Teaching Medical Students About Counseling: Smoking Cessation

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


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.


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


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!


Physician-Based Interventions: Criteria

Evidence-based; demonstrated to be effective

Brief; fit in context of regular medical visit



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 occurs along a continuum from very directive to very non-

directive.


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..


Stages of ChangePrecontemplation

Contemplation

Action

Maintenance

Relapse


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)



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



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.


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.


Evidence that pt-centered counseling is effective


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.


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


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.



Office systems are necessary to remind/prompt physicians to intervene


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


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


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)


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.



“Listen to the patient,

he is telling you the diagnosis.”

Sir William Osler


“You can observe a lot by watching.”

Yogi Berra(spring training)

Documents

Teaching Medical Students About Counseling: Smoking Cessation