Prevention and health promotion in primary care: Baseline results on physicians from the INSURE project on lifecycle preventive health services

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MEDICINE

13, 535-548 (1984)

Prevention and Health Promotion in Primary Care: Baseline Results on Physicians from the INSURE Project on Lifecycle Preventive Health Services’ MATTHEW A. RosEN,*~,~ DONALDN. LOGSDON,*~ ANDMICHELE M. DEMAK* *INSURE Project on Lifecycle Preventive He&h Services, 330 Park Avenue South, New York, New York 10010 and fDepartment of Public Health, Division of Sociomedical Sciences, Columbia University, New York, and #Department of Community Medicine, Mount Sinai School of Medicine, CUNY, New York The INSURE Project on Lifecycle Preventive Health Services is a 3-year feasibility study to develop and test a clinical model of preventive health services, including patient education, in primary medical care as an insurance benefit. Seventy-four primary care physicians in group practices were surveyed regarding their baseline attitudes toward, and practice of, preventive services. Physicians report that they tend to be conscientious in educating their patients about their health risks, although they spend little time in patient education. Physicians arc not sanguine about their success in getting their patients to follow their recommendations and tend to harbor doubts about their own efficacy in these areas. Specialty differences exist in these parameters. Physicians evidence contradictory attitudes about prevention. They believe doctors should spend more time providing preventive services but also believe that the lack of insurance reimbursement is an obstacle to providing these services. The concept of structural or sociological ambivalence is advanced to explain this pattern. 0 1984 Academic Press, Inc.

INTRODUCTION

The last decade has witnessed major advances in our knowledge of specific behaviors and their effects on health, morbidity, and mortality. Sufficient data have come out of numerous clinical trials and case-control studies to suggest that reduction of risk factors is associated with improved health status and reduced morbidity and mortality. The next appropriate set of questions concerns how best to introduce this knowledge into the context of clinical medicine. Specifically, how can risk factor reduction become integrated into the practice of medicine and become a part of primary medical care? This paper presents baseline results on physicians’ attitudes toward prevention based upon preliminary findings from the INSURE Project on Lifecycle Preventive Health Services. The Lifecycle Preventive Health Services (LPHS) study is a 3-year feasibility study to develop and test a clinical model of providing preventive health services, including patient education, in primary medical care as an insurance benefit. Utilizing a lifetime health-monitoring approach as developed by Breslow and Somers (3), the Institute of Medicine (8), and the Canadian Task Force (4), among ’ INSURE is a nonprofit organization supported by voluntary contributions from the private life and the health insurance industry, and by grants from the Robert Wood Johnson Foundation and the John D. and Catherine T. MacArthur Foundation. ’ To whom reprint requests should be addressed. 535 0091-7435/84 $3.00 Copyright All rights

D 1984 by Academic Press. Inc. of reproduction in any form reserved.

