Role of Behavioral Medicine in Primary Care

Abstract

Purpose of review Behavioral medicine is a vast field with an ever-increasing knowledge base. We review important findings over the last 18 months.
Recent findings We organized advances in behavioral medicine into four main topic areas: the doctor and patient, healthrelated behavior, integration of behavioral medicine in primary care, and teaching and assessing behavioral medicine competencies in primary care. Section I reviews research on difficult encounters, delivering bad and sad news, and physician well being. Section II examines improvements in the treatment of obesity and tobacco abuse, as well as interventions which boost adherence. Section III discusses advancements in care management and collaborative care in the USA and resource-constrained settings. Finally, section IV deals with teaching and assessing communication skills, behavior change, and professionalism.
Summary Physician skills such as communication, professionalism, behavior change, and self-care are not innate abilities, but teachable and learnable skills. Collaborative care and the integration of behavioral medicine with care for other conditions can benefit patients, and can be done effectively with case management and telemonitoring strategies. Future behavioral medicine research should include evaluation of implementation strategies so that we may incorporate principles of behavioral medicine more widely into clinical practice.
Introduction

The term ‘behavioral medicine’ is widely used in the social and behavioral science and medical literature, but there is little agreement as to its scope and definition. In this review of the role of behavioral medicine in primary care, we define behavioral medicine as an ‘interdisciplinary field that aims to integrate the biological and psychosocial perspectives on human behavior and apply them to the practice of medicine’.[1] What unifies the diverse topics of this review is that they represent, through either cause or treatment, links from behavior to health. In addition, these are issues that commonly are confronted by primary care providers in their day-to-day practice of medicine. Although several books are devoted to the topic,[1,2] keeping abreast of the most recent developments is better suited to a review article. To our knowledge, this is the most comprehensive up-to-date review of these behavioral medicine topics.

This review is organized under four main headings: the doctor and patient, health-related behavior, integration of behavioral medicine in primary care, and teaching and assessing behavioral medicine competencies in primary care. Under each heading, we focus on key articles published over the past 2 years. To identify these articles, we searched by the relevant key words and MeSH terms in the Medline database, Cochrane clinical trials and reviews database, and the Database of Abstracts of Reviews of Effects. The bibliographies of systematic reviews and key articles were manually searched for additional references.
The Doctor and Patient

The medical interview is the main medium of patient care in the primary care setting, and remains a major area of research in the field of behavioral medicine.
Working With Difficult and Challenging Patients

Since Groves'[3] classic study ‘taking care of the hateful patient’, researchers have attempted to understand and characterize the components of the challenging or difficult medical interview.[4,5] A recent study examined the predictors and outcomes of difficult patient encounters at a primary care clinic.[6••] They found that almost 18% of encounters were classified as difficult. Physicians with fewer years of clinical experience and lower standardized communication style ratings were more likely to perceive patient encounters as difficult. Moreover, patients involved in difficult encounters had less trust in their physicians and were more likely to report worsening symptoms.

Difficult encounters in primary care can have a negative impact on both physician burnout and quality of care.[7] A survey of physicians throughout the USA found that those classified as perceiving a high (vs. low) proportion of encounters as difficult were more likely to experience burnout and to report suboptimal care practices. This study and the previous one underscore the fact that difficult encounters are common in primary care, and may contribute to adverse clinical outcomes. Patients involved in difficult encounters have less trust in their physicians, lower satisfaction, and worse symptoms. It is imperative that primary care providers be taught effective strategies for managing difficult encounters.[8,9]
Giving Sad and Bad News

No communication task is more challenging for primary care providers than the delivery of bad and sad news. To date, most of what is known and taught about bad news delivery is based on expert opinion.[10] However, a small but growing body of empirical evidence is accumulating to help guide these discussions.

Vail et al. [11••] report on a study of how 46 experienced hospital-based consultants deliver bad news to simulated patients. They found that physicians tend to adopt a ‘disease-centered’ rather than a ‘patient-centered’ approach, focusing on biomedical information rather than on psychosocial issues. They suggest using videotaped simulated patient interactions in teaching how to deliver bad news. Another small study points to a unique method for training physicians in bad news delivery. Andrade et al. [12] used acomputerized female avatar to teach medical trainees how to deliver news of newly diagnosed breast cancer. Overall, they found that trainees’ self-efficacy in bad news delivery improved. The study by Back et al. [13] reports on a teaching strategy for communication challenges in which the learner is aware that the preceptor will intervene if the encounter is not going well. When this occurs, the preceptor role models an effective strategy, but then ‘hands’ the interview back to the learner and debriefs the session afterward. This approach is in contrast to the usual pedagogical style in which the preceptor takes over the interview from the learner. Role-modeling communication skills in real time without taking over the interview can effectively teach challenging topics such as bad news delivery.
Physician Well Being

