Physicians’ CVD Counseling Practices

Prevention counseling rates were significantly lower for exercise and diet than for smoking and medication compliance (Table 2). Only 16% and 20% of physicians reported that they “always” counseled about exercise and diet, respectively, whereas 88% and 52% reported counseling smoking cessation and medication adherence, respectively (p<0.0001). Attending physicians were significantly more likely than residents (79% vs. 45%) to “always” counsel new patients about medication compliance (p=0.025). No other statistically significant differences between attending physicians and residents were found. Additionally, no significant differences were found in CVD counseling practices for new patients based on physician gender (data not shown).

With respect to specific CVD risk factors, the level of physician training was generally not a determining factor in the patterns of counseling (Table 3). However, attending physicians were more likely than residents to “always” counsel patients with high blood cholesterol about specific dietary recommendations. Attending physicians were significantly more likely than residents to “always” counsel patients with high blood cholesterol about decreased saturated fat intake, decreased dietary cholesterol intake, and weight loss (Table 3). There were no other significant differences in CVD counseling based on physician gender (data not shown).

Table 2. Percentage of Physicians Who “Always” Provide CVD Risk-Factor Counseling Practices for New Patients

Physicians were significantly more likely to provide CVD preventive care on exercise to patients with risk factors, such as obesity, hypertension, high blood cholesterol, sedentary lifestyle, and/or smoking, than to patients without such risk factors (Tables 2 and 3). Exercise counseling was “always” recommended in only 16% of patients without other CVD risk factors. For patients with obesity, hypertension, and high blood cholesterol, physicians always addressed counseling 61%, 40%, and 39% of the time, respectively (Table 3). The difference in exercise counseling frequency for patients with CVD risk factors compared to those without was significant (p<0.001).
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Table 3. Counseling Practice Patterns: Percentage of Physicians Who “Always” Engage in Specific Counseling Techniques

Physicians did a poor job helping patients set a plan to make behavioral changes. Only 16% of physicians encouraged patients that smoke to set a quit date. Few physicians set an exercise goal (17%), suggested specific exercises (29%), or gave specific instructions about exercise safety (13%) when counseling their sedentary patients (Table 3).
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Table 4. Percentage of Physicians Who Considered Counseling about the Following CVD Risk Factors “Very Important”

Physicians’ CVD Counseling Attitudes

The majority of respondents felt that it was “very important” to counsel patients about cholesterol, blood pressure, exercise, diet, smoking, weight reduction, and blood pressure medication compliance (Table 4). However, there were differences in the percentages of physicians who felt it was “very important” to counsel based on the type of risk factor. While 100% of physicians felt it was “very important” to counsel on smoking and 95% felt it was “very important” to counsel compliance with blood pressure medications, only 76% felt it was “very important” to counsel on exercise and diet, and only 79% felt it was “very important” to counsel on weight reduction.
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Table 5. Percentage of Physicians Reporting at Least “Moderate” Effectiveness in Preventive Patient Counseling

Physicians’ Perceived Lifestyle Counseling Effectiveness

Physicians felt significantly more effective when counseling on medication compliance than smoking cessation, diet, and weight (Table 5). Less than one-third of physicians felt “very” or “moderately” effective when counseling their patients about smoking cessation, exercise, healthy diet, or weight reduction, compared to 69% of physicians who felt at least “moderately” effective counseling on medication compliance (p<0.0001). There was no significant difference between attending and resident physicians in their perceived effectiveness in counseling.
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Table 6. Factors Affecting Physician Counseling (Percentage “Yes”)

Physicians’ Self-Reported Barriers to Prevention

The majority of physicians felt limited in their prevention practices by a lack of preventive care training (83%), and by a lack of knowledge about prevention guidelines (55%), and by general attitudes which value “acute” care more than preventive care (67%). Significant attitudinal differences were found between attending physicians and residents with regard to prevention recommendations and training. Attending physicians were significantly more likely than residents to state that “unclear” prevention recommendations were a limitation to providing preventive care. Significantly more attending physicians than residents felt that physicians were not very knowledgeable about current prevention guidelines and that physicians receive little training in prevention. Other barriers to prevention cited by physicians included lack of time, perceived lack of patient interest, missing or inadequate information in patient charts, communication difficulties with patients, and cultural differences between doctors and patients (Table 7).
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Table 7. Barriers to Counseling (Percentage “Yes”)