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ROSEN,LOGSDON,ANDDEMAK

others, the project has divided the life cycle into ten age groups and defined the appropriate preventive services, tests, and patient education based on the age and sex of the patient. The project orients physicians in this approach to preventive medicine, and physicians provide a Lifecycle exam to a random sample of their patients. The cost of the examination is paid by INSURE, based upon a negotiated fee schedule. The project assesses the short-term effects of the program primarily in terms of attitudinal and health behavioral change of patients and, secondarily, by attitudinal and practice change among physicians. In addition, the project studies the costs of providing the examination and explores the various insurance issues associated with providing insurance reimbursement for preventive services. The design, cost issues, and some preliminary results have been published elsewhere (7, 10, 1I). The scientific literature on physicians’ practice patterns and attitudes about prevention has, until recently, been quite limited. With the exception of the work of Coe and Brehm, it has only been in the last several years that data on physicians’ prevention practices have been reported (1, 2, 5, 6, 16, 18, 19). This paper presents baseline data on 74 physicians in five fee-for-service group practice sites in Wisconsin, Pennsylvania, and Florida. The physicians are drawn from the four primary care specialties: family medicine, pediatrics, obstetrics-gynecology, and general internal medicine. Data are presented on physicians’ current practice patterns with regard to prevention and patient education, their attitudes about prevention, their knowledge, and their perceived effectiveness in counseling their patients in this area. Changes in practice patterns with regard to prevention among study and control physicians will be the subject of a forthcoming paper. The baseline data presented in this paper were collected by means of telephone interviews with participating physicians conducted for the INSURE Project by Mathematica Policy Research in Princeton, New Jersey. Survey instruments were developed by INSURE Project staff and pretested on physicians in the New York metropolitan area. The initial focus of the Lifecycle intervention is the physician. One of the distinctions of the Lifecycle model as a health promotion program is that physicians act as interveners with their patients. The focus of this health promotion/ disease prevention effort is neither the worksite nor the community, but the primary care physician’s office-the place where the vast majority of the U.S. population receives its medical care. The Lifecycle model attempts to build on the credibility that physicians have with their patients. A 1978 Louis Harris survey found a majority of people reporting that they would be more likely to engage in health promoting behavior if these recommendations were made by their physician as opposed to any other source (14). There is a growing scientific literature that suggests physicians can have an impact on their patients’ ability to change their health behavior (9, 17). The primary care physician, therefore, can be viewed as representing a reservoir of untapped potential in the effort to get the American public to engage in health promoting behavior. This focus on the physician is essential for another and perhaps more important reason. Physicians are the gatekeepers in the health care field. Writings in the field of the sociology of knowledge suggest that if the concepts, beliefs, and

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preliminary scientific findings in the field of health promotion/disease prevention are to be taken seriously in our society, they require the legitimacy only physicians can confer on them (12). In addition, if the insurance reimbursement structure in the United States is to be modified from an almost exclusive focus on illness to begin to reimburse for preventive services, it is also essential that the physician-the leader of the health care team-be the focus. In short, the Lifecycle model is an effort to modify and enlarge the discipline of clinical preventive medicine to incorporate and integrate the principles of health promotion and disease prevention into primary medical care. METHODS Study Design

The evaluation of the short-term effects of the Lifecycle model on physicians and patients was accomplished by means of a quasi-experimental design. Three study or experimental sites where the Lifecycle program has been implemented were matched to similar group practice sites in the same region of the country which do not receive the intervention. As outlined in Fig. 1, the study design calls for inclusion of 750 well patients of about 18 primary care physicians at each of the group practice sites. The sampling procedure excludes patients suffering from chronic disease and is geared to selecting disease-free patients. Identical procedures for sample selection were used at study and control sites. Approximately 18 physicians from the four primary care specialties at each site (pediatrics, family practice, obstetrics-gynecology, and general internal medicine) were identified. The study was implemented at a small group practice in Wisconsin, a large medical center in Pennsylvania, and a large group practice in Florida. Serving as control sites are 3 Study (Experimental)

Sites

3 Control

Sites

Patients - 750 1 And Physicia

(Suwey

Of Nonrespon~dank

iAlTime1

]

(225 Palknb) mlho

$i!iEgg (Follow Up Sumy Of Patient Subsample [n=25]) Reinlorarment sessionr (2) with Physicians +

Survey 01 Pallenb And Phyakianr Al Time 2 (Examlnalion

Fig. 1. Study design for

INSURE

0140-59 Year Old High Rkk Males At Time 2 [n-171)

Project on Lifecycle Preventive Health Services study.

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matched clinics in the same areas. Due to delays experienced at the third study site, it became too late in the study to identify a control site; thus, only five sites were actually utilized. The total sample size for the five sites is 4,696 patients. To take the place of the sixth site, the INSURE Project conducted a Time 1 baseline descriptive study of physicians and their patients regarding preventive health services and practices at a large health maintenance organization in the Northwest, which is not discussed or included in this paper. Baseline data on physician attitudes reported herein were collected by means of a telephone questionnaire. These data are self-reports, and the Project has no means of independently validating them. We are aware of some of the problems of using self-reported data, especially about physicians’ baseline practice pattern. Indeed, some of the high positive levels of involvement that are reported below raise concern about possible ceiling effects and whether any change will be observed at Time 2. In addition, since some of the responses are in the socially desirable direction, these data should be treated with appropriate caution. The Intervention:

