Dietary Counseling of Hypercholesterolemic Patients by Internal Medicine Residents MARK A. LEVINE, MD, ROBERT S. GROSSMAN, MD, PAUL M. DARDEN, MD, SHERRON M. JACKSON, MD, JAMES G. PEDEN, MD, ALICE S. AMMERMAN, DrPH, RD, MINA L. LEVIN, MD, RICHARD D. LAYNE, MD, LAURA Q. ROGERS, MD, CHARLES B. SEELIG, MD, ARTHUR T. EVANS, MD, MPH, MIRIAM B. SETTLE, PhD, SUZANNE W. FLETCHER, MD Objective: To assess the knowledge, attitudes, and practices o f internal medicine residents concerning dietary counseling f o r hypercholesterolemic patients. Design: Cross-sectional, self-administered q u e s t i o n n a i r e
Key words: Hypercholesterolemia; dietary counseling. physician counseling, internship and residency; health promotion. J GENINTERNMEt) 1992;7:511 - 516.
survey.
Setting: Survey conducted August 1989 in seven internal medicine residency programs in f o u r southeastern and middle Atlantic states. Participants: AH 130 internal medicine residents who w e r e actively participating in ou~atient continuity clinic. Interventions: None. Measurements and main results: Only32% o f the residents felt prepared to provide effective dietary courtseiin~ and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree o fpractical knowledge about dietary facts varied. Residents reported giving dietary counseling to 5896 o f their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use o f effective behavior modification techniques in counseling. Forty-three percent o f residents had received no training in dietary counseling skills during medical school or residency. Conclusion: Internal medicine residents k n o w much m o r e about the rationale f o r treatment f o r hypercholesterolemia than about the practical aspects o f dietary therapy, and theyfeel ineffective and ill-prepared to provide dietary counseling to patients.
Received from the University of North Carolina Faculty Development Program in General Medicine and General Pediatrics, the Department of Medicine (RSG,MLL,CBS,ATE,sWF), the AreaHealth Education Center Program (RSG,MLL,CBS), School of Medicine, the Department of Nutrition, School of Public Health (ASA), and the Health Services Research Center (ATE, MBS), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of General Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania (MAL);the Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina (PMD, SMJ); the Departments of Medicine and Psychiatry, East Carolina University School of Medicine, Greenville, North Carolina, (JGP); the Department of Medicine, West VirginiaUniversitySchool of Medicine, Morgantown, West Virginia (RDL); and the Department of Medicine, Medical College of Georgia, Augusta, Georgia (LQR). Presented in part at the annual meeting of the Societyof General Internal Medicine, Arlington, Virginia, May 2- 4, 1990. Supported by the Universityof North Carolina Faculty Development Fellowship Program in General Medicine and General Pediatrics (54004-05, Bureau of Health Professions,Washington, DC) and by grants from the MedicalFoundation of North Carolina, the Georgia Affiliate of the American Heart Association, and the Geisinger Foundation. Address correspondence and reprint requests to Dr. Levine: Department of General Internal Medicine, Geisinger MedicalCenter, Danville, PA, 17822.
DIETARY THERAPY remains the initial i n t e r v e n t i o n of c h o i c e for all patients w i t h p r i m a r y h y p e r c h o l e s t e r o l e mia, 1 and p h y s i c i a n s are e x p e c t e d to initiate d i e t a r y counseling. However, little is k n o w n a b o u t h o w w e l l p r e p a r e d physicians are to give s u c h c o u n s e l i n g . After the results of the Lipid Research Clinics Coronary Primary Prevention Trial w e r e p u b l i s h e d , a 1985 National Institutes of Health (NIH) consensus confere n c e strongly a d v o c a t e d t r e a t m e n t for h y p e r c h o l e s t e r olemia. A majority (64%) of 1,2 77 p h y s i c i a n s surveyed by t e l e p h o n e in 1986 t h o u g h t that r e d u c i n g high serum c h o l e s t e r o l levels w o u l d have a major effect on r e d u c i n g heart disease. 2 However, o n l y 15% felt successful in h e l p i n g patients l o w e r their c h o l e s t e r o l levels. R e p o r t e d barriers to the successful d i e t a r y mana g e m e n t of h y p e r c h o l e s t e r o l e m i a i n c l u d e d lack of time, i n a d e q u a t e l y t r a i n e d staff, and p o o r insurance r e i m b u r s e m e n t for p r e v e n t i v e services. In 1987, the National Heart, Lung and Blood Institute l a u n c h e d a major program, the National Cholesterol Education Program (NCEP), 1 in an a t t e m p t to imp r o v e the a b i l i t y of h e a l t h care professionals to r e c o g n i z e and manage h y p e r c h o l e s t e r o l e m i a . It is unk n o w n to w h a t e x t e n t p h y s i c i a n s w i l l c o m p l y w i t h the NCEP g u i d e l i n e s or w h e t h e r the barriers p h y s i c i a n s enc o u n t e r w h e n p r o v i d i n g n u t r i t i o n a l assessment and c o u n s e l i n g w i l l be effectively dealt w i t h b y this educational effort. R e s i d e n c y training is an o p t i m a l t i m e for physicians to a c q u i r e m u c h of the k n o w l e d g e , attitudes, and skills n e e d e d to treat patients w h o have e l e v a t e d cholesterol levels. I n d e e d , the s t r u c t u r e d learning environm e n t of a r e s i d e n c y p r o g r a m w o u l d be e x p e c t e d to p r o m o t e a greater level of a d h e r e n c e to p r o p e r managem e n t g u i d e l i n e s than has b e e n d e m o n s t r a t e d by pract i c i n g physicians. However, this has not b e e n prev i o u s l y shown, and r e s i d e n t c l i n i c s m a y have t h e i r o w n u n i q u e barriers to the d e l i v e r y of p r e v e n t i v e care. Madlon-Kay r e p o r t e d that in a family p r a c t i c e training program, o n l y 29% of h y p e r c h o l e s t e r o l e m i c patients rec e i v e d any d i e t a r y therapy. 3 511
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We hypothesized that although residents might be familiar with the current guidelines, other barriers affect their ability to provide dietary therapy for hypercholesterolemic patients. Eighteen months after publication of the NCEP guidelines we surveyed a large cohort of resident physicians to determine their knowledge, attitudes, and reported behaviors concerning the management of hypercholesterolemic patients.
