Whom do people trust the most for accurate, up-to-date information about their health? In this age of rapid-fire information technology, one might guess Dr. Google or some other online source. In fact, recent studies show that people mostly trust their own personal physicians for health information. A Pew Research Center report issued last year showed that 74% of us have a positive view of medical doctors and 68% have a “mostly favorable” view of medical research. A 2019 survey reported that 90% of respondents endorsed doctors as the most trusted professionals. In another survey, this high level of trust in doctors was seen in both liberals and conservatives. In Critica’s recent online focus groups in which we asked people where they get their information about vaccines and what sources they trusted the most, participants overwhelmingly named their own doctors. Internet sources were used frequently as well but were not cited as often as doctors. Federal health agencies like CDC and FDA were seen as less trustworthy by many.
It is probably no surprise that people are more likely to believe and follow information they receive from trusted sources. It may surprise some, however, to see that doctors have held on to this trusted position for decades despite the many changes that have taken place in the American healthcare delivery system. The trusted family physician whom patients know for years and who in turn knows everything about them has largely been replaced by large group practices and specialists. Today, the electronic health record knows everything about us, not our personal physician (if we even have one).
This situation seems ripe to erode the classic patient-physician relationship and drive people to find other sources of health information. If doctors get all the information they need about us from a computer, why shouldn’t their patients do the same thing and turn to the myriad online sources of medical information available today?
Prevention Not Emphasized
Yet, despite the insidious commercialization of medical practice, people continue to put a great deal of trust in doctors. The critical question becomes: are we putting that high level of trust to the best use? It is clear that even in an era in which the amount of time doctors get to spend with their patients becomes shorter and shorter, doctors are important influencers. Studies show that people who trust their doctors are most likely to follow the advice they give. Hence, it is reasonable to assume that since most people trust their doctors, physicians are in an excellent position to steer people toward health-enhancing practices and behaviors.
This is not a topic emphasized in medical training. The science of health has grown to such enormous complexity and depth that medical students have all they can handle learning about basic physiology and biochemistry, a myriad of diseases, and seemingly unending numbers of treatments and interventions. As is often noted, doctors are trained to respond to disease, not to prevent it. And patients generally have the same agenda: we generally go to see a doctor for one of two reasons, either we have a new symptom like pain that demands attention or we need scheduled care for a known, chronic illness. During those visits, our doctors focus attention on our “chief complaint,” the reason we tell them we are there. Appropriate history, physical examination, and tests are considered and we are sent home with instructions on what to do about the problem with which, in medical jargon, we “presented.”
Primary care doctors are in fact urged by every medical society and preventative health association to also think during each of these visits about dozens of other things the patient should do to prevent illness or at least detect it at its earliest and hopefully less ominous stages. The gastroenterologists want the primary care doctor to look up whether the patient is a candidate for a colonoscopy; the psychiatrists want her to inquire about mood and suicidal thoughts; the urologists want men to have a test for prostate cancer (PSA); and everyone expects the doctor to encourage good diets and lots of exercise. More than a decade ago the median amount of a time a primary care physician got to spend with a patient was already only around 15 minutes. Those visits have certainly not gotten any longer and make dealing with all of these demands for preventative care a daunting task.
What Preventative Steps Can We Prioritize?
Perhaps one thing that would help would be to figure out some priorities for doctors to consider at each visit after they have dealt with the presenting issue. What are, say, three things that a physician can bring up during a routine visit that are both critically important to health and for which there is some evidence that brief discussions on the order of five to 10 minutes can make an actual difference in the patient’s life?
We decided to first consider the ten leading causes of death in the United States. They are:
- heart disease
2. cancer
3. chronic lower respiratory disease (such as emphysema)
4. stroke
5. unintentional injuries
6. Alzheimer’s disease
7. diabetes
8. pneumonia and influenza
9. kidney disease
10. suicide
None of these ten leading causes of death is entirely preventable. The causes of many forms of cancer, including some of the deadliest like pancreatic cancer and the type of brain cancer called glioblastoma, are largely unknown and therefore nearly impossible to prevent. We don’t know what causes Alzheimer’s disease either and therefore prevention is not really possible. As tragic as suicide is, it is not a predictable event and therefore also difficult to prevent.
