Clinical Preventive Medicine in Primary Care: Background and Practice: 1. Rationale and Current Preventive Practices
2000; Elsevier BV; Volume: 75; Issue: 2 Linguagem: Inglês
10.4065/75.2.165
ISSN1942-5546
Autores Tópico(s)Chronic Disease Management Strategies
ResumoImpressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, eg, smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, eg, mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, eg, cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice. Impressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, eg, smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, eg, mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, eg, cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice. The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.Thomas A. Edison To some degree, these words by Edison are echoing in the halls of medicine long after they were first conceived. In recent years there has been heightened interest in the prevention of disease, and preventive medicine is assuming an increasingly important role in promoting and maintaining health as evidence supporting its intuitive rationale has accumulated. Although therapeutic medicine has made great strides in this century, it has become clear that the potential for preventive care to improve the health of the population is also great.1Healthy People 2000: National Health Promotion and Disease Prevention Objectives. US Government Printing Office, Washington, DC1991Google Scholar Preventive care services can be delivered in a variety of ways, such as through public health programs or during a visit to a physician. On average, 3 of every 4 people in the United States see a physician each year, and the majority of visits are to primary care practitioners who are an important source of health care information.2Ries P Physician contacts by sociodemographic and health characteristics: United States, 1982-83.Vital Health Stat 10. 1987; 161: 1-63PubMed Google Scholar3David AK Boldt JS A study of preventive health attitudes and behaviors in a family practice setting.J Fam Pract. 1980; 11: 77-84PubMed Google Scholar Because health concerns are at the forefront of people's minds during an office encounter where a physician's message can make a powerful, reliable, and credible impression, physician visits provide a unique opportunity to deliver preventive care. Despite this, preventive services are currently underutilized by physicians due, in part, to the way some aspects of clinical medical care are commonly practiced. Much of medical practice is based on a disease/treatment model rather than a prevention model in that the predominant focus is on treating existing symptoms and conditions. While few would argue this approach is necessary for acute conditions, there is some question whether this is the most efficient and effective way of delivering preventive care. In the traditional annual periodic health examination, a patient sees a physician and proceeds through a series of steps, including a medical history, physical examination, and laboratory studies that culminate in an assessment and plan of action. The content of this visit has evolved more from the concerns of the examination's advocates at various historical times, rather than any formal process and evaluation.4Han PKJ Historical changes in the objectives of the periodic health examination.Ann Intern Med. 1998; 127: 910-917Crossref Scopus (71) Google Scholar The periodic health examination became popular in the 1920s and was endorsed by the American Medical Association after an apparent decrease in mortality was observed in life insurance policy holders who had undergone such an examination.5Charap MH The periodic health examination; genesis of a myth.Ann Intern Med. 1981; 95: 733-735Crossref PubMed Scopus (27) Google Scholar However, these data were probably confounded by many methodologic problems. A critical analysis of the value of the individual components of the periodic health examination would not occur for more than half a century. Frame and Carlson6Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 1 : selected diseases of respiratory, cardiovascular, and central nervous systems.J Fam Pract. 1975; 2: 29-36PubMed Google Scholar, 7Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 2: selected endocrine, metabolic, and gastrointestinal diseases.J Fam Pract. 1975; 2: 123-129PubMed Google Scholar, 8Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 3: selected diseases of the genitourinary system.J Fam Pract. 1975; 2: 189-194PubMed Google Scholar, 9Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 4: selected miscellaneous diseases.J Fam Pract. 1975; 2: 283-289PubMed Google Scholarfollowed by the Canadian Task Force10Canadian Task Force on the Periodic Health Examination The periodic health examination.Can Med Assoc J. 1979; I21: 1193-1254Google Scholar and later the US Preventive Services Task Force11US Preventive Services Task Force Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Williams & Wilkins, Baltimore, Md1989Google Scholar outlined evidence regarding the relative effectiveness of different preventive interventions. In many cases standard components of the current periodic health examination, such as certain laboratory tests, were found to have little supportive data while potentially valuable interventions, including many areas of health behavior counseling, were not widely utilized. A major task, therefore, is to modify the traditional medical model to incorporate more preventive services. Moreover, to effectively practice preventive medicine, information concerning its rationale and clinical application must be available to physicians and other health care providers. This article reviews relevant background information, evidence supporting preventive services, and current preventive practices. The second and third parts of this review will provide suggestions for incorporating clinical preventive medicine into adult primary care practice. Clinical preventive medicine is that part of preventive medicine concerned with the maintenance and promotion of health and the reduction of risk factors that result in injury and disease.12Critical issues discussed at preventive medicine summit in Atlanta ACPMNews. 