Doctors as Agents of Public Health Promotion

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:

  1.  Physicians will likely feel undermined by an external mandate to counsel patients about their health behaviors.
  2.  Patients will resent or resist health behavior messages that come from health providers.
  3.  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.

About Brendan Saloner

I am a postdoctoral fellow at the University of Pennsylvania in the Robert Wood Johnson Health and Society Scholars Program. I completed a PhD in health policy at Harvard in 2012. My current research focuses on children's health, public programs, racial/ethnic disparities, and mental health. I am also interested in justice and health care.
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3 Responses to Doctors as Agents of Public Health Promotion

  1. markgamsu says:

    Hi Brendan – regrettably I think that the “every contact counts” message is problematic for the following reasons:

    First – and most importantly – its a diversion from the real issues – is this really what some of the best minds in the UK can come up with as one of the key mechanisms for improving the publics health? There are more important strategic issues that we need to be focussing on – such as equitable access to primary care, whether we have the right balance with regard to investment between action to tackle the social determinants of health and clinical provision etc etc.

    Second – its ill thought out and largely rhetorical. Think of a patient journey along a clinical pathway – where they may see 4 or 5 health professionals in the course of the one visit – this proposal calls for each of them to be using brief interventions to talk to the same individual – think of the impact on health costs here let alone the irritation of the patients!

    Finally – there is nothing wrong with reminding health professionals that part of their role is use brief interventions to promote good health – but that is all this – its good practice which happens already in many cases. This proposal is not one of the key strategic solutions to improving population health – which given the space it has been given the NHS Future Forum document is how it appears.

  2. Hi Mark,

    Thanks so much for the thoughtful reply.

    First, I think we can all agree that equitable access is an important goal, but why does an every contact counts message undermine equitable access? Is this a point about political strategy (that there is only attention to deal with one of these issues?) or is it a point about resource allocation (that you clog up physician hours that could be used to see more patients by emphasizing brief interventions?). In either case, I tend to believe that resources (political or provider time) are not so constrained that they preclude better screening and counseling in primary care. Note, for example, that if we count an encounter as a single trip to a provider that some of these goals can be achieved through non-physician medical personnel such as nurses.

    Second, my point from above applies here. In a world of excellent integration and patient-centered care, patients are not asked the same questions multiple times. Rather, the specialist can look at a printout and say “I noticed that you are currently smoking, and in your visit with your GP last week you discussed attending a class to help you quit. Do you need any help identifying resources in your area?” Integrated care means that each linkage reinforces what the previous one is doing, not duplication of efforts.

    Finally, I think we should be agnostic about how much population health could improve through physician intervention. I tend to agree with people that emphasize the importance of safe neighborhoods, better early intervention etc., but in terms of secondary prevention this may be a pretty good leverage point.

    Anyway, great comments!

  3. Pingback: 2. Analysis – Public Health System – Keeping Sweet in Seattle

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