1. 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 Medicine University of Massachusetts Medical School

2. 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.

3. 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

4. Importance of Providers Doing Preventive Counseling Counseling for Health Enhancement (PPS)

5. 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)

6. Physician-Based Interventions: Criteria l Evidence-based; demonstrated to be effective l Brief; fit in context of regular medical visit Counseling for Health Enhancement (PPS)

7. 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.

8. Counseling for Health Enhancement (PPS) Counseling occurs along a continuum from very directive to very non- directive.

9. 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

10. 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

11. 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)

12. Stages of Change Precontemplation Contemplation Action Maintenance Relapse Counseling for Health Enhancement (PPS)

13. Social Learning Theory: Albert Bandura (1977) l Behavior is learned and can be unlearned l People learn best by active participation l People need to believe they can change (self-efficacy) Counseling for Health Enhancement (PPS)

14. Autonomy Recognizes the patient’s capacity to reason and make his/her own choices in accordance with personal values and life plans.

15. Six general principles: l Accept patient where she is; l Use medical evidence; l Acknowledge patient autonomy and that he/she has the answers; l Build self-efficacy; l Set realistic expectations for self & patient; and l Share responsibility. Patient-Centered Counseling Model Counseling for Health Enhancement (PPS)

16. 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.

17. 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)

18. 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)

19. Evidence that pt-centered counseling is effective Counseling for Health Enhancement (PPS)

20. Physician Delivered Smoking Intervention Project Six Month Self-Reported Smoking Cessation Rates Advice (n=439) Counseling (n=401) Counseling Plus Nicorette TM (n = 378) Physician-Intervention Condition p<.002 Ockene, JK et. al., (1991), JGIM 6:1-8. Counseling for Health Enhancement (PPS)

21. Usual Care 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)

22. Physician Delivered Smoking Intervention Project l 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)

23. Office systems are necessary to remind/prompt physicians to intervene

24. Counseling for Health Enhancement (PPS) A Clinical Practice Guideline for Treating Tobacco Use and Dependence U.S. Public Health Service Agency 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

25. 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

26. 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)

27. Counseling for Health Enhancement (PPS) Vital Signs Stamp Blood Pressure_________________________ Pulse_________________________________ Temperature___________________________ Respiratory Rate________________________ Smoking Status Current Former Never Circle

28. 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)

29. “Listen to the patient, he is telling you the diagnosis.” Sir William Osler

30. Counseling for Health Enhancement (PPS) “You can observe a lot by watching.” Yogi Berra (spring training)