METHODS
Subjects and Setting One hundred thirty internal medicine residents in seven programs across four southern and mid-Atlantic states were surveyed in August 1989. The clinical settings ranged from community hospitals to university medical centers: New Hanover Medical Center, Wilmington, NC; Moses Cone Memorial Hospital, Greensboro, NC; East Carolina University School of Medicine, Greenville, NC; University of North Carolina, Chapel Hill, NC: Geisinger Medical Center, Danville, PA; West Virginia University, Morgantown, WV; and the Medical College of Georgia, Augusta, GA. All second-, third-, and fourth-year internal medicine residents were eligible if they were actively involved in outpatient management. Active involvement in outpatient management was defined as seeing patients in continuity clinic for six of the succeeding ten weeks. Because first-year residents rarely satisfied this requirement, they were excluded from the study. Only ten (7%) of 140 residents in their second through fourth years did not meet this criterion and were excluded. All subjects were informed of the nature of the study and gave written consent. The study was approved by the institutional review board at each site.
Questionnaire The study instrument was adapted from a questionnaire developed by one of the authors for a prior study. 4 The measurement scales from that instrument had been formally evaluated for reliability and validity and extensively pretested. Cronbach's alpha for internal consistency of scale items averaged 0.73 across all scales in a sample of 87 resident and attending physicians. Content validity was assessed by having all of the items reviewed by experts (physicians and nutritionists with expertise in preventive cardiology) who were aware of the intended uses of the questionnaire. Some additional questions were adapted from the National Heart, Lung and Blood Institute national physician survey. 2 The revised, self-administered questionnaire included 106 predominantly closed-ended items utilizing a six-point Likert scale, semantic differential, and true/false questions. Additional reliability testing was conducted with a group of graduating residents at the same institutions. All of the attitudinal scales achieved
Cronbach alpha values of >0.70." The questionnaire was designed to evaluate residents for the following: 1. Knowledge of NCEP screening guidelines, stratification of cardiovascular risk, effect of diet on blood lipids, rationale for intervention, appropriate management strategies, and practical dietary knowledge. 2. Attitudes regarding preparedness to counsel dietary change, effectiveness of dietary change in lowering serum cholesterol, confidence in counseling skills, physician responsibility for counseling, relative priority of dietary counseling, and the potential barriers to counseling, including limited time, inadequate educational materials, and patient noncompliance. 3. An estimate of the proportion of hypercholesterolemic patients counseled by each physician and a characterization of their dietary counseling practices, including their use of behavior modification. 4. Demographic information such as site and level of training, prior dietary counseling training, medical school attended, and career plans. 5. Knowledge of their own serum cholesterol levels and recent personal dietary modifications. The questionnaire was distributed by investigators who were general medicine faculty at their institutions. Residents who did not initially complete the survey were contacted by the authors, who personally requested they complete the survey.
Analysis Responses across sites were tested for homogeneity before they were analyzed in the aggregate. For the purposes of reporting, we dichotomized responses to the six-point Likert scales. Responses 1 through 3 of the scales were classified as disagreement, whereas responses 4 through 6 signified agreement. Residents were classified as in agreement if the mean score on the items of an attitude scale was higher than 3.5. Residents estimated the percentage of hypercholesterolemic patients offered dietary counseling, and the mean and standard deviation were calculated. Residents' selforeported use of a spectrum of behavior modification strategies for dietary assessment and counseling was measured by a 23-item scale. Responses were dichotomized at the scale midpoint, and relationships between the dichotomized scales measuring knowledge, attitude, •The entire questionnaireand psychometricdata regardingindividual scale items are available from the authors upon request.
JOURNALOF GENERALINTERNALMEDICINE, Volume 7 (September/October), 1992
and self-reported behavior were examined using the chi-square test. To ensure that collapsing our scales did not alter the apparent significance of interrelationships between variables, an ordinary least-squares computer regression model was used to analyze the original, nondichotomized scales as well.
RESULTS Respondents All 130 eligible residents completed the questionnaire for a 100% response rate. Fifty-one percent of the subjects were second-year residents; 40%, third-year; and 9%, fourth-year. Three-fourths (75%) were categorical medicine residents; 23%, medicine/pediatrics; and 2%, medicine/psychiatry. While 45% planned to practice general medicine, 28% did not plan to and 26% were still unsure of career plans. Forty-three percent of residents reported receiving no training in dietary counseling during medical school or residency. Thirty-five percent reported training in medical school and 44% during residency. Fifty-seven percent of residents knew their own cholesterol levels and 57% had reduced their dietary fat and cholesterol intakes within the preceding year.
Knowledge The mean percentage correct score on four questions testing knowledge of NCEP guidelines for cholesterol detection and coronary risk classification was 78% (range, O- 100%). Performance on seven patient management problems evaluating use of lipoprotein analysis, diet, and drug therapywas excellent, with the mean percentage correct 88% (range, 43-100%). Most residents (90%) understood that a 10 - 15% reduction in serum cholesterol can be expected from
513
moderate dietary intervention in patients with hypercholesterolemia (Table 1). On average, 71% of the dietary knowledge questions were answered correctly. However, responses to questions concerning specific, practical dietary items varied. Few (15%) knew that it is necessary to consume a greater volume of food to maintain the same weight on a cholesterol-lowering diet, and only 51% realized that most margarines have no cholesterol. A substantial percentage (38%) mistakenly thought that all forms of pork must be restricted on a cholesteroldowering diet. In fact, while it is commonly assumed that pork is among the worst offenders in raising serum cholesterol, the saturated fat and cholesterol profile of fresh lean pork is preferable to that of beef and superior to those of many commercially prepared foods that contain large amounts of tropical fats that are more highly saturated than meat fats.
Attitudes Residents agreed that dietary counseling was the physician's responsibility and a high priority (Table 2). Most (92 %) also felt that dietary modifications could be effective in lowering coronary artery disease risk. Even though they agreed on the appropriateness of providing dietary counseling, only 32% felt prepared to do so. Even more striking, only 25% felt successful or confident in the ability to help patients change their diets. Residents perceived several barriers to counseling, including poor patient compliance (82%), lack of sufficient time (70%), and inadequate educational materials (48%).
