In Britain, the NHS Future Forum issued a report calling on the medical establishment to carry the banner of public health: “every contact must count as an opportunity to maintain and, where possible, improve their mental and physical health and wellbeing.” To realize this goal conversations about preventive health may need to extend into new arenas: dentists could talk to patients about smoking, and nurse visitors could talk to new mothers about mental health care such as anxiety management.
The Lancet editors oppose this policy:
The average GP consultation time is 11.7 minutes in the UK. So, if a patient comes in with stomach pain, for example, a GP would have just over 10 minutes to encourage and let the patient talk, listen, establish a good relationship, communicate effectively, and make an accurate diagnosis. Lecturing the patient on their lifestyle choices during this time is likely to appear rushed and inappropriate, especially if doctors see the task as a box-ticking exercise. There is a high risk that such an approach will leave the patient feeling frustrated, resentful, and reluctant to return.
At least three claims motivate the Lancet editors:
- Physicians will likely feel undermined by an external mandate to counsel patients about their health behaviors.
- Patients will resent or resist health behavior messages that come from health providers.
- There are other strategies that are less intrusive and more effective outside of the medical realm.
Each of these claims is at least debatable.
In the United States context – as in Britain – encounters between doctors and patients are typically less than 15 minutes. This is, indeed, a very brief window to have a meaningful conversation about lifestyles or to engage in adequate counseling about tobacco, alcohol, or mental health. Nevertheless, we know that such counseling is taking place already (albeit on a limited and scattered basis). For example, 2/3 of all visits in primary care for adults include tobacco screening (although there are substantial racial and insurance disparities). Why is tobacco screening now a part of most visits with providers? Undoubtedly, many physicians realize that tobacco use is part of the overall assessment of patient health, and screen for tobacco use in order to help their patients become healthier. Beyond screening, the real breakdown is in helping patients to change their behaviors. To get to this point will require systems of care that make transitions to smoking cessation, drug treatment, and mental health more seamless, and feed this information back into primary care to improve future treatment.
Will patients resent their providers bringing up health behaviors in the office visit? I imagine some patients will, since many people believe that questions about their personal behaviors are intrusive and harassing. Others, however, appreciate the opportunity to learn about how to make themselves healthier. Even if the initial conversation is bumpy, physicians can gain much by opening up a line of communication that will allow the topic to be revisited in the future. More broadly, physicians are at the front lines of communication with patients, and are able to lower the stigma of talking about health behaviors by presenting topics in a frank and honest light. Talking about safe sex, for example, is embarrassing for teens, but communication with professional is improving on this topic over time and this is beneficial from a public health standpoint that young people receive accurate information.
Finally, should we leave public health promotion to other arenas? Here is what the Lancet editors say: “Effective, evidenced-based public health measures do not include nudging people into healthy behaviours or getting NHS staff to lecture patients on healthy lifestyles. They include measures such as raising taxes on cigarettes, alcohol, fatty foods, and sugary drinks, reducing junk food and drink advertising to children, and restricting hours on sale of alcoholic drinks.” This strikes me as a false dilemma. First, pairing health promotion through “nudging” in the physicians office with large-scale policy changes is likely to create a positive policy interaction. Smoking is once again an informative example where the public was steered away from cigarettes in the store and informed about the consequences of smoking from their medical providers. The editors are right to argue that we should be guided by evidence-based strategies, but the science of communicating with patients effectively is still a work in progress. Not all strategies will work, but the medical community should pay careful attention to messages that work well and train (in medical school and continuing education) to be the messengers of positive health behaviors.