Officebased Obesity Care

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One of the most significant obstacles to patient counseling during a routine office visit is availability of time. Two 1998 national surveys found that the average office patient visit length was 21.5 min and 18.3 min, respectively (5). The Direct Observation of Primary Care (DOPC) study found that the average duration of direct physician-patient contact during an office visit was actually only 10 min (6). Within the confines of this time, the physician typically elicits a brief history, performs a limited physical examination, reviews and interprets pertinent laboratory and diagnostic tests, and provides recommendations that may include ordering further tests, writing prescriptions, and conducting counseling. Accordingly, care of the obese patient (and all patients) would be greatly facilitated by incorporating efficient and effective office-based systems. Put Prevention into Practice (PPIP), a national campaign by the Agency for Health Care Policy and Research (AHCPR) to improve the delivery of clinical preventive services such as counseling for health behavior change, provides a useful framework for analyzing the office systems designed to deliver patient care (7). PPIC identifies key components that can either expedite or hinder the care of patients in the office. They include organizational commitment, clinicians' attitudes, staff support, establishing policies and protocols, using simple office tools, and delegating tasks, among others. This section reviews the office-based systems that are uniquely geared to the care of the obese patient (Table 1). Collectively, they address a need for heightened sensitivity and thoroughness throughout all office systems.

A The Physical Environment

Accessibility to the office is critical for the obese patient. Facility limitations include difficult access from the parking lot or stairs, narrow doors and hallways, and cramped restrooms. These are the same problems that face other patients with disabilities, and are covered under the regulations of the Americans with Disabilities Act of 1990. One of the first concerns obese patients have upon entering the waiting room is where they can safely sit. Office chairs of standard width and side arm rests will not comfortably accommodate moderately to severely obese patients. Ideal chairs have no arms so that patients do not have to squeeze themselves

Table 1 Office-Based Obesity Care

The physical environment

Accessibility and comfort: stairs, doorways, hallways, restrooms, waiting room chairs and space, reading materials and other educational materials Equipment

Large adult and thigh blood pressure cuffs, large gowns, step stools, weight and height scales, tape measure Materials

Educational and behavior promoting handouts on diet, exercise, medications, surgery, BMI, obesity-associated diseases Tools

Previsit questionnaires, BMI stamps, food and activity diaries, pedometers Protocols

Patient care treatment protocols for return visit schedule, medications, referrals to dietitians and psychologists Staffing

Team approach to include office nurse, physician assistant, nurse practitioner, health advocate into predefined ''normal'' dimensions. Although often thought insignificant, hanging artwork and magazines in the waiting and examination rooms can convey misinterpreted messages to patients. Magazines, newspapers, television, movies, and billboards constantly remind overweight individuals of society's beauty ideals. Magazines, newsletters, and artwork can be chosen that don't contribute to these unattainable images.

B Equipment

Measurement of an accurate height and weight is paramount to treating patients with obesity. All too often, the physicians' office has a scale that does not measure above 350 pounds, or the foot platform is too narrow to securely balance the overweight individual. Although a wall-mounted sliding statiometer is the most accurate instrument, a sturdy height meter attached to the scale will suffice. The weight scale should preferably have a wide base with a nearby handlebar for support if necessary. Depending on the patient population, it is reasonable to select a scale that measures in excess of 350 pounds. To protect privacy, the scale should be located in a private area of the office to avoid unnecessary embarrassment.

Examination rooms should have large gowns available to wear as well as a step stool to mount the examination tables. Each room should be equipped with large adult and thigh blood pressure cuffs for measurement of blood pressure. A bladder cuff that is not the appropriate width for the patient's arm circumference will cause a systematic error in blood pressure measurement; if the bladder is too narrow, the pressure will be overestimated and lead to a false diagnosis of hypertension. To avoid errors, the bladder width should be 40-50% of upper-arm circumference. Therefore, a large adult cuff (15 cm wide) should be chosen for patients with mild to moderate obesity, while a thigh cuff (18 cm wide) will need to be used for patients whose arm circumferences are > 16 inches. Lastly, a cloth or metal tape should be available for measurement of waist circumference as per the NHLBI Practical Guide for obesity classification (8).

