Nutrition and exercise play an important role in the prevention and treatment of chronic diseases. However, since these topics have traditionally received little attention in the medical school curriculum, many physicians and other health professionals are not adequately trained on how to help patients adopt effective lifestyle changes. To change this, one medical school is giving tomorrow’s physicians the skills they need to counsel patients on their lifestyle behaviors and motivate them to take greater control of their health.
“We’ve been doing behavioral change counseling in our doctoring courses, now called Delivery of Clinical Care,” Anton Alerte, MD, told AMA Wire®. “It’s always been part of an overall approach to behavioral counseling.” He is associate professor of pediatrics at the University of Connecticut School of Medicine (U. Conn.), a member school of the AMA Accelerating Change in Medical Education Consortium.
In the first-year curriculum, topics cover diet, exercise, smoking cessation and alcohol use. Within these topics, students are taught the basic principles of behavioral counseling and intervention techniques.
“This is solidified in actual practice sessions with our patient instructors in our clinical simulation lab throughout their time in the clinical portion of the medical education curriculum,” Dr. Alerte said. The “patient instructors” are standardized patients trained to provide feedback.
The school’s clinical simulation lab gives students the opportunity to practice challenging, immersive simulation training within a safe, hands-on learning environment. While in the lab, students identify barriers and opportunities for behavioral change on standardized patients. Once an assessment is made, students receive feedback from instructors as well as from faculty observers.
“It’s a motivational interviewing kind of approach with identifying barriers and opportunities, and coming up with a shared plan for behavior change,” said Lynn Kosowicz, MD, associate professor of medicine at the school.
Second-year students complete a section on “well care” and preventive maintenance. This covers a number of medical diagnoses that require chronic management, including hypertension. Students work through what the literature says in terms of management goals, intervals for screenings and the steps for managing chronic illnesses.
More than writing a prescription
Caring for patients goes beyond medications. However, patients often find it difficult to maintain proper exercise and nutrition. And physicians face the challenge of helping those patients make such changes.
“It’s not really so much about what we do that matters in the long run as far as patient health is concerned—it’s what we can help them do,” said David Henderson, MD, associate dean for medical student affairs, and multicultural and community affairs at U. Conn.
“We can write as many prescriptions as we want, but if we can’t get people to conduct themselves differently, to develop habits that are healthier, if we can’t help them deal with some of the social and economic issues that affect their health, then we can’t really accomplish very much,” said Dr. Henderson.
He also believes that behavior change and empowering patients constitutes a major portion of the successful delivery of health care.
For example, Dr. Henderson explains that if he knows he will be treating a patient who has salt-sensitive hypertension and doesn’t explore “why they spend so much time worshiping at the salt lick, then it’s going to be difficult for me to bring their blood pressure down to desirable levels.”
“If I don’t talk to them about the fact that they don’t exercise and try to help them figure out how they might be able to become more active and less sedentary, I am less likely to help them succeed in managing their chronic illness,” he added.
Students will have a new opportunity to better understand how difficult it can be to adhere to a new medicine regimen, according to Dr. Alerte. In this new project, students will receive prescriptions—to be filled with Tic Tacs. They will be tasked with taking these medications on a regular basis and report back on how easy or difficult it is to comply with the regimen.
Also for first three years of medical school, U. Conn. students spend one afternoon each week with a physician mentor in the community. The students have the opportunity to assist patients in changing behaviors and monitor the outcome longitudinally.
U. Conn. also offers a program, called Community Based Education (CBE), that helps med students gain a broader view of their future role as physicians. Community organizations offer students opportunities to interact with and learn from people from a wide range of social, cultural and ethnic backgrounds. This program also allows students to learn about the relationships between patients’ physical and social environment and their health and well-being, as well as available community resources.
Helping physicians make the best use of evidence-based interventions for patients with hypertension is a major initiative of the AMA. With the recent release of the American Heart Association-American College of Cardiology hypertension guideline, about half of American adults are classified as having hypertension. Yet most of those newly designated as having high blood pressure (BP) will first benefit from nonpharmacological lifestyle changes as well as support to overcome health barriers.
The AMA’s Target: BP initiative recognizes practices that improve their BP control rates through an effective combination of accurate measurement, rapid action through lifestyle change and medication as indicated, and partnerships with patients, families and communities.
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