The Lifecycle

Model

The intervention consists of educating study physicians to use the Lifecycle model with their patients. In this model, orientation sessions designed to familiarize physicians with the Lifecycle protocols and to increase their awareness of their potential role in patient health behavior change are conducted prior to patient visits. Physicians receive Category 1 Continuing Medical Education credit for attending these seminar-format meetings. In addition, physicians are paid an honorarium of $200 to attend these four evening meetings as well as to participate in two telephone surveys. Educational materials for physicians and patients were developed jointly with Dartmouth Medical School, Department of Community and Family Medicine, and include a reference manual for physicians and patient guides for young children, adolescents, and adults. Selected pamphlets on risk reduction were compiled and provided to the study physicians for distribution to patients. Lifecycle Encounter Forms were developed to remind physicians of the protocols and to collect data on individual patients (patient record). A prevention prescription is part of the Lifecycle Encounter Form which is completed by the physician for each patient. The prescription includes the specific “treatment” the physician recommends for risk factor reduction and is given to the patient at the time of the visit. Follow-up letters were sent to patients several weeks after the visit to remind them of the prescribed behavior change. Feedback sessions with the physicians were held to review the protocols and to report the progress of their patients regarding abnormalities detected and any immediate behavior change reported. At each of the three study sites, a payment schedule for the Lifecycle exam was negotiated with the group practice centers. This process involved defining the preventive services to be covered under the plan and agreeing to the documented usual and customary fees for such services. CPT codes were used to identify the charges for services rendered in accordance with the Lifecycle protocols that would be paid in full. Fifteen minutes of patient education on risk reduction is specifically included as a “covered benefit,” in addition to medical

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TABLE 1 SELECTED TIME 1 BACKGROUND AND PROFESSIONALCHARACTERISTICS OF LIFECYCLE PREVENTIVE HEALTH SERVICES PHYSICIANS (N = 74)

Sex Male Female

91.9% 8.1%

Mean age Mean year graduated medical school Mean years in practice

40.1 Years old 1968 10.4 Years

Specialty Family medicine Pediatrics Obstetrics-gynecology Internal medicine

21.6% 28.4% 17.6% 32.4%

(16) (21)

Subspecialty Yes No

13.5% 86.5%

(10) (64)

Medical school affiliation Yes No

50.0% 50.0%

(37) (37)

(13) (24)

history, physical exam, laboratory, and X-ray services. Physicians record these items on the Encounter Form. The group practice center is paid on a monthly basis according to a cumulative bill after comparing services noted on the Encounter Form to Lifecycle standard protocols. Exception was made for payment of services “not covered” (not in the Lifecycle protocols) only if the services resulted from Lifecycle examination (e.g., ECG for a patient with chest pain, or chest X-ray for a smoking patient with cough) and where clinically indicated. Physicians’

Attitude

toward and Practice

of Prevention

Table 1 shows selected background and professional characteristics of the 74 primary care physicians at the five group practice sites in the study.3 These group practice physicians tend to be male, are about 40 years old, and have been in practice for about 10 years. The sample is fairly equally distributed by specialty with the exception of obstetrics-gynecology. The physicians are mostly involved in primary care as evidenced by the fact that only 14% have a subspecialty. Exactly one-half of the physicians are affiliated with a medical school. Practice

Characteristics

Physicians in this study see an average of 92 patients per week. In one of the sites, the doctors are salaried and part of a large teaching hospital center, and 3 For the purposes of this paper (i.e., physicians’ baseline attitudes toward prevention and a possible understanding of the sources of those attitudes), physicians from the study and control groups are pooled to increase sample size. Future papers will compare study and control physicians.

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ROSEN, LOGSDON, AND DEMAK

consequently see fewer ambulatory patients. The average at the other sites is over 100 patients a week-close to national norms. According to the doctors, a substantial part of their practice involves preventive care. When asked what percentage of their patients’ visits were “preventive” in nature (where “preventive” was defined to include checkups, pap smears, immunizations, etc.) the mean response was 31.7% (see Table 2). Expected differences arose between departments. Pediatricians see the most patients, internists the fewest. Pediatricians and obstetricians reported the highest proportion of preventive visits, and internists reported the lowest proportion. TABLE 2 SELECTED TIME 1 PRACTICECHARACTERISTICS REGARDING PREVENTIVE SERVICES AND PATIENT EDUCATION OF LIFECYCLE PREVENTIVE HEALTH SERVICES PHYSICIANS (N = 74)