Numerous studies have reported high rates of burnout, job dissatisfaction, and impairment among primary care physicians.[14–18] Factors responsible for this trend include increased paperwork and other administrative demands that leave many primary care physicians with a sense of diminished autonomy and loss of control over their work. Burnout among primary care physicians is associated with real and perceived medical errors, lower quality of care,[19–21] and decreased work productivity and job retention.[22] Additionally, primary care physicians who work in academic medical centers face diminished research funding opportunities and ‘unfunded mandates’ derived from teaching and mentoring.[23] Among internal medicine residents, suboptimal quality of life and burnout are associated with higher levels of depression,[24] whereas for medical students burnout is linked with unprofessional conduct and less altruistic professional values.[25] It is not clear whether dutyhour reforms will have an appreciable impact on resident burnout and mental health, but a recent systematic review concluded that there has been an improvement in resident well being following the mandated decrease in work hours in 2003.[26]

Emerging research demonstrates the effectiveness of educational programs to help ameliorate the negative impact of burnout.[27] For example, Krasner et al. [28] report on a before-and-after study of 70 primary care physicians who participated in a course that included mindfulness meditation, self-awareness exercises, appreciative interviews, and other similar activities. They found program participation was associated with sustained improvements in well being and in attitudes supporting patient-centered care. Likewise, Sood et al. [29] report on a randomized trial in which a 90-min one-on-one session for physicians, focusing on meditation, relaxation and mindfulness, significantly decreased reported stress and anxiety, and improved quality of life. Although the data are limited, it appears that introducing stress management and mindfulness programs into primary care settings can lead to decreased burnout, improved resiliency, and greater well being.
Health-related Behavior

Illnesses related to patient behavior represent a significant percentage of annual mortality in the USA,[30] and behavior is known to be a major component of attributable risk for many common illnesses.[31] In addition, a patient’s ability to participate in and adhere to a treatment plan has an enormous impact on treatment outcomes. A physician or care team’s ability to motivate behavior change and adherence to treatment is fundamental to successful care. In this section, we detail recent advances in treatments for behavior-related illness, as well as work focused on changing patient behavior and boosting treatment adherence.
Obesity

Although obesity is epidemic in the USA, treatment is often frustratingly ineffective. However, several recent well conducted evaluations of structured dietary and exercise interventions have contributed to a growing evidence base to help clinicians improve their decision-making and treatment. Foster et al. [32•] provide important evidence in the debate about low-carbohydrate vs. low-fat diets, demonstrating that both can lead to successful weight loss (around 7% of total starting bodyweight at 2 years). In a study examining severely obese patients, Goodpaster et al. [33] show that a lifestyle intervention, combined with either immediate or delayed initiation of a physical activity program, leads to weight loss and improved cardiovascular risk profiles. Kreider et al. [34] demonstrate that a structured meal-plan-based diet and supervised exercise program were more effective than a meal replacement plan, with participants in the former losing almost twice as much weight (3.1 vs. 1.6 kg at 12 months). Rock et al.’s[35] research also supports a structured meal plan and dietary counseling over counseling alone. Finally, in an area with little previous study, Villareal et al. [36] found that a dietbased and exercise-based intervention was superior to either component alone in overweight elders.

Two new pharmacological interventions, both based on combinations of medications used for other indications, were recently evaluated for weight loss. Gadde et al. [37•] report on the results of a trial of combination extended release phentermine and topiramate, showing that this led to increased weight loss above placebo. Greenway et al. [38•] demonstrated the effectiveness of combination naltrexone and buproprion over placebo.

Clinicians may have questions regarding their patients’ suitability for bariatric surgery, and the types of operations available. In general, a patient is considered a candidate for surgery if he or she has failed nonsurgical management, usually including at least a structured weight management program, and has a BMI greater than 40, or greater than 35 with a medical comorbidity associated with obesity, such as diabetes.[39] The three most common bariatric procedures in the USA currently are the adjustable gastric band, the sleeve gastrectomy, and the Roux-en-Y gastric bypass. Although bariatric surgery has been shown to reduce weight in the order of 25–35 kg at 1 year,[39] and in some cases improve glycemic control,[40] concerns about long-term effectiveness and nontrivial mortality rates for a procedure that has not been shown to be lifesaving remain.
Tobacco Abuse

