Recommendations: Who is Counseled on What and When?

Making decisions on what, when, and how often to counsel a patient depends on the risk factors, demographic characteristics, life expectancy, and leading causes of death relevant to an individual patient. Most of this is identified through the history, some through physical examination, and occasionally from screening interventions.

Examples of Counseling

Counseling may focus on a range of topics including alcohol consumption, recreational drug use, contraception, injury prevention, oral health, physical activity, and nutrition. We will briefly focus on two: tobacco smoking cessation and intimate partner violence.

The Five A’s for Facilitating Smoking Cessation

We know from the wealth of research on smoking cessation that counseling and support by physicians is critical (Whitlock et al, 2002; Okuyemi et al, 2006). A well-known framework for behavior change is the Five A’s Model for Facilitating Smoking Cessation. This framework unifies the models of behavior change, motivational interviewing, and patient-centered counseling interventions and can be applied in everyday clinical settings.

Ask about tobacco use during every office visit.

  • Include questions about tobacco use when assessing the patient’s vital signs.
  • Place tobacco-use status stickers on patient charts and/or note tobacco use in electronic medical records.
Advise all smokers to quit. Advice should be:

  • Clear (e.g., “I think it is important for you to quit now.”).
  • Strong (e.g., “As your physician, I need to tell you that smoking cessation is one of the most important decisions you can make for your health.”).
  • Personalized (i.e., physicians should talk about impact on the patient’s life, family, and finances).
Assess the patient’s willingness to quit.

  • If the patient is willing to make a quit attempt, offer medication, brief counseling, self-help resources, and schedule a follow-up visit.
  • If the patient is unwilling, identify why the patient is ambivalent. Explore what he or she likes or does not like about smoking; the potential advantages and disavantages of quitting.
Assist the patient in his or her attempt to quit.

  • Set a quit date.
  • Request encouragement from family and friends.
  • Anticipate triggers and cues to smoking.
  • Suggest changes to the environment (e.g., throw away cigarettes, lighters, and ashtrays; vacuum car and home; avoid other smokers and alcohol).
Arrange follow-up contact.

  • Follow-up should occur within the first week after the quit date.
  • Second follow-up is recommended within the first month.
  • Congratulate success.
  • If relapse occurs, review the circumstances and elicit a new commitment to quit.
  • Follow-up can be by phone, e-mail, or in-person.

Counseling and pharmacotherapy used either alone or in combination can improve rates of success with attempts to stop smoking. Self-help approaches have little effect when offered without any person-to-person intervention. Brief (3 minutes or less) individual cessation counseling is efficacious. It is unclear whether more intense counseling yields a greater effect than less intensive interventions.

Nicotine replacement therapy (e.g., gum, transdermal patch, inhaler, or nasal spray) is an effective aid in smoking cessation (Ranney, 2006). Sustained-release bupropion is also safe and effective. There are other oral medication options but they have worse side effect profiles.

In pregnant women who smoke, intensive counseling (5-15 minutes) using messages and self-help materials tailored for pregnant smokers substantially increases abstinence rates when compared with brief generic counseling. There is limited evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy (USPSTF, 2003; reaffirmed 2009).

Intimate Partner Violence

Intimate partner violence (IPV) is a major health concern, with a lifetime prevalence of 31% of women (USPSTF, 2013). It contributes to poor physical and mental health, particularly among women (Fogarty, 2002). There is particularly strong evidence that disparities in breast and cervical cancer screening are correlated with a history of exposure to violence (Gandhi et al, 2001), and IPV is associated with negative pregnancy outcomes (USPSTF, 2013).

The United States Preventive Services Task Force (USPSTF) recommends that all women of childbearing age be screened for intimate partner violence, with provision of or referral to services for women who screen positive (USPSTF, 2013). The USPSTF found insufficient evidence for the screening of elderly or vulnerable adults. The incidence of domestic violence in gay and lesbian relationships is as common as in heterosexual relationships, so screening should be deployed regardless of sexual orientation (Renzetti, 1996).

Two randomized control trials demonstrated no difference in domestic violence prevalence whether screened by patient-completed questionnaire or direct interview using the same tool (MacMillan et al, 2006; Chen et al, 2007). Different screening tools have different sensitivities and specificities, and only some have been studied in the primary care setting (Phelan et al, 2007). The HITS (Hurt, Insult, Threaten, Scream) and HARK (Humiliation, Afraid, Rape, Kick) are both brief, effective scales with high sensitivity and specificity in primary care. While both can be self-administered, HITS has also been validated for clinician administration and for use in Spanish (USPSTF, 2013).

The ideal screening interval is unclear. Interventions, including counseling, home visits, information cards, referrals to community services, and mentoring support, are effective in reducing exposure to abuse, physical and mental harms, and mortality. Harms of screening are likely small if any (USPSTF, 2013).

In summary, physicians should be aware of the high likelihood of unrecognized intimate partner violence among their patients, and screen accordingly. Physicians should remain empathetic and supportive when these issues arise, and provide or refer to local resources for these patients.

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