Characteristic

%

Mean number patients per week

92

Mean percentage preventive visits

31.7%

Do patient education at preventive visit All the time Some of the time Rarely Never

74.0 23.3 2.7 0.0

Time spent doing patient education Less than 5 min 5- 10 min 11-15 min More than 15 min

37.0 49.3 12.3 1.4

Physician’s approach to patient education “I tell the patient my recommendation.” “I try to elicit a reaction from the patient to my recommendation.” “I try to engage the patient in an active discussion about the recommendation.”

41.9

Usually refer patients to community agencies Yes No

51.4 48.6

Usually do patient education during illness visit All of the time Some of the time Rarely Never

32.4 54.1 10.8 2.7

Routinely ask adults about smoking Yes No

90.1 9.8

Routinely ask adolescents about smoking Yes No

73.2 26.8

23.0 35.1

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PROMOTION IN PRIMARY CARE TABLE 3

PERCENTAGE FREQUENCY OF DOING PATIENT EDUCATION AT A PREVENTIVE VISIT, BY SPECIALTY

(N = 74)

All the time Some of the time Rarely or never Total N

Family practice

Pediatrics

81.3 18.8 0.0 100.1 16

71.4 28.6 0 100.0 21

OB-GYN 46.2 38.5 15.4 100.1 13

Internal medicine 87.0 13.0 0 100.0 23

Patient Education on Prevention The doctors in this study appear, based on self-reports, to be unusually well aware of the importance of educating patients about their lifestyle and health risks. Almost three-quarters of the physicians report that as a part of a preventive exam, they counsel their patients about their lifestyle “all of the time.“4 It is clear, however, that obstetricians are much less likely to conduct patient education “all the time” than the other primary care specialists (Table 3). Although physicians reported that they are conscientious about educating their patients as part of a preventive exam, they spend little time doing it. More than four-fifths of the physicians reported that they spend less than 10 min per visit in patient education. Again, obstetricians-gynecologists are less “prevention oriented” than the other specialties; whereas more than half of family physicians, pediatricians, and internists spent at least 5-10 min in patient education, only 23% of obstetricians-gynecologists spent even that small amount of time (Table 4). These physicians, according to self-reported data, do not seem to conform to the stereotypical physician whose style of patient education is to “tell the patient what to do.” One survey item gave physicians three choices or “styles” of educating patients: 23% chose “I tell the patient my recommendation”; 35% said that they try to elicit a reaction from the patient to that recommendation; and 42% said that they try to engage the patient in active discussion. Internists and pediatricians reported that they were more likely to engage the patient in an active discussion-the recommended approach-than did family physicians and obstetricians-gynecologists (Table 5). About one-half of the doctors said that they usually refer patients to community agencies for smoking cessation, weight loss, etc., although doctors had varying success in being able to recall the names of local community agencies. Their level of awareness of both the existence and quality of community facilities is questionable. A substantial proportion of physicians conduct patient education during illness 4 The high proportion of physicians reporting that they do patient education “all the time” at Time 1 raises questions about possible ceiling effects. It decreases the likelihood of observing positive changes in this area at Time 2. The Project has no means of validating these self-reported data.

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ROSEN, LOGSDON, AND DEMAK TABLE 4 PERCENTAGE OF TIME SPENTIN PATIENTEDUCATION, BY SPECIALTY (N = 74)

