Leif I. Solberg

The systematic practice of preventive cardiology

The Preventive Strategy Delivery of preventive services differs little from that of therapeutic services. In traditional practice we obtain the medical history, carry out the physical examination, order and interpret the laboratory work, formulate diagnoses and prescribe therapy. The ap preach to preventive cardiology is similar. Begin with a traditional work-up. This is impressive to the patient and revealing to you. It gives credibility to your summation of the evidence for risk and to your preventive recommendations. It also sets a personal tone of caring for your patient. It sharply focuses your attention on the patient as an individual. Summarize the clinical and laboratory findings. Link them to a general class of risk sufficiently real to command attention but not exaggerated for its accuracy of individual prediction. Specific recommendations for new behaviors reduce the fear and rejection that can be associated with labeling as “high risk.” Link the risk class to the patient’s personal behavior and genetic legacy, thus balancing the modifiable and unmodifiable factors of risk. Review smoking, eating, physical activity and weight change patterns in daily living. Then try to tie the risk and personal habits to family and social behaviors, giving the patient insights into the nature and causes of excess risk. Point out situations in the home and worksite that influence the eating activity and smoking patterns of the patient’s spouse, children and colleagues. Finding a relatively low risk status provides the occasion for congratulations, but also allows you to indicate the influence of the patient’s behavior on others, i.e., the development of risk in family and friends. A11 in the family need to

Smoking patterns among social contacts of smokers, ex-smokers, and never smokers: the Doctors Helping Smokers Study.

Smoking status of spouses/partners and other social contacts was examined among 5,241 adults who had recently visited a family physician. Associations between smoking status and proportion of social contacts who smoke among men and women of three different age groups were assessed by analysis of covariance, with age and education as covariates. The proportion of smoking contacts was found to be greatest for smokers, less for ex-smokers, and least for never smokers. Comparison of data across four types of social contacts by smoking groups suggests that, in general, the social contacts of ex-smokers more strongly resemble those of never smokers than those of current smokers. The results suggest that smokers desiring to become nonsmokers need to enlarge their social group to include more nonsmoking contacts, as well as to learn and use coping strategies to prevent relapse in the presence of smokers.

Initiation and maintenance of patient behavioral change

If the physician is to help a patient adopt and maintain “preventive behaviors,” the processes that influence and shape both patient and physician behaviors must be understood, the physician’s role in the behavioral change process must be acceptable to both the patient and the physician, and an environment that both permits the physician to act and reinforces the physician for acting appropriately must be designed for the physician. A physician’s role that is acceptable to both the patient and the physician can be seen as six obligations. The physician must 1) evaluate the medical literature on prevention to determine which services are indicated for which types of patients, 2) when seeing an individual patient, identify the services and behaviors needed by that patient, and 3) advise the patient of the need for action. As the patient responds positively to the physician’s advice, the physician must 4) enable and assist the patient to have the indicated tests or procedures and accomplish the suggested behavioral changes, and 5) reinforce the patient’s new and ongoing preventive behaviors. The sixth obligation of the physician is to establish, support, and maintain a system to facilitate tasks 2 through 5.