicine. Spencer Nadolsky, DO, is a primary care physician board-certified in family and obesity medicine. Both have patient-facing blogs, at DocsWhoLift.com and DrSpencer.com.
Karl and Spencer Nadolsky disclosed no relationships with industry.
Primary Source: Hivert M-F, et al, Medical training to achieve competency in lifestyle counseling: An essential foundation for prevention and treatment of cardiovascular diseases and other chronic medical conditions: A scientific statement From the American Heart Association. Circulation 2016; DOI: 10.1161/CIR.0000000000000442.
This article was first published on MedPage Today and reprinted with permission from UBM Medica. Free registration is required.