Tobacco is the leading cause of preventable death in the USA.[41] Piper et al. [42] report on important comparative effectiveness research, comparing five different strategies of nicotine replacement therapy. Their analysis found that nicotine patch–nicotine lozenge provided the greatest benefit compared with other strategies such as those components alone and with bupropion. Additionally, Rigotti et al. [43] provide important reassurance for those considering prescribing varenicline for patients with a history of cardiovascular disease. They report that it is both well tolerated and effective, at least for the 52-week follow-up of the trial. Looking at nonpharmacologic means to boost cessation, Free et al. [44] demonstrate the effectiveness of a text message-based smoking cessation program in their randomized clinical trial (RCT), with a relative risk of abstinence at 6 months of 2.20 for the intervention group. Also, Graham et al. [45] showed that a tobacco cessation program using an enhanced internet resource with a telephone intervention effectively increased smoking cessation rates at 18 months, compared with a static internet-based cessation resource.
Treatment Adherence

Although there may be more discussion of novel therapeutics, interventions that boost treatment adherence maximize benefits from established treatments. Two important strategies in adherence-boosting interventions can be thought of, in general, as case management, in which a peer, lay health worker, or mid-level practitioner takes responsibility for a particular aspect of treatment for a group of patients, and telemonitoring, wherein telephone-based or internet-based transmissions of clinical data lead to more frequent adjustments of care plans than would otherwise be done.

Heisler et al. [46•] report on an RCT in which a peer-led diabetes support group showed improvements in glycemic control superior to a nurse-led group.

Telemonitoring shows promise in increasing control of chronic conditions, with Bosworth et al. [47] and McManus et al. [48] both reporting improvements in blood pressure control with telemonitoring programs. Additionally, Kroenke et al. [49••] demonstrated improvements in depression and pain symptoms in a telemanagement program for patients with cancer. An important counterpoint to these successes, however, is Chaudhry et al.’s[50••] work, which did not demonstrate improvement in heart failure outcomes. Although the idea of telemonitoring certainly holds promise, how best to implement it in particular conditions remains an area for future research.
Integration of Behavioral Health in Primary Care

Increasing evidence across many different disease processes has demonstrated the effect of behavioral health conditions on other medical conditions seen in primary care.[51,52] In this section, we focus on work that describes strategies to improve the treatment of behavioral health conditions in the primary care setting, including the coordination of behavioral healthcare with that of other medical conditions.

Although treatments for depression and anxiety continue to increase, dissemination of these interventions has not kept pace. A clear trend is moving well established interventions from the specialist setting into primary care, often with the help of nonexpert care managers. An important study by Roy-Byrne et al. [53••] focused on the treatment of common anxiety disorders using a structured intervention that allowed medical management, cognitive behavioral therapy (CBT) performed by care managers with a computerized assistance, or both, and provided real-time web-based outcomes tracking and interventions to increase treatment adherence. This proved to be highly effective in improving anxiety and depression symptoms, as well as function, with a number needed to treat of 5.27 over usual care.

The undertreatment of behavioral health conditions is pervasive in the developing world.[54,55] Given the shortage of professionally trained healthcare providers, lay healthcare workers are an attractive solution. An intervention by Patel et al. [56] in Goa, India (a developing area with an advance government-run healthcare network) successfully identified and treated depression using lay health workers, particularly for patients seen at public primary care facilities. This is an interesting model for behavioral healthcare in the developing world.

Collaborative care models help integrate the treatment of depression and anxiety with diabetes, heart disease, and hypertension. Katon et al. [57••] demonstrated that patients with depression in addition to diabetes, coronary heart disease, or both had improvements in depression symptoms, glycemic control, low density lipoprotein cholesterol, and systolic blood pressure when enrolled in a nurse-led collaborative care program that focused on providing evidence-based care for these conditions, compared with patients receiving usual care. Given the shortage of both behavioral health and primary care providers, support for doing panel management at a nursing or case management level is welcome indeed.
Teaching and Assessing Behavioral Medicine Competencies in Primary Care

Health-related behaviors are responsible for at least 50% of actual causes of mortality in the USA.[30] In recognition of this, the Institute of Medicine issued a seminal study[58] in 2004 that offered a number of recommendations for integrating social and behavioral sciences into medical education. Since this publication, there has been increasing recognition of the importance of creating comprehensive curricula to teach key behavioral medicine concepts and techniques to medical students, residents, and practicing physicians.[59] Below, we summarize some recent research in teaching and assessment of communication skills, promoting health related behavior change and professionalism.
Teaching and Assessing Communication Skills

Prior research has shown that competency in physician– patient communication is linked to enhanced diagnoses and medical outcomes, better patient adherence, improved patient and physician satisfaction, and less likelihood of malpractice litigation.[60–62] Training medical students in communication skills has been shown to result in improved relationship building, time management, and shared decision-making.[63,64] Unfortunately, however, a recent systematic review found that medical student and resident empathy, a key component of effective care,[65] declines during the clinical practice phase of education and training, primarily due to the influence of the ‘hidden curriculum’.[66] Roberts et al. [67] found that medical residents, own illness experiences may increase compassionate patient care and foster empathy and Shield et al. [68] report that a curriculum that teaches compassionate care may improve rapport with patients and their family members. A recent study by Collins et al. [69] underscores the importance of teaching nonverbal communication skills to medical students. They found that students caring for standardized older African- American patients did not recognize the importance of hand gestures and facial expressions in communicating in a culturally sensitive manner.