Self-reported Behavior Residents reported screening for hypercholesterolemia in a mean of 55 + 30.43% of their continuity care patients. Although most residents (92%) discussed the
TABLE 1 Resident Physicians' Knowledge about Cholesterol, Heart Disease, and Diet Percentage of Residents Who Answered Correctly (N = 130) Cholesterol and heart disease knowledge* For patients with high serum cholesterol, a 1O - 15% reduction in cholesterol can be expected from moderate dietary intervention Potential benefit of cholesterol reduction is greatest in those individuals with multiple cardiovascular risk factors For patients with high serum cholesterol, a 10% reduction in serum cholesterol is associated with a 20% reduction in coronary heart disease risk With a combination of diet and hypolipidemic drugs, it is possible to see regression of atherosclerotic lesions Practical dietary knowledge* Foods labeled "cholesterol free" can raise serum cholesterol Organ meats are higher in cholesterol than other types of meat Intake of starchy foods need not be limited on a cholesterol-lowering diet All forms of pork need not be restricted on a cholesterol-lowering diet Most margarines contain no cholesterol Most cholesterol is in the lean rather than the fatty portion of the meat It is necessary to eat a greater volume of food to maintain weight on a cholesterol-lowering diet Overall mean score on specific practical dietary knowledge *Items have been rewritten so that " t r u e " is the correct response.
90 77 64 58 96 89 87 62 51 26 15 71
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TABLE 2
Resident Physicians'Attitudes and Beliefs Regarding Dietary Counseling and Bamers to Counseling Percentageof Residents Who Agree* (N = 130)
Attitudes about dietary counseling Dietary counselingis the physician's responsibility Dietary counselingis a high priority I feel prepared to provide dietary counseling I feel successfulor confident in my ability to improve patients' diets Factors consideredto be barriers to effective counseling Poor patient compliance Inadequatetime Inadequate educationalmaterials
82 72 32 25
82 70
48
*Each percentage reflects responses on multiple-item scalesthat assessed the specific variable under consideration. Residents indicated their levels of agreement with each attitude on a six-point Likert scale from strongly disagree to strongly agree. For purposes of reporting, we dichotomized the results into agree and disagree. TABLE 3 Resident Physicians' Self-reported Dietary CounselingSkills Percentage of Residents Using Strategy (N-- 122)
Strategy for dietary assessment Determine patients' motivation toward making dietary changes Determine patients' confidenceabout making dietary changes Assessthe frequency with which patients eat certain foods Assess patients' perception of taste and convenienceof a cholesterollowering diet Strategy for dietary behavior change Point out specific problem areas in patients' diets Evaluate family support Discuss obstaclesto dietary change Positively reinforce small dietary changes made by patients Positively reinforce healthy aspects of patients' diets Individualizerecommendations Set short-term dietary goals Spread dietary counselingover several visits Schedulefollow-up specificallyto discuss diet Suggest that a cholesterol-lowering diet might taste good
64 54
mine patients' motivations for making dietary changes, only 27% were likely to assess patients' perceptions of the taste and convenience of a cholesterol-lowering diet (Table 3). Although 58% o f housestaffwere likely to point out specific p r o b l e m areas in the patients' diets, only 27% were likely to schedule follow-up visits specifically to discuss dietary changes.
Relation among Self-reported Behavior, Knowledge, and Attitudes No significant relation c o u l d be found between knowledge and the reported f r e q u e n c y of dietary counseling (R = 0.164, p = 0.07). However, residents w h o felt more self-confident, felt more prepared to counsel, or perceived counseling as a high priority also reported using more counseling strategies than did those w h o felt less efficacious and p r e p a r e d or those w h o felt that counseling was a lower priority (Table 4). Housestaff w h o had received training during residency were more likely to feel prepared to counsel and more likely to engage in counseling than were those w h o had received no prior training (Table 5). Senior residents w e r e no more likely to use dietary counseling than were junior residents. Residents w h o had recently modified their own diets, or those w h o k n e w their own serum cholesterol levels, were not significantly more likely to provide dietary counseling to their patients than were those w h o had made no personal dietary changes. Those w h o were planning careers as generalists were no more likely to counsel patients than were those w h o w e r e not.
40
DISCUSSION 27
58 58 55
54 51 48 48 37 27 26
health benefits of a p r u d e n t diet with their hypercholesterolemic patients, residents reported providing actual dietary recommendations to only a mean of 58 + 34.30% and written educational materials to just 35 + 36.40% of these patients. Only 40% of residents w e r e likely to specifically assess dietary cholesterol and fat. Although 64% of housestaff w e r e likely to deter-
Our study provides recent data describing h o w internal medicine residents deal with hypercholesterolemia. Residents are fairly knowledgeable about screening, classification, evaluation, rationale for intervention, and management of hypercholesterolemic patients, but we found them less familiar with specific dietary advice. They accept dietary counseling as their responsibility and acknowledge its importance, but they feel ineffective and ill prepared and lack confidence in their skills. They use effective counseling techniques infrequently, and they miss many opportunities for providing dietary counseling and educational materials to their hypercholesterolemic patients. Almost half have not received training in dietary counseling in either medical school or residency. While it has been previously shown that practicing physicians feel ill-prepared and unsuccessful in counseling hypercholesterolemic patients, our findings, w h i c h for the first time extend these observations to residents, are particularly disappointing. Our sample includes most upper-level internal medicine residents at each site, and our response rate was 100%. Questionnaire administration was timed so
JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (September/October), 1992
that physicians had had sufficient opportunity to bec o m e familiar with the NCEP guidelines and to implement them in their practices. Our study instrument was carefully pretested and validated. An important limitation is the self-reported nature of the practice behaviors. Direct observation of such behaviors w o u l d obviously strengthen the findings. However, we w o u l d e x p e c t self-reported findings to be biased towards more frequent reports of counseling; indeed, previous research has demonstrated that physicians' own estimates of performance in a variety of screening activities fall significantly b e l o w actual performance rates. ~,6 The fact that residents reported counseling for only 58% of hypercholesterolemic patients may mean that even fewer are actually counseled. Our findings are likely to be generalizable to other housestaff training settings. The seven study sites, w h i c h range from small to large training programs throughout the eastern United States and include community hospitals as well as university medical centers, are representative of internal medicine training programs in the country. Comparisons between the data and findings before
TABLE 4
Numbers (and Percentages) of Resident PhysiciansClassifiedby Use of Effective Dietary CounselingSkills and Attitudes Regarding Dietary Counseling
S 1S
TABLE 5
Numbers (and Percentages) of Resident PhysiciansClassifiedby Use of Effective Dietary CounselingSkills and PersonalCharacteristics Use*
Personal Characteristic
High
Low
p Valuer
Prior training in residency Yes No
34 (28) 27 (22)
19 (15) 43 (35)
0.005
Prior training in medical school Yes No
26 (21) 34 (28)
17 (14) 45 (37)
0.066
Any prior training Yes No
45 (36) 17 (14)
25 (20) 37 (30)
0.001
Level of training PGY-2 PGY-3-4
30 (24) 32 (26)
34 (27) 28 (23)
0.472
Plans career as generalist Yes No
23 (25) 19 (20)
35 (37) 17 (18)
0.213
Recent modification of own diet Yes No
40 (32) 22 (18)
31 (25) 31 (25)
0.102
Knows own cholesterol level Yes No
35 (29) 26 (21 )
37 (30) 25 (20)
0.796
* Residents' self-reported use of a spectrum of behavior modification strategies for dietary assessmentand counselingwas measured by a 23item scale with responses dichotomized at the scale midpoint into highand low-use groups. ~Using chi-squaretest,
Use* Attitude
High
Low
p Valuer
Dietary counselingis a high priority Agree Disagree
51 (42) 10 ( 8 )
37 (30) 24 (20)
0.005
I feel confident in my ability to improve patients' diets Agree Disagree
23 (19) 38 (31)
7 (6) 55 (44)
0.001
I feel prepared to counsel Agree Disagree
24 (20) 38 (31 )
14 (11) 47 (38)
0,059
Inadequate resources are a barrier to counseling Agree Disagree
22 (18) 39 (32)
38 (31) 23 (19)
0.004
Dietary counselingis the physician's responsibility Agree Disagree
53 (43) 9 (7)
49 (40) 12 (10)
0,447
Time is a barrier to counseling Agree Disagree
42 (34) 20 (16)
45 (37) 15 (13)
0.376
Patient compliance is a barrier to counseling Agree Disagree
49 (40) 13(11)
54 (44) 6(5)
0.391
*Residents"self-reported useof a spectrum of behavior modification strategies for dietary assessmentand counselingwas measured by a 23item scale with responses dichotomized at the scale midpoint into highand low-use groups, tUsing chi-squaretest.
