BACKGROUND: Physicians do not provide preventive care at the level recommended by national organizations. This may be because of physicians’ lack of training or low level of confidence or because of patients’ fears, beliefs, and lack of health knowledge.
METHODS: We used an observational prospective cohort study in an academic family practice office to investigate changes in patients’ functional status associated with receiving recommendations to change behavior from family physicians. Patients 18 years and older presenting for health maintenance visits to family physicians completed a functional status instrument and a brief intake questionnaire by telephone before their visit. After the visit patients were randomized to a debriefing interview or an observation-only group. The interview included the Patient/Doctor Interaction Scale and an assessment of whether patients received a recommendation to change behavior.
RESULTS: One hundred thirty-two patients were randomized to the debriefing group, and of those, 92% completed assessments at 3 months. Patients reporting recommendations to change behavior had lower scores at 1 and 3 months for mental health, social health, and self-esteem and higher anxiety and depression scores than patients not receiving these recommendations.
CONCLUSIONS: There are declines in social and emotional functional status in patients presenting to family practice clinicians for health maintenance visits during which recommendations for behavioral change were made. Such declines may inhibit physicians from making recommendations for behavioral change or patients from accepting them.
Preventive care is not sought by patients or provided by physicians at the level recommended by national organizations.1 This may be because of inadequate attention resulting from a physician’s lack of training,24 forgetting to provide preventive care,5 negative attitude toward such care,6 or low confidence in its effectiveness.7 The low level of preventive services delivery may also be caused by inadequate reimbursement to physicians,8 out-of-pocket costs to patients, patient fears of finding disease, patients’ health beliefs,9 lack of agreement between the physician and the patient regarding the need for behavioral change,10 and lack of information given to the patient.11 It is likely that the interaction among multiple factors results in the lack of provision of preventive care. Our previous work11 suggested an additional explanation: We found statistically significant declines in emotional and social functioning of patients who had been advised to change health-related behaviors, even though no organic illness was diagnosed. Similar results were reported by Stoate,12 who found patients with no acute complaints felt worse after receiving routine preventive care. Assuming the declines in functioning are representative of a widespread phenomenon, this may explain patients’ resistance to purely preventive care and provide insight into why physicians cite overall lack of gratification and satisfaction with providing it.2,3
These findings may be an extension of other known negative effects of preventive medicine. It is known that the diagnosis (or labeling) of asymptomatic patients with diseases is associated with negative outcomes. For example, the diagnosis of asymptomatic hypertension has been associated with a greater number of sick days,13 as well as lower income.14,15 The investigators did not find a decrease in psychological well-being, however. It is likely that similar functional changes could occur with the diagnoses of other conditions. For example, the cessation of smoking can cause physical symptoms (withdrawal) and be associated with the onset of depression.16 Starting a health promotion habit, such as physical exercise, may cause temporary symptoms as well. Patients may feel guilty if not engaging in the healthy behavior that was recommended or disappointed if results from behavioral change are not immediate. Changes in the way that a family functions may result from the knowledge of a new diagnosis or new behaviors, such as dietary changes.
We hypothesized that the pressure exerted by the physician’s advice challenges patients with limited confidence in their ability to manage change and causes a decrease in social and emotional functioning. To investigate this phenomenon, we conducted an observational study involving patients presenting for health maintenance in an academic family practice center.
Methods
Our study was completed in 3 phases: recruitment and baseline data collection, postvisit data collection, and telephone follow-up of patients at 1 month and 3 months. Patients from all socioeconomic strata aged 18 years and older presenting for health maintenance visits at the Family Practice Center of Bowman Gray School of Medicine were eligible. The Family Practice Center is an academic office where family-physician faculty, residents, and physician assistants care for patients. Appointment lists were screened to identify likely candidates, excluding those who were younger than 18 years and those presenting for acute care. Patients who met the inclusion criteria were contacted by telephone before their clinic visits, and after providing informed consent were given the Duke Health Profile (DUKE)17 and a brief intake questionnaire. We used the intake questionnaire to gather information on the reasons for visiting the clinician, previous experience with the clinician, and visit expectations. The DUKE profile is a 17-item questionnaire with 6 health measures (physical, mental, social, general, perceived health, and self-esteem) and 4 dysfunction measures (anxiety, depression, pain, and disability). The DUKE takes a broad view of health, has been validated in family practice populations, and is easy to administer.18