C Using an Integrated Team Approach

How practices operate on a day-to-day basis is extremely important for the provision of effective obesity care. Several key office-based strategies have been shown to improve practice performance in relation to goals for primary care. Two of the most successful features are use of a multidisciplinary or interdisciplinary team and incorporation of protocols and procedures (9). Current therapies for obesity may be best provided using an integrative team approach (10,11). Because of limited time, physicians are generally unable to provide all of the care necessary for treatment. Moreover, other personnel are often better qualified to deliver the dietary, physical activity, and behavioral counseling. Accordingly, there is an opportunity for other office staff to play a greater role in the care of obese patients. A sense of ''groupness,'' defined as the degree to which the group practice identifies itself and functions as a team, will enhance the quality and efficiency of care (12).

The optimal team composition and management structure will vary among practices. However, as an example of an integrative model, receptionists can provide useful information about the program, including general philosophy, staffing, fee schedules, and other written materials; registered nurses can obtain vital measurements including height and weight (for body mass index) and waist circumference; instruct on and review food and activity journals and other educational materials; and physician assistants can monitor the progress of treatment and assume many of the other responsibilities of care. A new position of health advocate, whose role is to serve as a resource to the physician and to patients by providing additional information and assisting in arranging recommended follow-up, may be particularly useful (13). Regardless of how the work load is delegated, the power of the physician's voice should not be underestimated. The physician should be perceived as the team leader and source of common philosophy of care (14).

D Protocols and Procedures

A significant portion of the time spent in the evaluation and treatment of the obese patient can be expedited by use of protocols and procedures. A self-administered medical history questionnaire can be either mailed to the patient prior to the initial visit or completed in the waiting room. In addition to standard questions, sections of the form should inquire about past obesity treatment programs, a body weight history, current diet and physical activity levels, social support, and goals and expectations. The review-of-systems section can include medical prompts that are more commonly seen among the obese, such as snoring, morning headaches and daytime sleepiness (for obstructive sleep apnea), urinary incontinence, intertrigo, and sexual dysfunction, among others.

Identifying the body mass index (BMI) as a fifth vital sign may also increase physician awareness and prompt counseling. This method was successfully used in a recent study where a smoking status stamp was placed on the patient chart, alongside blood pressure, pulse, temperature, and respiratory rate (15). Use of prompts, alerts, or other reminders has been shown to significantly increase physician performance of other health maintenance activities as well (9,16). Once the patient is identified as overweight or obese, printed food and activity diaries and patient information sheets on a variety of topics such as the food guide pyramid, deciphering food labels, healthy snacking, dietary fiber, aerobic exercise and resistance training, and dealing with stress can be used to support behavior change and facilitate patient education. Ready-to-copy materials can be obtained from a variety of sources free of charge such as those found in the Practical Guide, or for a minimal fee from other public sites and commercial companies.

Based on the health promotion literature, use of written materials and counseling protocols should lead to more effective and efficient obesity care. In a study of community-based family medicine physicians, Kreuter et al. (17) showed that patients were more likely to reduce smoking, increase physical activity, and limit dairy fat consumption when physician advice is supported by health education materials. In another randomized intervention study by Swinburn et al. (18), a written goal-oriented exercise prescription, in addition to verbal advice, was more effective than verbal advice alone in increasing the physical activity level of sedentary individuals over a 6-week period. Several exercise assessment and counseling protocols have been developed that can be easily incorporated into obesity care. These include Project PACE (Provider-based Assessment and Counseling for Exercise) (19), ACT (the Activity Counseling Trial) (20), and STEP (the Step Test Exercise Prescription) (21). Finally, protocols and procedures for various treatment pathways can be established for obtaining periodic laboratory monitoring and referral to allied health professionals, such as registered dietitians, exercise specialists, and clinical psychologists.