the NCEP suggest that there has been little improvement over time. In 1986, Schucker and associates 2 found that 58% of practicing physicians surveyed felt prepared to counsel, yet only 15% felt that they could change their patients' dietary habits. In our study of physicians in training, a smaller number, 32%, felt prepared, and 25% felt confident of the efficacy of their counseling skills. This implies that the physician educational materials of the NCEP were not effective in improving residents' attitudes about their preparedness to counsel or confidence in their counseling skills, even though the materials were available 18 months prior to our survey. In two recent chart audit studies from family practice settings, Bell and Dippe reported that only 46% of hypercholesterolemic patients received dietary counseling, 7 whereas Madlon-Kay found a counseling rate of 59%. 8 In a chart audit of internal medicine and family medicine residents' practices from January 1988, 48% of patients with serum cholesterol values of at least 240 mg/dL received dietary counseling or therapy. 9 Our residents' self-report, 18 months after the publication of the NCEP guidelines, of counseling 58% of hypercholesterolemic patients is remarkably consistent with these earlier data. Recently, family practice and internal medicine residents affiliated with one medical school agreed that
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counseling hypercholesterolemic patients is important and is the responsibility of the primary care physician. 1oHowever, when graded on specific skills such as motivating the patient and tailoring the regimen to the individual, resident performance was judged inadequate for routine counseling in the primary care setting. Our results are consistent with these findings and extend them by linking important attitudes, such as physician confidence, with self-reported counseling skills as well as showing no relation between lipid knowledge and counseling skills. Part of the explanation for residents' failure to provide adequate dietary counseling may lie with training deficiencies at the medical school and residency program levels. Few physicians finish training feeling confident in their abilities to counsel patients successfully about smoking cessation, dietary change, or other health-promoting lifestyles.t i Surveys on smoking cessation counseling have shown that knowledge alone is not sufficient to ensure appropriate counseling behavior. In fact, studies have shown a strong association between previous training in smoking cessation counseling and performance of specific counseling activities but have not shown a link between the simple knowledge of smoking cessation techniques and the performance of counseling activities. 12 Our study suggests that there are analogous relationships for hypercholesterolemia and dietary counseling. Scientific knowledge about cholesterol and heart disease does not seem to correlate well with specific counseling behaviors or with physicians' confidence in their abilities to change dietary habits. However, those residents who had been trained in methods of providing dietary counseling to hypercholesterolemic patients were more likely to provide counseling than were those who had received no training. These data are consistent with theoretical models of counseling behavior. 13, 14 Physicians' lack of practical skills and lack of confidence are the key items to target in physician training efforts. The NCEP represents a major commitment of resources to the education of health care professionals. The major desired outcome is not greater physician knowledge per se, but more timely and effective physician action that will ultimately improve public health. We have shown that physicians in training are ill-prepared to counsel their hypercholesterolemic patients
successfully and need help in developing confidence in their dietary counseling skills and in overcoming the common barriers to effective counseling. Future educational efforts should address these important attitudinal issues and barriers if they are to be successful in promoting effective resident counseling behavior.
The authors thank Dr. O. Dale Williams for his editorial assistance.
REFERENCES 1. Goodman DS, Hulley SB, Clark LT, et al. Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Publication #88-2925. New York: National Cholesterol Education Program, National Heart, Lung, and Blood Institute (NIH), 1988. 2. Schucker B, Wittes JT, CutlerJA, et al: Change in physician perspective on cholesterol and heart disease. JAMA. 1987; 258:3521-6. 3. Madlon-Kay DJ. Family physician recognition and treatment of severe hypercholesterolemia. J Faro Pract. 1987;24:54-6. 4. Ammerman AS, DeVellis RD, CareyTS, Keyserling TC, Haines PS, Simpson RJ. physician-based diet counseling for cholesterol reduction: current practices, determinants, and strategies for improvement (manuscript under review). 5. McPhee SJ, Richard RJ, Solkowitz SN. Performance of cancer screening in a university general internal medicine practice: comparison with the 1980 American Cancer Society guidelines. J Gen Intern Med. 1986; 1:275-81. 6. Woo B, Woo B, Cook F, Weisberg M, Goldman L. Screening procedures in the asymptomatic adult: comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice. JAMA. 1985;254:1480-4. 7. Bell MM, Dippe SE. Recognition and treatment of hypercholesterolemia in a family practice center. J Faro Pract. 1988; 2 6 : 5 0 7 - 13. 8. Madlon-Kay DJ. Improvement in family physician recognition and treatment of hypercholesterolemia. Arch Intern Med. 1989;149:1754-5. 9. McBride PE, Pacala JT, Dean J, Plane MB. Primary care residents and the management of hypercholesterolemia. Am J Prev Med. 1990;6(2):71-6. 10. Hoppe RB, Farquhar LJ, Henry R, Stoffelmayr B. Residents' attitudes towards and skills in counseling: Using undetected standardized patients. J Gen Intern Med. 1990;5:415-20. 11. Wechsler H, Levine S, Idelson RK, Rohman M, Taylor JO. The physician's role in health promotion. A survey of primary care practitioners. N Engl J Med. 1983;308:97-100. 12. Kenney KD, Lyles MF, Turner RC, et al. Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics. Arch Intern Med. 1988;148:2469-73. 13. Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice Hall, 1977. 14. Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM. The role of self-efficacy in achieving health behavior change. Health Educ Q. 1986;13:73-91.
