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Counseling for Health Enhancement (PPS)
Teaching Medical Students About Counseling: Smoking Cessation
Judith K. Ockene, Ph.D., M.Ed.Professor of Medicine and Chief,
Division of Preventive and Behavioral MedicineUniversity of Massachusetts Medical School
Counseling for Health Enhancement (PPS)
This session is intended to help you understand that:
• The physician’s role is important for educating and assisting patients to make behavioral changes.
• Counseling occurs along a continuum from very directive to very non-directive.
• Behavior change is a process and not a one-time event.• Patient-centered counseling reflects the values of the patient and
physician and medical evidence.• Active participation by patients is an important part of the change
process.• Office systems are necessary to remind/prompt physicians to
intervene.
Counseling for Health Enhancement (PPS)
Brief 5A Intervention Model
• ASK about tobacco use at every visit
• ADVISE all tobacco users to quit
• ASSESS willingness to quit
• ASSIST the patient in quitting
• ARRANGE follow-up contact
Importance of Providers Doing Preventive Counseling
Counseling for Health Enhancement (PPS)
Primary Care Physicians are Important for Prevention and Intervention
• Provide continuity of care• 80% of adults visit an MD/year• Credible information source• People are aware of their health when
visiting an MD• Can refer to other providers• They are effective!
Counseling for Health Enhancement (PPS)
Physician-Based Interventions: Criteria
Evidence-based; demonstrated to be effective
Brief; fit in context of regular medical visit
Counseling for Health Enhancement (PPS)
Counseling for Health Enhancement (PPS)
Patient-Centered Counseling Acknowledges:
• The patient and physician have important information to exchange when addressing a problem;
• The patient brings a view of his/her needs, goals and interests;
• The physician brings knowledge about health consequences and his/her own values;
• Medical evidence affects the patient-physician dialogue.
Counseling for Health Enhancement (PPS)
Counseling occurs along a continuum from very directive to very non-
directive.
Counseling for Health Enhancement (PPS)
Continuum of Counseling
• The patient’s perspective is an important starting point.• Non-directive: Physician presents options but does not
make recommendations; patient decides with little guidance.
• Directive: Physician makes clear recommendations. At extreme – does not take patient values/needs into account.
• Most Counseling occurs in between two extremes.• Counseling is dynamic. It shifts back and forth.
__________________________________________________
Non-directive Directive
Counseling for Health Enhancement (PPS)Continuum of Counseling (cont’d)
Each point determined by combination of three factors:
Medical Evidence
Patient’s Views/Values/Preference
Physician’s Views/Values
___________________________________________________
Known Uncertain Unknown
____________________________________________________
Strong Uncertain None
____________________________________________________
Strong Uncertain None
Theories and Models for Behavior Change and Education
The Theories and Models to be discussed apply to the education of the provider and the treatment of the patient..
Counseling for Health Enhancement (PPS)
Stages of ChangePrecontemplation
Contemplation
Action
Maintenance
Relapse
Counseling for Health Enhancement (PPS)
Social Learning Theory: Albert Bandura (1977)
Behavior is learned and can be unlearned
People learn best by active participation
People need to believe they can change (self-efficacy)
Counseling for Health Enhancement (PPS)
Counseling for Health Enhancement (PPS)
Autonomy
Recognizes the patient’s capacity to reason and make his/her own choices
in accordance with
personal values and life plans.
Six general principles: Accept patient where she is; Use medical evidence; Acknowledge patient autonomy and that he/she
has the answers; Build self-efficacy; Set realistic expectations for self & patient; and Share responsibility.
Patient-Centered Counseling Model
Counseling for Health Enhancement (PPS)
Counseling for Health Enhancement (PPS)
Patient-Centeredness
• Reflects the concept of personal autonomy.
• Helps the patient to make his/her choices in
according to personal values and life plan.
• Therefore, the importance of autonomy is
reflected in patient-centeredness.
Patient-Centered Counseling Components
• Provide information;
• Use a series of “guided questions” to
help move the pt along the continuum of
change; and
• Provide feedback.
Counseling for Health Enhancement (PPS)
Patient-Centered Counseling
Uses questions related to five content areas:• Desire and motivation to change behavior;
• Past experiences with the behavioral change;
• Factors that inhibit the change (barriers);
• Resources for change (strengths); and
• Plan for change and followup.
Counseling for Health Enhancement (PPS)
Evidence that pt-centered counseling is effective
Counseling for Health Enhancement (PPS)
Physician Delivered Smoking Intervention Project
9%12%
17%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Six Month Self-Reported Smoking Cessation Rates
Advice(n=439)
Counseling(n=401)
Counseling Plus NicoretteTM
(n = 378)Physician-Intervention Condition
p<.002
Ockene, JK et. al., (1991), JGIM 6:1-8.
Counseling for Health Enhancement (PPS)
4%6.1%
8.8%
0%
2%
4%
6%
8%
10%
UsualCare
Cued Only with Gum
Cued + MD Training with Gum
% Cessation
Physician-Delivered Smoking Intervention:Wilson et al. (1988)
Wilson et al., (1988), JAMA.Physician Intervention Condition
Counseling for Health Enhancement (PPS)
Physician Delivered Smoking Intervention Project
The more the physician does with the patient, the more likely he will stop smoking!!
Ockene, JK et. al., (1991), JGIM 6:1-8.
Counseling for Health Enhancement (PPS)
Counseling for Health Enhancement (PPS)
Office systems are necessary to remind/prompt physicians to intervene
Counseling for Health Enhancement (PPS)
A Clinical Practice Guideline for Treating Tobacco Use and Dependence
U.S. Public Health ServiceAgency for Healthcare Research & Quality
• It is essential that clinicians and health care delivery systems (including insurers and purchasers) institutionalize the identification, documentation and treatment of every tobacco user.
JAMA, June 28, 2000--Vol. 282, No. 24
Counseling for Health Enhancement (PPS)
ASK . . . . . . . .
• Systematically identify all tobacco users at every visit: Implement an office-wide system that ensures that every patient is queried each visit. Expand the vital signs, use status stickers on charts or computerized reminder systems.
JAMA, June 28, 2000--Vol. 282, No. 24
Counseling for Health Enhancement (PPS)
Odds Ratio (95% CI)
Cessation Rates (95%
CI)
No System 1.0
3.1%
System 2.0 (0.8-4.8)
6.4% (1.3-11.6)
Efficacy of Office Systems to Identify Smokers at Each Clinical Encounter
(Meta-Analysis of 3 Studies)
Counseling for Health Enhancement (PPS)
Vital Signs Stamp
Blood Pressure_________________________
Pulse_________________________________
Temperature___________________________
Respiratory Rate________________________
Smoking Status Current Former Never Circle
Summary
• Providers can develop PCC skills.
• Brief PCC is effective in helping pts stop smoking,
and decrease sat. fat intake, LDL, total chol, weight,
& alcohol intake.
• Providers use PCC skills when they are reminded &
given materials.
• PCC is more effective than advice alone.
• Systems remind and support providers to intervene.
Counseling for Health Enhancement (PPS)
Counseling for Health Enhancement (PPS)
“Listen to the patient,
he is telling you the diagnosis.”
Sir William Osler
Counseling for Health Enhancement (PPS)
“You can observe a lot by watching.”
Yogi Berra(spring training)