But there are things we can do to prevent some of these deadly diseases and to at least delay the onset of others. Of these, the one that most stands out is cigarette smoking. Tobacco smoking remains the leading cause of preventable death in the U.S. and around the world. Despite the fact that smoking is difficult to quit, brief screening and counseling about tobacco use by primary care physicians works during routine visits. Doctors often fail to realize that asking people if they smoke and advising them to stop is an effective intervention that increases the chances a smoker will actually quit smoking. Moreover, there are several medications that can be prescribed that also increases the rates of smoking cessation. One clear way to parlay the trust in doctors that pays off, then, is to enquire about tobacco use at every visit.
A second effective intervention is to make sure adult patients have had recommended vaccinations. Right now, of course, that conversation is dominated by the need to have everyone vaccinated against the virus that causes COVID-19 as soon as possible. For adults, however, vaccination recommendations also include those for pneumonia, influenza (“the flu”), and herpes zoster (shingles). We and others are developing brief interventions that all healthcare professionals can use to reduce vaccine hesitancy and increase uptake of vaccines that clearly save lives.
Our third recommendation concerns obesity, which is implicated in heart disease, Alzheimer’s disease, some cancers, and adult-onset (or type 2) diabetes. Here it is perhaps less clear that a doctor’s brief intervention meaningfully impacts obese patients’ behavior, but there is some evidence that it does. Given the number of diseases impacted by a person’s weight, we include brief interventions to address overweight and obesity as one of our top three.
An immediate objection to our list is that even addressing these three issues—tobacco use, adult vaccinations, and weight—could together double or even triple the length of an average doctor visit. It is obviously not sufficient to merely ask the patient if they smoke and have all their vaccinations and check if they weigh more than is healthy for them. Each of these conditions demands at least a few minutes of conversation between doctor and patient about the options for improvement. Let us assume for a moment, however, that each patient has a problem with only one of these three problems. Given that brief interventions for each have been shown to be effective, then most visits would be lengthened by only the 5 to 10 minutes it takes to discuss these options and make recommendations.
A healthcare system that cannot extend primary care physicians’ visits by ten minutes in order to address even these three leading risk factors for poor health outcomes is clearly working against itself. Those ten minutes counseling someone about smoking cessation and possibly prescribing a medication to help such as bupropion or varenicline will prevent countless numbers of cases of cancer, terminal respiratory disease, and heart disease. Making sure the patient gets their pneumonia and flu vaccines will help reduce the rate of the eighth leading cause of death. Discussing a diet and exercise plan and referral to a dietician will definitely result in some patients losing weight and averting the early onset of a number of diseases on the list. The savings in human suffering and medical costs would, we are sure, far outweigh the costs of those extra ten minutes.
There are so many other things that doctors could, and probably should, address during each visit, but again we need to remember how short these visits are and think about how we can leverage high levels of trust in doctors to make the greatest impacts on public health. We are not for a moment dismissing all the things doctors must pay attention to that are incidental to what the patient has come in seeking help. Obviously, for example, if a person coming to the doctor because of a cough and runny nose has an elevated blood pressure, the doctor should address the possibility that the patient’s real health problem is not his cold but rather hypertension. We do hope our readers will let us know what they think about our top three and suggest others that are critical to add to the list.
What we are trying to come up with is a workable plan whereby doctors use the trust people still have in them to bring up health issues for which they can have impact in a very short period of time during every visit. We conclude that the three at the top of the list are tobacco smoking, vaccines, and obesity. If at every encounter, regardless of the reason for the visit, doctors ask patients if they smoke, if they have had all their recommended vaccines, and if they are taking steps to keep their weight at appropriate levels, we predict that countless numbers of premature deaths will be averted. We wish we could add more things to this list—there is good evidence for instance that screening by primary care physicians for alcohol use problems and depression can also be effective—but we are cognizant of the realities of modern-day doctor visits. Let’s start with smoking, vaccines, and weight and see if these at least can be accomplished. Otherwise, we stand to waste the most trusted source of health information known.
criticascience 