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[ANNIVERSARY COMMENTARY]

Shedding a Stereotype: Our Low-Income Patients Are Listening

Robert J. Johnson, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 3 - MARCH 2021


For the last 13 years I've been a family physician in the inner city. Currently, 70% of my patients are on some form of general or medical assistance. They are culturally diverse, and some are so new to this country that taking a history is difficult because I must work through an interpreter.

Because of my patients, I was especially struck by a recent study (1) that focuses on the relationship between patients' incomes, the health risk behaviors that are discussed with physicians—such as lack of exercise—and the patients' attempts to change. Particularly poignant was the conclusion that, when physicians discussed risky behaviors with patients, those "with less income were more likely to report attempting to change their behavior in every area based on their physician's advice."

The study was based on a survey of over 6,500 employees of the state of Massachusetts, conducted by the Health Institute at New England Medical Center in Boston, and focused on the universal risk assessment recommended by the US Preventive Services Task Force. It stratified the subjects by income and assessed the frequency of physician-patient discussions regarding diet, exercise, stress, safe sex practices, and the use of cigarettes, alcohol, and seat belts. It also gauged patients' responses to these discussions. According to the study, physicians are doing an adequate job discussing such behaviors, but sometimes we may be making false assumptions about what advice patients need and about how motivated they are to change. (See Highlights item, "Risky Behaviors Need More Physician-Patient Discussion," page 16)

Findings That Fit My Practice

Some of the results of the study paralleled my own clinical experience and thus were not so surprising. Higher-income patients, for example, tended to have healthier behaviors than lower-income patients. However, the more affluent reported more stressful lives and were more likely to drink alcohol, though heavy drinkers constituted about 2% of every income level. Individuals who had lower incomes were more likely to be obese and to smoke, and less likely to wear seat belts and to exercise, than those with higher incomes.

About 87% of the patients' physicians were either general internists, family physicians, or general practitioners, and the rest were subspecialists. More than 50% of the patients reported discussing exercise, diet, stress, and smoking with their physician; during a typical office visit, most talked about multiple behaviors, and two-thirds addressed at least three health risk behaviors.

Some Surprises

More discussion needed. Other results of the study were surprising and underscore our need to persist in addressing all of these behaviors with all of our patients. When a patient was at risk because of a certain behavior, the number of physicians addressing that behavior varied widely. For example, 73% discussed exercise with patients who exercised fewer than three times per week, and 70% discussed diet with obese patients. However, only 39% of physicians discussed alcohol use, 19% discussed safe sex practices, and 16% discussed seat belt use with patients who were at risk in those areas.

Among patients who had dietary and exercise problems, physicians were more likely to address these problems with high-income than low-income patients; the opposite was true regarding smoking.

Encouraging news. Some results were surprisingly encouraging and show us that our patients are listening. Nineteen percent of patients believed that they were given too little information by their physician, but only 5% thought they were given too much. In other words, 76% of patients thought that they received just about the right amount of information when they saw their physician.

More important, patients are trying to heed our advice. Even among those who reported receiving too much information, 80% reported practicing safer sex, 82% reported changing their diet, and 61% reported attempting to reduce or quit smoking. Among patients who attempted to change their smoking habits because of their physician's advice, 49% reported that they had quit altogether.

Patients who want to change. Most surprising of all, however, were the results that showed that the least affluent patients who received advice from physicians made greater efforts to modify risk behaviors of all types than patients of higher incomes. The most dramatic examples of this involved safe sex practices and seat belt use. Among those who discussed these behaviors with their physicians, more than 70% of those earning less than $20,000 per year attempted change in these areas, compared with 35% of those whose incomes were more than $80,000 per year.

A Challenge To Our Thinking

This study challenges our assumptions. Physicians who counsel patients rarely see the success of such interventions but most certainly see the failures when patients return with the same or a worse condition. If this pattern is repeated too often, we may believe that patients do not value our recommendations. To think that even 35% of our patients attempt to change based on our advice is highly encouraging. To learn that 70% try to change is astounding, especially among lower-income patients.

Attitude toward the poor. This study means that we may need to rethink our attitude toward our poorer patients. Many of my patients, for example, earn considerably less than $20,000 per year. I see them living from check to check each month, often having less education and bearing a greater burden of illness than my more affluent patients. Because they are beset by such problems, I could be tempted to see them as victims who are less able to control their lives and less interested in changing behaviors to improve their health. This study suggests otherwise.

Creating healthy lives. If we are to help lower-income patients create a healthy life for themselves, we may have to rethink our attitude and advice about changing risk behaviors. Take exercise, for example. Fitness is not just the domain of those who can afford to work out frequently and vigorously at a health club. Patients can benefit significantly from exercise they perform on their own, but we may have to teach them specific activities or develop a specific walking program for them. For smoking cessation, we may have to become more knowledgeable about inexpensive or free community programs available to lower-income patients. Perhaps most of all, we may have to be more like a good coach or teacher, so we can motivate our patients to make healthy choices.

The message from this study is clear. Our patients are listening and willing to change to be more healthy. Learning to be gently relentless in pursuing the health of our least affluent patients may help us be more effective in improving the well-being of all.

Reference

  1. Taira DA, Safran DG, Seto TB, et al: The relationship between patient income and physician discussion of health risk behaviors. JAMA 1997;278(17):1412-1417

Dr Johnson is the director of primary care sports medicine in the Department of Family Practice at Hennepin County Medical Center in Minneapolis, a fellow of the American College of Sports Medicine, and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Robert J. Johnson, MD, Director of Primary Care Sports Medicine, Department of Family Practice, Hennepin County Medical Center, Five West Lake St, Minneapolis, MN 55408.


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