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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Smoking as a vital sign just the first step
Raise the Flag of Relationships
Role for quality improvment processes
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Abigail C Halperin, Seattle USA Acting Assistant Professor, Dept of Family Medicine, University of Washington
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Boyle and Solberg make the point very well that incorporating the first of the five ‘A’s from the USPHS Clinical Practice Guideline for treating tobacco use and dependence will not automatically lead physicians or other providers to complete the steps that have been proven to help patients quit smoking. Asking about tobacco use at every visit is a necessary first step in identifying those who smoke or use other forms of tobacco, but the success rate of patients’ quit attempts is correlated, in a dose-response relationship, with the remaining ‘A’s: Advising them to quit, assessing willingness to quit, assisting in the quit attempt and arranging for follow-up. Assistance, in the form of motivational and practical counseling along with pharmacotherapy (if indicated) is the key component in this equation. Unfortunately, due to the well-known constraints on providers’ time with any given patient, it is unrealistic to expect that we will be able to spend even a minute or two on this issue with all our patients who smoke. Yet, thirty seconds worth of advice, with whatever authority is invested in us, plus referral to a program or service that provides the evidence-based treatment we know works, can double or triple our patients’ tobacco quit rates. Of course, for this benefit to be realized, office systems must be in place to ensure and expedite patients’ referral, and barriers to accessing a cessation program must be minimized. Personalizing advice to quit by utilizing a “teachable moment” in the encounter can increase motivation for the patient to follow through with the referral, and use of a convenient program (like a telephone quit line) can maximize ease of access for the patient. Use of pharmacotherapy (nicotine replacement and/or bupropion) plus proactive telephonic counseling optimizes patients’ chances for overcoming their addiction, but this resource is underutilized. One major barrier for the patient is cost of treatment and lack (or perceived lack) of insurance coverage for medication and the more intensive counseling that’s been proven to increase success in quitting. Although many insurers (and some states) now cover both medication and counseling for tobacco cessation, physicians and patients are often unaware of this benefit, and the ease and effectiveness of a telephone-based cessation service. Again, we get back to the question of asking, this time about insurance coverage, and the incorporation of office systems to streamline the process of assisting patients with utilizing their benefits and arranging the referral. Abigail Halperin MD, MPH Dept of Family Medicine, University of Washington Competing interests: I currently work (part time) as the Associate Medical Director of the Center for Health Promotion (CHP), which runs the Free and Clear telephone-based tobacco cessation program and provides quit line services for the states of Washington and Oregon. |
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William L. Miller, MD, MA, Allentown, USA Family Physician, Chair
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Surely, if you document smoking status as a vital sign and thus alert educated physicians, they will promote change; it's only rational. Rationality appears so clean. Surely, it can purify the messiness and muddiness of emotions and social, cultural, and spiritual differences and make things right in the world. Or so we seem to repeatedly think. Thank you, thank you, thank you, Drs. Boyle and Solberg. Finally, a rational study that might help to undermine our culture's obsession with rational simplicity. What is the current usual scenario? There is a problem (in this case, too many smokers). Inevitably, two solutions are proposed - educate and document. Surely, if people (such as physicians and patients) know the facts, they will act accordingly. Certainly, if it's documented, it must have happened that way. We have attempted to solve many important problems this way. The result, for example, is our current system of Medicare reimbursement, litigation, quality assurance, safety improvement, and accreditation (e.g. Joint Commission, etc.). The result is that I'm documenting more, and I've answered more test questions, but, as I read the literature and reflect on my own work, I don't see any evidence that primary care incomes are rising or that care is better or safer. The data are actually somewhat distressing. Should that really be a surprise? Wake up! Get real! Each of us knows, deeply knows, that most human behavior is not predominantly driven by rationality. This assumption is patently false. We are, and have always been, more likely to behave from our emotions and social expectations and in unconscious, culturally patterned ways than from what we learned in formal educational settings. And, frustratingly paradoxical creatures that we are, if our livelihoods depend on it, we are easily trained to document what we must, even if it didn't happen that way (often because the time to do the task was filled by documentation). Admit it - who among us has never "stretched the truth" in our documentation? Okay, I apologize for the polemical tone. The problems are serious, important, and our intentions have been good. It's because quality of care matters so much that my frustrations escaped. I'm mostly exasperated because our efforts to address these problems seem so misguided, so wasteful of time an money, and based upon false assumptions. Rationality is a wonderful and powerful tool with which humanity is blessed, but, I contend, needs to be used to serve people as they are in the complex world as it is. Some may wish that humans would always behave rationally, and some may wish that the world would work like a machine in a standardized, fixable way, but that is wishful and dangerous thinking and bad science. So, what can we do if there is a problem? Think culture! Nothing easy and nothing fast. It will first mean that values are addressed. Solutions that require time (and most effective and sustainable ones do) will probably cost money. There may even need to be a small reduction in income. Values trump rationality. Sigh and take a deep breath. Sit down with your colleagues. Develop your emotional intelligence, sharpen your conflict resolution skills, practice mindfulness. Then, invite some staff and a patient or two. Brew tea. Share stories of your imperfections, frustrations, and successes. Appreciate each other. Forgive each other. Collect appropriate and accurate data. Then begin the emotionally, socially, and spiritually messy, slow work (and fun) of systems' change - systems' change that fits people, not forcing people to fit the system. Begin the patient work of creating a culture of learning and inquiry that helps love grow. Identity and relationships trump education and documentation. Identity and relationships trump rationality. They don't replace rationality; reason serves identity and relationships. A better life together will need to prioritize values, agency, and communion. Acknowledge that you already live with this truth. Become comfortable with it. Work with it. The solutions will often not be standardizable; they will be human scale, flexible, and responsive to the multiplicities of context. And, it is also true that system change, culture change, will go better if some rationality, appropriate, contextualized education and minimal, strategic documentation are part of the community change process. Could this be a dimension of what it means for family medicine offices to be personal medical homes? Thank you, Drs. Boyle and Solberg! It is, finally, time to create healthy human communities of practice and to abandon the rationalistic mechanical model. It's time for a revolution! Raise the flag of values, agency, and communion; raise the flag of relationships! If you have a problem with this, please document it on TRACK, and then come over for tea. We have much to do! Competing interests: None declared |
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Alice S. Petrulis, seven hills, oh usa physician- medical director of Ohio KePRO
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The article by Boyle and Solberg underlies, once again, that documentation of smoking status alone does not lead to behavioral change. The problem may be 2-pronged: physician underestimation of themselves as a powerful motivator of patient change and the lack of available tools for the physician to use to affect that change. Patient education may be necessary in some cases. However, in addition, provider education may be an issue. Emphasis on the contributory role of smoking towards heart disease may be lacking as many patients focus on lung cancer as the outcome of a long-term smoking habit. The physician may also be at a loss as to recommendations to make regarding smoking cessation techniques such as the location of local programs. There appears to be an opportunity for introduction of quality improvement processes to be initiated to achieve alterations in patient behavior. Multi-level interventions involving not only patient self- management, office staff involvement in the use of guidelines, flowsheets and other tools, data collection with analysis and feedback, and utilization of the physician as a clinical champion and motivator, may be the recipe needed for effective change. Competing interests: None declared |
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