Key words: Hypercholesterolemia; dietary counseling. physician counseling, internship and residency; health promotion. J GENINTERNMEt) 1992;7:511 - 516.
survey.
Setting: Survey conducted August 1989 in seven internal medicine residency programs in f o u r southeastern and middle Atlantic states. Participants: AH 130 internal medicine residents who w e r e actively participating in ou~atient continuity clinic. Interventions: None. Measurements and main results: Only32% o f the residents felt prepared to provide effective dietary courtseiin~ and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree o fpractical knowledge about dietary facts varied. Residents reported giving dietary counseling to 5896 o f their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use o f effective behavior modification techniques in counseling. Forty-three percent o f residents had received no training in dietary counseling skills during medical school or residency. Conclusion: Internal medicine residents k n o w much m o r e about the rationale f o r treatment f o r hypercholesterolemia than about the practical aspects o f dietary therapy, and theyfeel ineffective and ill-prepared to provide dietary counseling to patients.
Received from the University of North Carolina Faculty Development Program in General Medicine and General Pediatrics, the Department of Medicine (RSG,MLL,CBS,ATE,sWF), the AreaHealth Education Center Program (RSG,MLL,CBS), School of Medicine, the Department of Nutrition, School of Public Health (ASA), and the Health Services Research Center (ATE, MBS), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of General Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania (MAL);the Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina (PMD, SMJ); the Departments of Medicine and Psychiatry, East Carolina University School of Medicine, Greenville, North Carolina, (JGP); the Department of Medicine, West VirginiaUniversitySchool of Medicine, Morgantown, West Virginia (RDL); and the Department of Medicine, Medical College of Georgia, Augusta, Georgia (LQR). Presented in part at the annual meeting of the Societyof General Internal Medicine, Arlington, Virginia, May 2- 4, 1990. Supported by the Universityof North Carolina Faculty Development Fellowship Program in General Medicine and General Pediatrics (54004-05, Bureau of Health Professions,Washington, DC) and by grants from the MedicalFoundation of North Carolina, the Georgia Affiliate of the American Heart Association, and the Geisinger Foundation. Address correspondence and reprint requests to Dr. Levine: Department of General Internal Medicine, Geisinger MedicalCenter, Danville, PA, 17822.
DIETARY THERAPY remains the initial i n t e r v e n t i o n of c h o i c e for all patients w i t h p r i m a r y h y p e r c h o l e s t e r o l e mia, 1 and p h y s i c i a n s are e x p e c t e d to initiate d i e t a r y counseling. However, little is k n o w n a b o u t h o w w e l l p r e p a r e d physicians are to give s u c h c o u n s e l i n g . After the results of the Lipid Research Clinics Coronary Primary Prevention Trial w e r e p u b l i s h e d , a 1985 National Institutes of Health (NIH) consensus confere n c e strongly a d v o c a t e d t r e a t m e n t for h y p e r c h o l e s t e r olemia. A majority (64%) of 1,2 77 p h y s i c i a n s surveyed by t e l e p h o n e in 1986 t h o u g h t that r e d u c i n g high serum c h o l e s t e r o l levels w o u l d have a major effect on r e d u c i n g heart disease. 2 However, o n l y 15% felt successful in h e l p i n g patients l o w e r their c h o l e s t e r o l levels. R e p o r t e d barriers to the successful d i e t a r y mana g e m e n t of h y p e r c h o l e s t e r o l e m i a i n c l u d e d lack of time, i n a d e q u a t e l y t r a i n e d staff, and p o o r insurance r e i m b u r s e m e n t for p r e v e n t i v e services. In 1987, the National Heart, Lung and Blood Institute l a u n c h e d a major program, the National Cholesterol Education Program (NCEP), 1 in an a t t e m p t to imp r o v e the a b i l i t y of h e a l t h care professionals to r e c o g n i z e and manage h y p e r c h o l e s t e r o l e m i a . It is unk n o w n to w h a t e x t e n t p h y s i c i a n s w i l l c o m p l y w i t h the NCEP g u i d e l i n e s or w h e t h e r the barriers p h y s i c i a n s enc o u n t e r w h e n p r o v i d i n g n u t r i t i o n a l assessment and c o u n s e l i n g w i l l be effectively dealt w i t h b y this educational effort. R e s i d e n c y training is an o p t i m a l t i m e for physicians to a c q u i r e m u c h of the k n o w l e d g e , attitudes, and skills n e e d e d to treat patients w h o have e l e v a t e d cholesterol levels. I n d e e d , the s t r u c t u r e d learning environm e n t of a r e s i d e n c y p r o g r a m w o u l d be e x p e c t e d to p r o m o t e a greater level of a d h e r e n c e to p r o p e r managem e n t g u i d e l i n e s than has b e e n d e m o n s t r a t e d by pract i c i n g physicians. However, this has not b e e n prev i o u s l y shown, and r e s i d e n t c l i n i c s m a y have t h e i r o w n u n i q u e barriers to the d e l i v e r y of p r e v e n t i v e care. Madlon-Kay r e p o r t e d that in a family p r a c t i c e training program, o n l y 29% of h y p e r c h o l e s t e r o l e m i c patients rec e i v e d any d i e t a r y therapy. 3 511
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We hypothesized that although residents might be familiar with the current guidelines, other barriers affect their ability to provide dietary therapy for hypercholesterolemic patients. Eighteen months after publication of the NCEP guidelines we surveyed a large cohort of resident physicians to determine their knowledge, attitudes, and reported behaviors concerning the management of hypercholesterolemic patients.
METHODS
Subjects and Setting One hundred thirty internal medicine residents in seven programs across four southern and mid-Atlantic states were surveyed in August 1989. The clinical settings ranged from community hospitals to university medical centers: New Hanover Medical Center, Wilmington, NC; Moses Cone Memorial Hospital, Greensboro, NC; East Carolina University School of Medicine, Greenville, NC; University of North Carolina, Chapel Hill, NC: Geisinger Medical Center, Danville, PA; West Virginia University, Morgantown, WV; and the Medical College of Georgia, Augusta, GA. All second-, third-, and fourth-year internal medicine residents were eligible if they were actively involved in outpatient management. Active involvement in outpatient management was defined as seeing patients in continuity clinic for six of the succeeding ten weeks. Because first-year residents rarely satisfied this requirement, they were excluded from the study. Only ten (7%) of 140 residents in their second through fourth years did not meet this criterion and were excluded. All subjects were informed of the nature of the study and gave written consent. The study was approved by the institutional review board at each site.