Less than 5 min 5- 10 min 11-15 min More than I5 min Total N

Family practice

Pediatrics

OBiGY N

Internal medicine

31.2 56.3 6.3 6.3 100.1 16

42.9 52.4 4.8 0 100.1 21

76.9 23.1 0 0 100.0 13

13.0 56.5 30.4 0 99.9 23

visits, a practice recommended by the Canadian Task Force (4). Thirty-two percent of physicians claimed that they educate patients who come in for an illness visit about their lifestyle and health risks “all the time,” while 54% reported doing it “some of the time.” As an indication of their orientation to prevention, 90% of the doctors reported that they routinely ask their adult patients whether they smoke cigarettes. The figure for adolescent patients is 73%. The figure for adults is comparable to that reported by Wechsler et al. in their study of Massachusetts physicians (19). Physicians’ attention to health behavior varies, depending on the behavior. For instance, only 30% of the physicians reported at baseline that they discuss seat belt use with all their patients (Table 6). Two-fifths of the doctors reported that they never discuss seat belt use with patients. Less than 7% discuss cholesterol consumption with all their patients, but 78% said that they bring the subject up with high-risk patients only. The doctors in the study were not optimistic about their success. Only 14% of physicians said that more than one-half of their patients follow their recommendations. Although three-quarters of the physicians claimed that they conduct patient education “all the time,” they did not feel very effective in doing it. Table 7 shows physicians’ perceived efficacy in dealing with selected lifestyle and risk factor problems. TABLE 5 PHYSICIANS’ APPROACH TO PATIENT EDUCATION, BY SPECIALTY (N = 74)

Family practice (%) I tell the patient my recommendation. I try to elicit a reaction from the patient. I try to engage the patient in an active discussion. Total N

Pediatrics (%)

OB-GYN (%)

Internal medicine (%I

25.0

28.6

15.4

20.8

43.8

23.8

53.8

29.2

31.3 100.1 16

47.6 100.0 21

30.8 100.0 13

50.0 100.0 24

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TABLE 6 PHYSICIANS’ REPORT OF PATIENT CATEGORIES WITH WHOM THEY DISCUSS SPECIFIC HEALTH BEHAVIORS (N = 61)

During a preventive checkup .

Cigarette smoking Obesity/weight loss Cholesterol Exercise Alcohol use Drug use Stress/anxiety Seat belt use Breast self-examination Family and sexual matters

Never or rarely discuss this c@J)

Bring subject up only for high-risk patients (%I

Usually bring subject up for all patients (%I

3.3 0.0 15.0 6.6 13.1 19.7 26.7 40.0 17.9 17.8

19.7 46.7 78.3 63.9 52.5 50.8 55.0 30.0 41.1 53.3

77.0 53.3 6.7 29.5 34.4 29.5 18.3 30.0 41.1 28.9

Note. These data exclude obstetricians-gynecologists,

who were not asked this question.

Except for hypertension, which has a defined medical protocol for treatment, there is no item that even as many as one-fifth of the doctors felt “very effective” in treating. Only 4% felt “very effective” in treating cigarette smoking and weight problems. Table 8 shows the percentage of physicians, by specialty, who felt “very effective” in dealing with various risk factors. Some specialty differences exist; in general, a greater proportion of family physicians than internists felt “very effective” in treating specific risk factors. Obstetricians-gynecologists were the least likely to report that they felt “very effective” in dealing with the health behavior problems of their patients. Surprisingly, age does not appear to discriminate between physicians more TABLE I PHYSICIANS’ PERCEIVED EFFICACY IN DEALING WITH SELECTED HEALTH RISK FACTORS (N = 74)

Percentage of physicians reporting they are: Health risk factor

Not effective

Somewhat effective

Very effective

Hypertension Overweight Excess sodium in diet Cigarette smoking Elevated cholesterol High stress levels Poor eating patterns

1.6 38.0 15.7 25.4 28.8 36.2 26.8

37.5 57.7 65.7 70.4 59.1 56.5 66.2

60.9 4.2 18.6 4.2 12.1 7.2 7.0

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ROSEN, LOGSDON, AND DEMAK TABLE 8 PERCENTAGE OF PHYSICIANS WHO REPORT THEY FEEL “VERY EFFECTIVE” IN DEALING WITH SELECTED RISK FACTORS, BY SPECIALTY (N = 74)

Risk factor

Family practice

Pediatrics

Hypertension Overweight Excess sodium in diet Cigarette smoking Elevated cholesterol High stress levels Poor eating patterns

