Counseling Patients in Primary Care: Evidence-Based Strategies

 

Family physicians spend substantial time counseling patients with psychiatric conditions, unhealthy behaviors, and medical adherence issues. Maintaining efficiency while providing counseling is a major challenge. There are several effective, structured counseling strategies developed for use in primary care settings. The transtheoretical (stages of change) model assesses patients’ motivation for change so that the physician can select the optimal counseling approach. Structured sequential strategies such as the five A’s (ask, advise, assess, assist, arrange) and FRAMES (feedback, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) are effective for patients who are responsive to education about health risk behavior. For patients ambivalent about change, motivational interviewing is more likely to be successful. Capitalizing on a teachable moment may enhance the effectiveness of health behavior change counseling. The BATHE (background, affect, troubles, handling, and empathy) strategy is useful for patients with psychiatric conditions and psychosocial issues. Patients should be referred for subspecialty mental health or substance abuse treatment if they do not respond to these brief interventions.

Counseling patients on lifestyle modification and psychosocial problems is a fundamental competency for family physicians.14 Approximately 40% of primary care office visits are for chronic illness5 in which psychosocial factors play a major role in etiology and disease progression.6 Counseling patients about health risk behaviors and health education is a core component of 18% of all primary care office visits.5 Although counseling regarding weight management, diet, smoking, and alcohol use is an important part of clinical practice, a survey found that only between 31% and 56% of primary care physicians rated themselves as having significant expertise in counseling about these issues.4

WHAT IS NEW ON THIS TOPIC

Research based on the transtheoretical (stages of change) model suggests that it is possible to change multiple health risk behaviors concurrently.

Application of the FRAMES counseling protocol to French primary care patients found reductions in cannabis use among patients up to 18 years of age at the six-month follow-up, whereas use increased among adolescents receiving routine care.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

The five A’s (ask, advise, assess, assist, arrange) technique has been associated with reduced smoking and alcohol use as well as modest weight loss.

B

10, 25, 26

Multisite studies; recommended by the U.S. Preventive Services Task Force

The FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) technique has been associated with reductions in alcohol-related risk behavior and reduced cannabis use.

B

31, 32

Leads to harm reduction

The use of motivational interviewing in primary care is associated with decreases in weight, blood pressure, and alcohol use.

A

16, 33, 35

Meta-analyses and systematic reviews specific to the primary care setting

The BATHE (background, affect, troubles, handling, empathy) technique is associated with increased patient satisfaction.

B

11, 45

Two recent studies have found this pattern

The transtheoretical (stages of change) model increases coaction of health behavior change for weight management.

B

3, 49

Three studies combined for analysis


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

The five A’s (ask, advise, assess, assist, arrange) technique has been associated with reduced smoking and alcohol use as well as modest weight loss.

B

10, 25, 26

Multisite studies; recommended by the U.S. Preventive Services Task Force

The FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) technique has been associated with reductions in alcohol-related risk behavior and reduced cannabis use.

B

31, 32

Leads to harm reduction

The use of motivational interviewing in primary care is associated with decreases in weight, blood pressure, and alcohol use.

A

16, 33, 35

Meta-analyses and systematic reviews specific to the primary care setting

The BATHE (background, affect, troubles, handling, empathy) technique is associated with increased patient satisfaction.

B

11, 45

Two recent studies have found this pattern

The transtheoretical (stages of change) model increases coaction of health behavior change for weight

The Author

H. RUSSELL SEARIGHT, PhD, MPH, is a professor of psychology at Lake Superior State University, Sault Sainte Marie, Mich.

Address correspondence to H. Russell Searight, PhD, MPH, Lake Superior State University, 650 W. Easterday Ave., Sault Sainte Marie, MI 49783 (e-mail: hsearight@lssu.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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