Towards a new model of patient-doctor interaction

In the last few posts, I have talked about the importance of adopting a risk-based approach to your own health and focusing on risk factors that can lead to the development of the “killer diseases”. I have also mentioned that this approach is the basis of clinical preventive medicine and that it is crucial to the concept of taking care of your own health before the development of disease.

In this post, I would like to spend some time of why the current doctor-patient model does not allow for this focus on prevention to happen naturally. In addition, I would like to propose a new model: one that is based on shared-decision making with the patient and a renewed focus on prevention.

We should all expect that our own doctors address the importance of these risk factors but this is not the case. For example, studies have shown that obese patients are advised to lose weight only 36% of the time during regular examinations, a proportion that improves only slightly to 52% if a patient already has obesity-related complications. Furthermore, only 28% of smokers reported that health care professionals had offered them assistance to quit smoking in the past year. (Lianov, Liana and Johnsson, Mark. Physician Competencies for Prescribing Lifestyle Medicine. JAMA July 10, 2010, 304(2).202-203.).

Moreover, approximately only 34% to 50% of adult patients remember receiving exercise counseling, and physicians miss many opportunities for physical activity counseling.

In 2001, only 8.2% of total outpatient visits included counseling or education related to exercise. (Jacobson et al. Physical Activity Counseling in the Adult Primary Care Setting Position Statement of the American College of Preventive Medicine. Am J Prev Med 2005;29(2). P.158-162.)

These types of studies show that doctors should be accountable for and be responsible for the inability to effectuate important health behavior changes in their patients. It is paramount and a crucial duty for doctors to help their patients adopt healthier behaviors, because patients cannot entirely effectuate these changes on their own.

Yet, physicians continue to ignore this important function, why?

Well for, one doctors have cited inadequate confidence and lack of knowledge and skill as major barriers to counseling patients about lifestyle interventions. Among the 620 respondents in a survey of family physicians, only 49% felt competent prescribing weight loss programs for obese patients (Lianov, Liana and Johnsson, Mark. Physician Competencies for Prescribing Lifestyle Medicine. JAMA July 10, 2010, 304(2).202-203.). In addition, several studies have shown that physicians in training do not adequately get trained these lifestyle-level interventions to prevent and treat chronic medical diseases (Sisson, S and Dalal, D. Internal medicine residency training in topics on ambulatory care: a status report. Am J Med. 2011; 124: 86-90).

 

Another reason for the lack of focus on risk factor assessment and prevention is the perverse reimbursement mechanism by insurance companies whereby doctors are paid to treat existing disease rather than focus on prevention. In fact, only recently did the Affordable Care Act (ACA) legislate the mandate to cover clinical prevention. Even though this represents a good start, ACA falls short of providing full comprehensive coverage on prevention.

Take home message: Patients are therefore left to fend for themselves to figure their own risk for diseases and how to best prevent them, unless you have a qualified doctor, such as a preventive medicine specialist, who can help with risk factor assessment and putting in place robust prevention plans. Preventive medicine specialists are able to help you complete risk assessment profiles and focus on behavioural counseling (smoking cessation, nutrition counseling and exercise prescriptions), recommendations for screening exams and preventive medications, while at the same time taking a holistic preventive approach to your health care needs.