E The Patient-Physician Encounter

Although all of the office-based systems reviewed above are important, the cornerstone of effective treatment for obesity is grounded in skillful and empathetic physician-patient communication. This vital interaction is affirmed by Balint's assertion that ''the most frequently used drug in medical practice is the doctor himself'' (22). From the patient's perspective, a caring physician is compassionate, supportive, trustworthy, open-minded, and nonjudgmental. He or she takes into account the patient's needs, values, beliefs, goals, personality traits, and fears (23). In a review of the literature, Stewart found that the quality of communication between the physician and patient directly influenced patient health outcomes (24). A large body of literature has described key elements of communication that foster behavior change. Since the primary aim of obesity counseling is to influence what the patient does outside the office, the time spent in the office needs to be structured and effective.

Effective counseling begins with establishing rapport and soliciting the patient's agenda. Attentively listening to the patient to understand his or her goals and expectations is the first essential step. Asking the patient, ''How do you hope that I can help you?'' is an information-gathering open-ended question that directly addresses his or her concerns. Among 28 identified elements of care that were inquired about with patients before the office visit, Kravitz found that''discussion of own ideas about how to manage condition'' was ranked as the highest previsit physician expectation (25). Interestingly, this is not always done in the primary care office. In a survey of 264 patient-physician interviews, patients completed their statement of concern only 28% of the time, being interrupted by the physician after an average duration of 23 sec (26). Physicians were found to redirect the patient and focus the clinical interviews before giving patients the opportunity to complete their statement of concern. Obesity interviewing and counseling should be patient centered, allowing the patient to be an active participant in setting the agenda and having his or her concerns heard. This requires skillful management by the physician to structure the interview within the time allocated.

The style of communication used by the physician refers to the approach taken when interacting with and counseling patients. Emanuel and Emanuel (27) describe four models of the physician-patient relationship: paternalistic—the physician acts as the patient's guardian, articulating and implementing what is best for the patient; informative—the physician is a purveyor of technical expertise, providing the patient with the means to exercise control; interpretive—the physician is a counselor, supplying relevant information and engaging the patient in a joint process of understanding; and deliberative-the physician acts as a teacher or friend, engaging the patient in dialogue on what course of action would be best.

Roter et al. (28) define four similar prototypes of doctor-patient relationships using a ''power'' balance sheet. In this model, power relates to who sets the agenda, whether the patient's values are expressed and considered, and what role the physician assumes. As illustrated in Table 2, high physician and high patient power (upper left) depicts a relationship of mutuality, balance, and shared decision making. High physician and low patient power (lower left) is consistent with Emanuel's paternalistic model where the doctor sets the agenda and prescribes the treatment. In the low physician and high patient power relationship (upper right), the patient sets the agenda and takes sole responsibility for decision making. Roter et al. (28) call this interaction consumerism. Lastly, in a low physician and low patient power relationship (lower right), the role of the doctor and patient is unclear and undefined. This is a dysfunctional relationship. According to Roter et al., the optimal relationship is that of mutuality or what they call ''relationship-centered medicine.'' In the course of providing obesity care, it is likely that more than one of these relationships is used among patients. The important point is that the encounter should be functional, informative, respectful, and supportive.

Depending on the patient's course of treatment and response, various strategies and techniques are used during the visit. The traditional therapeutic role of the physician is to address concerns, build trust, give advice, and be supportive (29). Novack (30) describes four therapeutic interventions that support patient behavior change. Each of the therapeutic strategies listed in Table 3 is directed toward keeping the patient motivated and providing a sense of control. Among the components of effective counseling, empathy is perhaps the most important. The feeling of being understood is intrinsically therapeutic. Patients with obesity typically provide emotionally laden testimony about the frustration, anger, and shame of losing (and gaining) weight, the discrimination they feel in the workplace and society for being overweight, and the ridicule they may have experienced with other health care providers. Recogniz-

Table 2 Patient-Physician Communication Relationships g

Physician power

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