The will to change

Behaviorists argue that doctors need to help turn patients around

July 08, 2001|By Jane E. Allen, Los Angeles Times.

Making even modest changes in health habits apparently is too difficult for many Americans.

We repeatedly hear that more exercise, watching our diets and losing just 10 pounds can lower our cholesterol and dramatically reduce the risk of diabetes.

Still, more than half of us are overweight, and more than one-fifth have high cholesterol. So-called late-onset diabetes is striking at younger and younger ages, and nearly a fifth of all seniors have it. You have to look pretty hard to find Americans who take the recommended half-hour or more of exercise five days a week.

For a long time, people have been blamed for not taking control of their health, accused of being lazy or unmotivated. But increasingly, behavioral experts are realizing that most folks want to change. They just need help.

Attention is turning to physicians. After all, they're in the best position to guide patients through long-term changes in their health habits and to monitor their progress.

Yet behavioral counseling "hasn't been incorporated into routine medical practice," said Jessie C. Gruman, executive director of the Center for the Advancement of Health.

Each year, U.S. patients visit doctors 829 million times, an average of 3.1 visits for each patient. That represents millions of potential counseling opportunities, Gruman said.

The not-for-profit organization recently surveyed doctors, HMOs and public health leaders and found that when health professionals talk briefly with their patients about lowering their health risks, managing chronic illness and pharmacy use, "they are more likely to attempt and succeed at changing poor health habits."

Patients are much less likely to adhere to mere instructions to "lose 10 pounds," "cut back on the sugar" or "watch your cholesterol."

Take Paul H. Scott, 54, an engineering manager from San Jose, Calif., who was diagnosed with diabetes. His sugar level was high, "but I didn't know what that meant. It was just a number," he recalled.

Patient did the opposite

Rather than heeding his doctor's advice to lose weight, he ballooned to 350 pounds, continuing "to eat everything in front of me."

When his doctor suggested he enroll in diabetes-education classes, "I said sure, but I never did," Scott recalled. "I blew him off."

To be fair, doctors are working against a tide.

Social forces conspire against doing the right thing. There are seductive invitations to grab a burger, fries and a super-sized soft drink and plop down on the couch with a channel-changer. That leaves a bigger selling job for doctors, who often are ill-prepared for behavioral counseling.

Few physicians feel comfortable in the counselor's role. Most complain they don't have time for detailed discussions. And they're not reimbursed for time spent talking, a factor that some say needs to change if counseling is to become routine during office visits.

Furthermore, knowledge about how to instill healthful habits "hasn't been recognized nor organized nor incorporated into medical training nor into continuing medical education," Gruman said. "It's not seen as something that's as scientifically driven as a prescription for medication."

Dr. Mitchell Feldman, an internist who trains primary-care residents at the University of California at San Francisco, said counseling "is what most clinicians don't do. They like to treat things with five days of antibiotics and the problem goes away."

Changing health habits takes time and patience. Doctors may not feel that they're making a difference. The gratification is often delayed. They may not hear until the next annual visit that a patient has lost the weight, begun to exercise or given up smoking.

Doctors give up

Like kids who need to fall off a bicycle several times before learning to ride, most people fail repeatedly before reaching their goal. Doctors often give up on patients after initial failure, though physicians frequently have the same difficulties changing their ways.

Feldman said primary-care doctors often "forget to try to sit back a little bit more and assess where the patient is at. The mistake I see over and over in residents and ... with many primary-care physicians is they don't really try to assess the person's readiness for change."

Some patients are only thinking about change; others are prepared to acknowledge their behavior's impact but aren't ready to make the commitment. Still others are making changes and need help with maintenance.

Often, patients don't receive the empathy they need to adopt and sustain new habits that may entail some sacrifice.

"It's not necessarily what you say, but how you say it: acknowledging that they're giving up something, maybe something they find very pleasurable," said Dr. Michael Goldstein, who helps primary doctors promote behavioral changes.