87.5 6.3 37.5 6.3 12.5 18.6 6.3

40.0 5.0 15.8 0.0 29.4 5.6 10.0

OB-GYN 22.2 0.0 0.0 9.1 11.1 0.0 9.1

Internal medicine 70.8 4.2 16.7 4.2 0.0 4.2 4.2

favorably predisposed towards prevention and those who are not. Coe and Brehm, in a major 1968 physician survey, found professional age and specialty (internists vs general practitioners) to be associated with many physician views and practices with regard to prevention. Although data from the 74 primary care physicians in our study do not replicate Coe and Brehm’s findings, a caveat is necessary. The mean age of the physicians in the present study is 40 years; there are too few older doctors to analyze the results by age, especially when specialty is controlled. In summary, the physicians surveyed appear sensitive to the importance of patient education as a part of preventive care. Almost all claimed they included it as a regular part of their practice, although they evidently did not spend much time doing so. A substantial number of doctors even reported doing patient education at illness visits. One-half of physicians reported that they usually referred patients to community agencies, yet they were not well informed about the existence or quality of these community resources. Despite this apparent commitment to patient education, physicians were not sanguine about their success in getting patients to follow their recommendations. Indeed, they appeared to harbor doubts about their own efficacy in many of these areas. In short, physicians seemed to evidence somewhat alternating and contradictory attitudes and behaviors with regard to prevention. Health Knowledge

Health knowledge, especially regarding nutrition, is another area where Time 1 data indicate substantial room for improvement. On a nine-item health knowledge test, these physicians show a mean score of 60%. The scores ranged from a low of 22% to a high of 88%. Doctors scored lower on the nutrition items than on the other prevention items. These data complement the picture described above. These doctors appear to be well motivated and well intentioned yet, in addition to those factors already noted, they are constrained in their practice of prevention by a lack of knowledge (both factual and skills oriented) of what to do.

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Physicians’ Attitudes toward Prevention Physicians’ attitudes toward prevention, as measured by a series of closedended survey items, show a similar pattern of contradictory and alternating attitudes evident in their practice patterns. Although at first glance one would assume that physicians would endorse prevention wholeheartedly-and several of these survey items taken singly would support that assumption-when their attitudes are examined as a whole, a more subtle and complex pattern begins to emerge. Table 9 shows selected attitudes of physicians about prevention. For instance, physicians agree by a great majority that doctors should devote more time to providing preventive services in their practices, with more than

TABLE 9 SELECTED

TIME

1 PHYSICIANS’

1. “Physicians should devote more time to providing preventive services to their patients.” 2. “The lack of insurance reimbursement is one of the major obstacles to the practice of preventive services.” 3. “The most important thing a physician can do to keep patients healthy is to influence them to adopt healthy lifestyles.” 4. “In general, I get a greater sense of gratification from diagnosing and treating ill patients than I do from preventive care.” 5. “The preventive aspects of medicine-doing physical examinations and educating patients-are not very interesting to me as a physician.” 6. “More formal instruction on preventive medicine should be a required part of the curriculum in medical schools.” 7. “I find educating patients to be a challenging and enjoyable part of my practice.”

ATTITUDES

ABOUT PREVENTION

(N

=

Somewhat disagree (%I

74)

Strongly agree (%)

Somewhat agree (%I

Strongly disagree (SD)

61.1

30.6

8.3

0.0

39.7

27.4

24.7

8.2

55.4

41.9

2.7

0.0

27.4

46.6

19.2

6.8

4.1

25.7

28.4

41.9

58.1

36.5

2.7

2.7

31.1

52.7

13.5

2.7

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three-fifths strongly agreeing with the statement. Yet two-thirds (67.1%) also believe that the lack of insurance reimbursement is a major obstacle to providing preventive services (with two-fifths strongly agreeing). Pediatricians express the strongest support of this statement. This is expected, in that a greater part of their practice is prevention oriented in the form of well-baby and well-child care than the other specialties. While 91% of pediatricians agree with the insurance reimbursement statement (52% strongly agree), the figures for the other specialties are: family practice, 69%; internal medicine, 63%; and obstetrics-gynecology, 50%. There would seem to be an inherent tension, if not contradiction, in advocating that doctors spend more time providing a service for which they are not reimbursed-especially if one views lack of reimbursement as an obstacle to providing the service in the first place. Another example of contradictory attitudes about prevention drawn from Table 9 is that more than 96% of physicians reported to agree with the statement, “The most important thing a physician can do to keep patients healthy is to influence them to adopt healthy lifestyles” (55% strongly agreed). This strong endorsement of prevention and patient education, however, should be contrasted with the fact that almost three-quarters (74%) of doctors reported that they “get a greater sense of gratification from diagnosing and treating ill patients than I do from preventive care.” The specialists responded to this item in an expected manner. Eightyseven percent of internists and 86% of obstetricians-gynecologists agreed that they get greater gratification from diagnosing and treating illness than from prevention. The figures for family physicians and pediatricians are 62.5% and 60%, respectively. DISCUSSION