Assessment of communication skills is a complex and evolving aspect of educational evaluation. In a recent review, Salmon and Young[70] argue that teaching communication skills should be more explicitly embedded in education theory and be taught and evaluated more holistically rather than being ‘atomized’ into a set of skills. A recent study by Kim et al. [71] suggests that the Web can be used effectively to measure and enhance physicians’ communication skills.
Teaching and Assessing Behavior Change Skills

Training in motivating behavior change is a critically important component of behavioral medicine education. Motivational interviewing is an evidence-based approach to health behavior change with a focus on overcoming ambivalence to change that can be used effectively by medical trainees and practicing physicians.[72] Evaluating the motivational interviewing paradigm, Lozano et al. [73] found that a 9-h behavior change curriculum based on brief motivational interviewing and personalized feedback on communication skills resulted in improved behavior change counseling techniques in pediatric residents. Two studies found that third-year medical students could be successfully taught the principles of motivational interviewing and could apply them in interactions with standardized patients,[74,75] and a study by Abramowitz et al. [76] creatively links a motivational interviewing curriculum to the self-management support component of the chronic care model in an internal medicine training program.
Professionalism

Although most educators agree that teaching and assessing professionalism should be a core component of any behavioral medicine curriculum, the question of how to do this is fraught with ambiguity and controversy.[77,78] In their seminal study, Epstein and Hundert[79] define professional competence as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’. Lesser et al. [80] propose a behavioral and systems approach to professionalism and argue that professionalism needs to evolve from being thought of as an ‘innate character trait or virtue’ to detailed and behaviorally derived competencies that can be taught and refined over a professional lifetime. They correctly move the concept of professionalism from a purely individual issue to one that is influenced by the broader organizational and social healthcare context. Several recent articles have examined the influence of social media on professionalism. For example, Mostaghimi et al.[81] found in a random survey of internal medicine physicians that personal and professional physician information is widely available on the internet, and often is not under direct control of the individual physician. The American Medical Association issued a new policy on Professionalism in the use of social media[82] and several recent commentaries point out the challenges to professionalismas well as the potential opportunities afforded by the rise of the internet and social media.[83,84]
Conclusion

Behavioral medicine is a vast field, and one in which research is advancing rapidly. Research in health communication continues to identify ways in which we can improve our rapport with patients and more effectively deliver health messages. Research in behavior change is giving clinicians more tools to help patients overcome behaviors that threaten their health. The increasing recognition of the interconnected nature of behavioral health topics with other medical issues is leading to improvements in the management of both types of conditions. And finally, we continue to make progress not only in knowing what care to deliver, but in teaching physicians to deliver it and assessing their ability to do so.
Sidebar
Key Points

Effective communication with patients is a learned skill, one that can and should be conscientiously improved, to the benefit of both doctor and patient.
Motivating behavior change should be approached in a multifactorial fashion, utilizing advances both in pharmacotherapy and in delivery of care.
Behavioral health is interconnected with all health conditions, and management strategies that recognize this outperform ones that do not.
Medical education, the nurturing of professionalism, and the assessment of competency require deliberate practice.

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••Important counterpoint tomany recent successful telemonitoring interventions. In this well conducted study of heart failure patients, there was no difference in hospitalizations or deaths in the telemonitoring group. It will be important to further determine the factors that led to success in some telemonitoring interventions, but not in others.
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••Very important study for management of anxiety disorders in primary care, which has received less study than depression, despite being as common. Showed that CBT delivered by nonexperts with computer support, among other interventions, could improve anxiety symptoms in primary care patients. Given the relative lack of availability of CBT despite its efficacy, strategies like this could be important in increasing its dissemination.
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••Important support for the panel management approach, and unique in its combination of both mental health and other chronic illness care. Used nurse-led panel management techniques to improve blood pressure, glycemic control, cholesterol, and depression scores. This led to improved quality of life as well.
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Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 161–162).

Acknowledgements
M.D.F. is supported in part by the Japan-United States Educational Commission, Fulbright Japan (JUSEC).

Conflicts of interest
There are no conflicts of interest.