Want to change patient behavior? Change tactics

Are your patient charts set up to track medical diagnoses and treatment plans — but not preventive services? Are your patient education brochures gathering dust on a rack in the hallway?

Improving physician counseling about health risks may involve making some organizational changes in your practice. Here are some tips from preventive medicine experts:

1. Assign patient education tasks to one staff member.

Giving one person responsibility for reviewing charts and following up on patient risk factors can make the physician’s efforts more focused and efficient.

Kathleen Soch, MD, associate professor of medicine with the Corpus Christi, TX, family practice residency program at Spohn Memorial Hospital, uses a coordinator to make sure risk assessments are completed every other year by all patients. She places pink alert stickers on the chart if a preventive screening test, such as the Pap smear, or counseling for a risk factor, such as smoking, are required.

The patient education coordinator also locates community resources where the physicians can refer patients, and she attaches appropriate education brochures to the chart for physicians to hand out and discuss.

Those reminders have improved preventive medicine at the family residency clinic, says Soch. "It’s easy to think you’re offering preventive services, [but] you get caught up in the day-to-day [acute] care of patients," she says.

While the patient education coordinator should have training in medical terminology, he or she does not need to be an RN, says Soch. Depending on the size of the practice, the patient education role also could fill a portion of a staff member’s responsibilities.

2. Conduct risk assessments, including body mass index, on each patient and attach results to the chart.

If physicians don’t know the patient is obese (more than 20% over the recommended body weight), then they aren’t likely to urge them to lose weight. The same is true for poor exercise habits, smoking, and other risky behaviors.

The U.S. Preventive Services Task Force in Washington, DC, recommends that screening for obesity should be included in the routine health checkup. Some physicians may be weighing patients but not measuring their height, which is necessary to determine the body mass index, notes Mary L. Adams, MPH, MS, an epidemiologist with the Connecticut Department of Public Health in Hartford, who has analyzed patient survey data about physician counseling.

Physicians may alter some questions on risk assessments based on the needs of their patients, the requirements of their health plans, and their own views about what is appropriate to include. For example, not all physicians will ask about firearm ownership or seat belt use. However, routine questions relate to major risk factors leading to disease, such as sedentary lifestyle, alcohol abuse, smoking, and poor nutrition.

3. Document the counseling you provide and follow up with patients.

Patient flow sheets provide an easy way to make sure patients received the screening and counseling they need at recommended intervals. That information also will be readily available when managed care organizations review charts for compliance with the National Committee for Quality Assurance’s Health Plan Employer Data and Information Set (HEDIS) standards.

The flow sheets enable physicians to log HEDIS events for their own outcomes management, notes Wilkinson. "[They] become a quality assurance audit tool," she says. "There’s one sheet you can [check] to see if [patients] meet all the criteria."

4. Make sure you communicate your advice clearly.

Physicians generally report higher levels of counseling about risk factors than patients do. In part, that disparity may be caused by ineffective communication.1 "The patient may not realize he or she had been counseled," says Adams.

For example, the Clinician’s Handbook of Preventive Services tells physicians to state directly to patients, "As your physician, I must advise you to stop smoking now." A more casual remark, or visible anti-smoking posters, may not be viewed as physician advice, Adams notes.


1. Friedman C, et al. Physician advice to reduce chronic disease risk factors. Am J Prev Med 1994; 10:367-71.