Questionnaire The study instrument was adapted from a questionnaire developed by one of the authors for a prior study. 4 The measurement scales from that instrument had been formally evaluated for reliability and validity and extensively pretested. Cronbach's alpha for internal consistency of scale items averaged 0.73 across all scales in a sample of 87 resident and attending physicians. Content validity was assessed by having all of the items reviewed by experts (physicians and nutritionists with expertise in preventive cardiology) who were aware of the intended uses of the questionnaire. Some additional questions were adapted from the National Heart, Lung and Blood Institute national physician survey. 2 The revised, self-administered questionnaire included 106 predominantly closed-ended items utilizing a six-point Likert scale, semantic differential, and true/false questions. Additional reliability testing was conducted with a group of graduating residents at the same institutions. All of the attitudinal scales achieved
Cronbach alpha values of >0.70." The questionnaire was designed to evaluate residents for the following: 1. Knowledge of NCEP screening guidelines, stratification of cardiovascular risk, effect of diet on blood lipids, rationale for intervention, appropriate management strategies, and practical dietary knowledge. 2. Attitudes regarding preparedness to counsel dietary change, effectiveness of dietary change in lowering serum cholesterol, confidence in counseling skills, physician responsibility for counseling, relative priority of dietary counseling, and the potential barriers to counseling, including limited time, inadequate educational materials, and patient noncompliance. 3. An estimate of the proportion of hypercholesterolemic patients counseled by each physician and a characterization of their dietary counseling practices, including their use of behavior modification. 4. Demographic information such as site and level of training, prior dietary counseling training, medical school attended, and career plans. 5. Knowledge of their own serum cholesterol levels and recent personal dietary modifications. The questionnaire was distributed by investigators who were general medicine faculty at their institutions. Residents who did not initially complete the survey were contacted by the authors, who personally requested they complete the survey.
Analysis Responses across sites were tested for homogeneity before they were analyzed in the aggregate. For the purposes of reporting, we dichotomized responses to the six-point Likert scales. Responses 1 through 3 of the scales were classified as disagreement, whereas responses 4 through 6 signified agreement. Residents were classified as in agreement if the mean score on the items of an attitude scale was higher than 3.5. Residents estimated the percentage of hypercholesterolemic patients offered dietary counseling, and the mean and standard deviation were calculated. Residents' selforeported use of a spectrum of behavior modification strategies for dietary assessment and counseling was measured by a 23-item scale. Responses were dichotomized at the scale midpoint, and relationships between the dichotomized scales measuring knowledge, attitude, •The entire questionnaireand psychometricdata regardingindividual scale items are available from the authors upon request.
JOURNALOF GENERALINTERNALMEDICINE, Volume 7 (September/October), 1992
and self-reported behavior were examined using the chi-square test. To ensure that collapsing our scales did not alter the apparent significance of interrelationships between variables, an ordinary least-squares computer regression model was used to analyze the original, nondichotomized scales as well.
RESULTS Respondents All 130 eligible residents completed the questionnaire for a 100% response rate. Fifty-one percent of the subjects were second-year residents; 40%, third-year; and 9%, fourth-year. Three-fourths (75%) were categorical medicine residents; 23%, medicine/pediatrics; and 2%, medicine/psychiatry. While 45% planned to practice general medicine, 28% did not plan to and 26% were still unsure of career plans. Forty-three percent of residents reported receiving no training in dietary counseling during medical school or residency. Thirty-five percent reported training in medical school and 44% during residency. Fifty-seven percent of residents knew their own cholesterol levels and 57% had reduced their dietary fat and cholesterol intakes within the preceding year.
Knowledge The mean percentage correct score on four questions testing knowledge of NCEP guidelines for cholesterol detection and coronary risk classification was 78% (range, O- 100%). Performance on seven patient management problems evaluating use of lipoprotein analysis, diet, and drug therapywas excellent, with the mean percentage correct 88% (range, 43-100%). Most residents (90%) understood that a 10 - 15% reduction in serum cholesterol can be expected from
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moderate dietary intervention in patients with hypercholesterolemia (Table 1). On average, 71% of the dietary knowledge questions were answered correctly. However, responses to questions concerning specific, practical dietary items varied. Few (15%) knew that it is necessary to consume a greater volume of food to maintain the same weight on a cholesterol-lowering diet, and only 51% realized that most margarines have no cholesterol. A substantial percentage (38%) mistakenly thought that all forms of pork must be restricted on a cholesteroldowering diet. In fact, while it is commonly assumed that pork is among the worst offenders in raising serum cholesterol, the saturated fat and cholesterol profile of fresh lean pork is preferable to that of beef and superior to those of many commercially prepared foods that contain large amounts of tropical fats that are more highly saturated than meat fats.
Attitudes Residents agreed that dietary counseling was the physician's responsibility and a high priority (Table 2). Most (92 %) also felt that dietary modifications could be effective in lowering coronary artery disease risk. Even though they agreed on the appropriateness of providing dietary counseling, only 32% felt prepared to do so. Even more striking, only 25% felt successful or confident in the ability to help patients change their diets. Residents perceived several barriers to counseling, including poor patient compliance (82%), lack of sufficient time (70%), and inadequate educational materials (48%).
Self-reported Behavior Residents reported screening for hypercholesterolemia in a mean of 55 + 30.43% of their continuity care patients. Although most residents (92%) discussed the
TABLE 1 Resident Physicians' Knowledge about Cholesterol, Heart Disease, and Diet Percentage of Residents Who Answered Correctly (N = 130) Cholesterol and heart disease knowledge* For patients with high serum cholesterol, a 1O - 15% reduction in cholesterol can be expected from moderate dietary intervention Potential benefit of cholesterol reduction is greatest in those individuals with multiple cardiovascular risk factors For patients with high serum cholesterol, a 10% reduction in serum cholesterol is associated with a 20% reduction in coronary heart disease risk With a combination of diet and hypolipidemic drugs, it is possible to see regression of atherosclerotic lesions Practical dietary knowledge* Foods labeled "cholesterol free" can raise serum cholesterol Organ meats are higher in cholesterol than other types of meat Intake of starchy foods need not be limited on a cholesterol-lowering diet All forms of pork need not be restricted on a cholesterol-lowering diet Most margarines contain no cholesterol Most cholesterol is in the lean rather than the fatty portion of the meat It is necessary to eat a greater volume of food to maintain weight on a cholesterol-lowering diet Overall mean score on specific practical dietary knowledge *Items have been rewritten so that " t r u e " is the correct response.
