Teaching Medical Students About Counseling: Smoking Cessation

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

5. 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!

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

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 occurs along a continuum from very directive to very non-directive.

9. Continuum of Counseling __________________________________________________ Non-directive Directive • 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.

10. 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. Counseling for Health Enhancement (PPS) 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..

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

13. 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)

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

15. Counseling for Health Enhancement (PPS) Patient-Centered Counseling Model 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.

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. Counseling for Health Enhancement (PPS) 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.

18. 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.

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

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

21. Counseling for Health Enhancement (PPS) Physician-Delivered Smoking Intervention: Wilson et al. (1988) % Cessation Usual Care Cued Only with Gum Cued + MD Training with Gum Physician Intervention Condition Wilson et al., (1988), JAMA.

22. 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.

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

24. A Clinical Practice Guideline for Treating Tobacco Use and DependenceU.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

25. 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. 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. Vital Signs Stamp Blood Pressure_________________________ Pulse_________________________________ Temperature___________________________ Respiratory Rate________________________ Smoking Status Current Former Never Circle

28. Counseling for Health Enhancement (PPS) 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.

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

30. “You can observe a lot by watching.” Yogi Berra (spring training)