The juxtaposition of these expressed attitude items shows strong forces pulling in opposite directions. The lack of expressed intellectual and professional gratification that physicians derive from prevention is not surprising given the structural and other impediments discussed by Relman (15). Not only are physicians trained to diagnose and treat- and thus the act of doing this validates their professional role-but a whole host of patient expectations are built around this role, including a reward structure that involves material and ego reinforcement. Relman’s notion that physicians do not find prevention intellectually or professionally interesting would seemingly be contradicted by physicians’ responses to Item 5 in Table 9: “The preventive aspects of medicine-doing physical examinations and educating patients-are not very interesting to me as a physician.” Seventy percent of physicians disagreed with this statement and 42% strongly disagreed. Yet this must be contrasted with item number four-that three-quarters of physicians claimed to get greater gratification from curative rather than preventive medicine. How should one interpret this obvious contradiction? Perhaps an appropriate explanation is that a subtle process is involved. In their role as physicians, doctors feel obliged to endorse the rhetoric of prevention. A physician qua physician has difficulty saying that prevention is not interesting. Yet, there is ample reason to suggest that prevention is nor as intellectually stimulating, nor does it provide the immediate, visible professional and material re-

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wards associated with the diagnosis and treatment of ill patients. So, at one level physicians speak about prevention with a voice that approaches the well-known aphorism, “An ounce of prevention is worth a pound of cure.” When probed, however, we see the existence of contradictory attitudes which suggest a less than whole-hearted embrace of prevention. The concept that perhaps best explains the pattern of alternating and contradictory attitudes evident in Table 9 is ambivalence. The concept of sociological or structural ambivalence developed by Merton best explains this situation (13). Sociological ambivalence differs from the more familiar psychological kind in that it refers to social structure, not personality. The existence of certain disincentives to prevention in primary care (primarily the lack of insurance reimbursement and the lack of time, as well as the lack of a reward structure and the cognitive and cultural structure of medical training which focuses on the doctor as diagnoser and healer) conspire to discourage the practice of prevention. At the same time, the lofty sentiments about prevention expressed in the aphorism are almost a given for most physicians. The structure of primary medical care, however, as well as the insurance reimbursement system that helps support it, constrains physicians and discourages the practice of prevention. SUMMARY Baseline data on physicians in this study suggest the existence of structural disincentives to the practice of prevention in primary care. At the outset of the study, the primary objective was to determine whether it was feasible to introduce a Lifecycle approach to preventive health services in primary care. Would physicians agree to do it? Would they follow the protocol? Would they educate their patients about their health behavior? Was it possible to implement a clinical model of preventive health services that attempted to take into account the principal barriers that discourage physicians from providing preventive health services to their patients? The Lifecycle model directly addresses some of these barriers by providing insurance reimbursement for preventive services including payment for time spent in patient education. In addition, through the use of CME materials designed for the study, physicians gain knowledge and skills about a range of behavioral risk factors. Should the Lifecycle model be found feasible and to have a positive impact on patients’ health behavior, the implications of these findings for the delivery of preventive health care, the future of health promotion, and the way in which insurance reimbursement for ambulatory care is structured would be considerable. REFERENCES 1. Battista, R. N. Adult cancer prevention in primary care: Patterns of practice in Quebec. Amer. J. Public Health 73, 1036-1039 (1983). 2. Battista, R. N., and Spitzer, W. 0. Adult cancer prevention in primary care: Contrasts among primary care settings in Quebec. Amer. J. Public He&h 73, 1040-1041 (1983). 3. Breslow, L., and Somers, A. R. The lifetime health monitoring program. New Engl. J. Med. 296, 601408 (1977).

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