90 77 64 58 96 89 87 62 51 26 15 71
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TABLE 2
Resident Physicians'Attitudes and Beliefs Regarding Dietary Counseling and Bamers to Counseling Percentageof Residents Who Agree* (N = 130)
Attitudes about dietary counseling Dietary counselingis the physician's responsibility Dietary counselingis a high priority I feel prepared to provide dietary counseling I feel successfulor confident in my ability to improve patients' diets Factors consideredto be barriers to effective counseling Poor patient compliance Inadequatetime Inadequate educationalmaterials
82 72 32 25
82 70
48
*Each percentage reflects responses on multiple-item scalesthat assessed the specific variable under consideration. Residents indicated their levels of agreement with each attitude on a six-point Likert scale from strongly disagree to strongly agree. For purposes of reporting, we dichotomized the results into agree and disagree. TABLE 3 Resident Physicians' Self-reported Dietary CounselingSkills Percentage of Residents Using Strategy (N-- 122)
Strategy for dietary assessment Determine patients' motivation toward making dietary changes Determine patients' confidenceabout making dietary changes Assessthe frequency with which patients eat certain foods Assess patients' perception of taste and convenienceof a cholesterollowering diet Strategy for dietary behavior change Point out specific problem areas in patients' diets Evaluate family support Discuss obstaclesto dietary change Positively reinforce small dietary changes made by patients Positively reinforce healthy aspects of patients' diets Individualizerecommendations Set short-term dietary goals Spread dietary counselingover several visits Schedulefollow-up specificallyto discuss diet Suggest that a cholesterol-lowering diet might taste good
64 54
mine patients' motivations for making dietary changes, only 27% were likely to assess patients' perceptions of the taste and convenience of a cholesterol-lowering diet (Table 3). Although 58% o f housestaffwere likely to point out specific p r o b l e m areas in the patients' diets, only 27% were likely to schedule follow-up visits specifically to discuss dietary changes.
Relation among Self-reported Behavior, Knowledge, and Attitudes No significant relation c o u l d be found between knowledge and the reported f r e q u e n c y of dietary counseling (R = 0.164, p = 0.07). However, residents w h o felt more self-confident, felt more prepared to counsel, or perceived counseling as a high priority also reported using more counseling strategies than did those w h o felt less efficacious and p r e p a r e d or those w h o felt that counseling was a lower priority (Table 4). Housestaff w h o had received training during residency were more likely to feel prepared to counsel and more likely to engage in counseling than were those w h o had received no prior training (Table 5). Senior residents w e r e no more likely to use dietary counseling than were junior residents. Residents w h o had recently modified their own diets, or those w h o k n e w their own serum cholesterol levels, were not significantly more likely to provide dietary counseling to their patients than were those w h o had made no personal dietary changes. Those w h o were planning careers as generalists were no more likely to counsel patients than were those w h o w e r e not.
40
DISCUSSION 27
58 58 55
54 51 48 48 37 27 26
health benefits of a p r u d e n t diet with their hypercholesterolemic patients, residents reported providing actual dietary recommendations to only a mean of 58 + 34.30% and written educational materials to just 35 + 36.40% of these patients. Only 40% of residents w e r e likely to specifically assess dietary cholesterol and fat. Although 64% of housestaff w e r e likely to deter-
Our study provides recent data describing h o w internal medicine residents deal with hypercholesterolemia. Residents are fairly knowledgeable about screening, classification, evaluation, rationale for intervention, and management of hypercholesterolemic patients, but we found them less familiar with specific dietary advice. They accept dietary counseling as their responsibility and acknowledge its importance, but they feel ineffective and ill prepared and lack confidence in their skills. They use effective counseling techniques infrequently, and they miss many opportunities for providing dietary counseling and educational materials to their hypercholesterolemic patients. Almost half have not received training in dietary counseling in either medical school or residency. While it has been previously shown that practicing physicians feel ill-prepared and unsuccessful in counseling hypercholesterolemic patients, our findings, w h i c h for the first time extend these observations to residents, are particularly disappointing. Our sample includes most upper-level internal medicine residents at each site, and our response rate was 100%. Questionnaire administration was timed so
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that physicians had had sufficient opportunity to bec o m e familiar with the NCEP guidelines and to implement them in their practices. Our study instrument was carefully pretested and validated. An important limitation is the self-reported nature of the practice behaviors. Direct observation of such behaviors w o u l d obviously strengthen the findings. However, we w o u l d e x p e c t self-reported findings to be biased towards more frequent reports of counseling; indeed, previous research has demonstrated that physicians' own estimates of performance in a variety of screening activities fall significantly b e l o w actual performance rates. ~,6 The fact that residents reported counseling for only 58% of hypercholesterolemic patients may mean that even fewer are actually counseled. Our findings are likely to be generalizable to other housestaff training settings. The seven study sites, w h i c h range from small to large training programs throughout the eastern United States and include community hospitals as well as university medical centers, are representative of internal medicine training programs in the country. Comparisons between the data and findings before
TABLE 4
Numbers (and Percentages) of Resident PhysiciansClassifiedby Use of Effective Dietary CounselingSkills and Attitudes Regarding Dietary Counseling
S 1S
TABLE 5
Numbers (and Percentages) of Resident PhysiciansClassifiedby Use of Effective Dietary CounselingSkills and PersonalCharacteristics Use*
Personal Characteristic
High
Low
p Valuer
Prior training in residency Yes No
34 (28) 27 (22)
19 (15) 43 (35)
0.005
Prior training in medical school Yes No
26 (21) 34 (28)
17 (14) 45 (37)
0.066
Any prior training Yes No
45 (36) 17 (14)
25 (20) 37 (30)
0.001
Level of training PGY-2 PGY-3-4
30 (24) 32 (26)
34 (27) 28 (23)
0.472
Plans career as generalist Yes No
23 (25) 19 (20)
35 (37) 17 (18)
0.213
Recent modification of own diet Yes No
40 (32) 22 (18)
31 (25) 31 (25)
0.102
Knows own cholesterol level Yes No
35 (29) 26 (21 )
37 (30) 25 (20)
0.796
* Residents' self-reported use of a spectrum of behavior modification strategies for dietary assessmentand counselingwas measured by a 23item scale with responses dichotomized at the scale midpoint into highand low-use groups. ~Using chi-squaretest,
Use* Attitude
High
Low
p Valuer
Dietary counselingis a high priority Agree Disagree
51 (42) 10 ( 8 )
37 (30) 24 (20)
0.005
I feel confident in my ability to improve patients' diets Agree Disagree
23 (19) 38 (31)
7 (6) 55 (44)
0.001
I feel prepared to counsel Agree Disagree
24 (20) 38 (31 )
14 (11) 47 (38)
0,059
Inadequate resources are a barrier to counseling Agree Disagree
22 (18) 39 (32)
38 (31) 23 (19)
0.004
Dietary counselingis the physician's responsibility Agree Disagree
53 (43) 9 (7)
49 (40) 12 (10)
0,447
Time is a barrier to counseling Agree Disagree
42 (34) 20 (16)
45 (37) 15 (13)
0.376
Patient compliance is a barrier to counseling Agree Disagree
49 (40) 13(11)
54 (44) 6(5)
0.391
*Residents"self-reported useof a spectrum of behavior modification strategies for dietary assessmentand counselingwas measured by a 23item scale with responses dichotomized at the scale midpoint into highand low-use groups, tUsing chi-squaretest.
the NCEP suggest that there has been little improvement over time. In 1986, Schucker and associates 2 found that 58% of practicing physicians surveyed felt prepared to counsel, yet only 15% felt that they could change their patients' dietary habits. In our study of physicians in training, a smaller number, 32%, felt prepared, and 25% felt confident of the efficacy of their counseling skills. This implies that the physician educational materials of the NCEP were not effective in improving residents' attitudes about their preparedness to counsel or confidence in their counseling skills, even though the materials were available 18 months prior to our survey. In two recent chart audit studies from family practice settings, Bell and Dippe reported that only 46% of hypercholesterolemic patients received dietary counseling, 7 whereas Madlon-Kay found a counseling rate of 59%. 8 In a chart audit of internal medicine and family medicine residents' practices from January 1988, 48% of patients with serum cholesterol values of at least 240 mg/dL received dietary counseling or therapy. 9 Our residents' self-report, 18 months after the publication of the NCEP guidelines, of counseling 58% of hypercholesterolemic patients is remarkably consistent with these earlier data. Recently, family practice and internal medicine residents affiliated with one medical school agreed that
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counseling hypercholesterolemic patients is important and is the responsibility of the primary care physician. 1oHowever, when graded on specific skills such as motivating the patient and tailoring the regimen to the individual, resident performance was judged inadequate for routine counseling in the primary care setting. Our results are consistent with these findings and extend them by linking important attitudes, such as physician confidence, with self-reported counseling skills as well as showing no relation between lipid knowledge and counseling skills. Part of the explanation for residents' failure to provide adequate dietary counseling may lie with training deficiencies at the medical school and residency program levels. Few physicians finish training feeling confident in their abilities to counsel patients successfully about smoking cessation, dietary change, or other health-promoting lifestyles.t i Surveys on smoking cessation counseling have shown that knowledge alone is not sufficient to ensure appropriate counseling behavior. In fact, studies have shown a strong association between previous training in smoking cessation counseling and performance of specific counseling activities but have not shown a link between the simple knowledge of smoking cessation techniques and the performance of counseling activities. 12 Our study suggests that there are analogous relationships for hypercholesterolemia and dietary counseling. Scientific knowledge about cholesterol and heart disease does not seem to correlate well with specific counseling behaviors or with physicians' confidence in their abilities to change dietary habits. However, those residents who had been trained in methods of providing dietary counseling to hypercholesterolemic patients were more likely to provide counseling than were those who had received no training. These data are consistent with theoretical models of counseling behavior. 13, 14 Physicians' lack of practical skills and lack of confidence are the key items to target in physician training efforts. The NCEP represents a major commitment of resources to the education of health care professionals. The major desired outcome is not greater physician knowledge per se, but more timely and effective physician action that will ultimately improve public health. We have shown that physicians in training are ill-prepared to counsel their hypercholesterolemic patients
successfully and need help in developing confidence in their dietary counseling skills and in overcoming the common barriers to effective counseling. Future educational efforts should address these important attitudinal issues and barriers if they are to be successful in promoting effective resident counseling behavior.
The authors thank Dr. O. Dale Williams for his editorial assistance.
REFERENCES 1. Goodman DS, Hulley SB, Clark LT, et al. Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Publication #88-2925. New York: National Cholesterol Education Program, National Heart, Lung, and Blood Institute (NIH), 1988. 2. Schucker B, Wittes JT, CutlerJA, et al: Change in physician perspective on cholesterol and heart disease. JAMA. 1987; 258:3521-6. 3. Madlon-Kay DJ. Family physician recognition and treatment of severe hypercholesterolemia. J Faro Pract. 1987;24:54-6. 4. Ammerman AS, DeVellis RD, CareyTS, Keyserling TC, Haines PS, Simpson RJ. physician-based diet counseling for cholesterol reduction: current practices, determinants, and strategies for improvement (manuscript under review). 5. McPhee SJ, Richard RJ, Solkowitz SN. Performance of cancer screening in a university general internal medicine practice: comparison with the 1980 American Cancer Society guidelines. J Gen Intern Med. 1986; 1:275-81. 6. Woo B, Woo B, Cook F, Weisberg M, Goldman L. Screening procedures in the asymptomatic adult: comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice. JAMA. 1985;254:1480-4. 7. Bell MM, Dippe SE. Recognition and treatment of hypercholesterolemia in a family practice center. J Faro Pract. 1988; 2 6 : 5 0 7 - 13. 8. Madlon-Kay DJ. Improvement in family physician recognition and treatment of hypercholesterolemia. Arch Intern Med. 1989;149:1754-5. 9. McBride PE, Pacala JT, Dean J, Plane MB. Primary care residents and the management of hypercholesterolemia. Am J Prev Med. 1990;6(2):71-6. 10. Hoppe RB, Farquhar LJ, Henry R, Stoffelmayr B. Residents' attitudes towards and skills in counseling: Using undetected standardized patients. J Gen Intern Med. 1990;5:415-20. 11. Wechsler H, Levine S, Idelson RK, Rohman M, Taylor JO. The physician's role in health promotion. A survey of primary care practitioners. N Engl J Med. 1983;308:97-100. 12. Kenney KD, Lyles MF, Turner RC, et al. Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics. Arch Intern Med. 1988;148:2469-73. 13. Bandura A. Social learning theory. Englewood Cliffs, NJ: Prentice Hall, 1977. 14. Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM. The role of self-efficacy in achieving health behavior change. Health Educ Q. 1986;13:73-91.