1989; 1: 3Google Scholar There are 3 main types of preventive medicine (Table 1). Primary prevention can be defined as an action or behavior that does not allow a disease or adverse event to occur. Examples of primary prevention include immunization, smoking cessation, or initiation of an exercise program with the goal of disease prevention. Health promotion activities are included under primary prevention. Secondary prevention is the early detection of a disease or condition in an asymptomatic stage so treatment can delay or block the occurrence of symptoms. Screening for disease such as mammographic detection of breast cancer falls in the category of secondary prevention. Tertiary prevention attempts to deter adverse consequences of existing clinical disease. A cardiac rehabilitation program to prevent the recurrence of a myocardial infarction is an example of tertiary prevention. Tertiary prevention overlaps with conventional medical care in that it can be considered treatment for an established condition.Table 1Types of PreventionPrevention typeGoalPrimary preventionDisease does not occurSecondary preventionDetection and treatment of asymptomatic disease before symptoms occurTertiary preventionConsequences of existing disease or recurrent disease does not occur Open table in a new tab If primary prevention is successful, the incidence of a disease decreases. In contrast, however, secondary prevention does not necessarily prevent a disease from occurring but rather detects it early enough to allow effective treatment. Similarly, tertiary prevention does not prevent the occurrence of a disease but tries to prevent the complications of established disease. The leading causes of death in the United States have changed markedly since the beginning of this century (Table 2).13Linder FE Grove RD Vital Statistics Rates in the United States 1900-1940. US Government Printing Office, Washington, DC1943Google Scholar14Peters KD Kochanek KD Murphy SL Deaths: final data for 1996.Natl Vital Stat Rep. 1998; 47: 1-100PubMed Google Scholar There has been a shift from acute infectious diseases to chronic diseases. Most of the current leading causes of death from chronic diseases are related to lifestyle factors, including health behaviors. The burden of suffering from the "actual" causes of death, ie, the underlying external (nongenetic) factors that contribute to mortality, have been described (Table 3).15McGinnis JM Foege WH Actual causes of death in the United States.JAMA. 1993; 270: 2207-2212Crossref PubMed Scopus (2369) Google Scholar An estimated 400,000 people die each year from tobacco-related illness, while unhealthy nutrition and physical activity patterns account for at least 300,000 deaths. Clearly, many of these deaths could potentially be prevented or delayed through primary prevention activities. At a minimum, some of the diseases resulting from these factors could be diagnosed and treated at an early stage through screening.Table 2Leading Causes of Death in the United States in 1900 and 19961900*Data from Linder and Grove.131996†Data from Peters et al.14Cause%Cause%1.Pneumonia/influenza131.Heart disease322.Tuberculosis112.Cancer233.Diarrhea/enteritis83.Cerebrovascular diseases74.Heart disease74.Chronic obstructive lung disease55.Nephritis55.Accidents46.Accidents46.Pneumonia/influenza47.Cerebrovascular disease47.Diabetes mellitus38.Cancer48.Human immunodeficiency virus19.Diseases of infancy39.Suicide110.Diphtheria210.Chronic liver disease1* Data from Linder and Grove.13Linder FE Grove RD Vital Statistics Rates in the United States 1900-1940. US Government Printing Office, Washington, DC1943Google Scholar† Data from Peters et al.14Peters KD Kochanek KD Murphy SL Deaths: final data for 1996.Natl Vital Stat Rep. 1998; 47: 1-100PubMed Google Scholar Open table in a new tab Table 3Actual Causes of Death in the United States in 1990*Adapted from McGinnis and Foege.'5CauseEstimated No. of deaths%of total deaths1.Smoking400,000192.Diet/activity patterns300,000143.Alcohol100,00054.Microbial agents90,00045.Toxic agents60,00036.Firearms35,00027.Sexual behavior30,00018.Motor vehicles25,00019.Illicit use of drugs20,000<1* Adapted from McGinnis and Foege.'5Charap MH The periodic health examination; genesis of a myth.Ann Intern Med. 1981; 95: 733-735Crossref PubMed Scopus (27) Google Scholar Open table in a new tab Some progress has been made over the latter half of this century in decreasing the morbidity and mortality of certain health conditions through prevention. Declines in the incidence of acute infectious diseases secondary to increased delivery of immunizations has been well documented for many illnesses, including measles, mumps, rubella, pertussis, diphtheria, and most recently invasive Haemophilus influenzae.16Center for Disease Control and Prevention Update: vaccine side effects, adverse reactions, contraindications, and precautions; recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Morn Mortal Wkly Rep. 1996; 45: 1-35PubMed Google Scholar Mortality from stroke has decreased by 60% since the mid-1970s due, in part, to increased detection and control of untreated hypertension.17Healthy People 2000 Review. US Dept of Health and Human Services, Public Health Service. Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Md1993Google Scholar, 18Garraway WM Whisnant JP The changing pattern of hypertension and the declining incidence of stroke.JAMA. 1987; 258: 214-217Crossref PubMed Scopus (94) Google Scholar, 19Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Arch Inlern Med. 1997; 157: 2413-2446Crossref PubMed Google Scholar, 20Mosterd A D'Agostino RB Silbershalz H et al.Trends in the prevalence of hypertension, antihypertensive therapy, and left ventricular hypertrophy from 1950 to 1989.N Engl J Med. 1999; 340: 1221-1227Crossref PubMed Scopus (247) Google Scholar More recently, however, stroke incidence appears to have increased in some populations.19Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Arch Inlern Med. 1997; 157: 2413-2446Crossref PubMed Google Scholar21Brown RD Whisnant JP Sicks JD O'Fallon WM Wiebers DO Stroke incidence, prevalence, and survival : secular trends in Rochester, Minnesota, through 1989.Stroke. 1996; 27: 373-380PubMed Google Scholar In addition, although the proportion of individuals with hypertension who are being detected and treated has improved over the past 30 years, a large number of people would benefit from treatment, yet their hypertension remains undetected.19Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Arch Inlern Med. 1997; 157: 2413-2446Crossref PubMed Google Scholar22Mulrow PJ Detection and control of hypertension in the population: the United States experience.Am J Hypertens. 1998; 11: 744-746Crossref PubMed Scopus (39) Google Scholar The mortality from coronary heart disease has declined 50% in the past 2 decades.17Healthy People 2000 Review. US Dept of Health and Human Services, Public Health Service. Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Md1993Google Scholar Part of this decline may be due to improved treatment from coronary artery bypass graft procedures, coronary care units, and better emergency response services. On the other hand, it was estimated the majority of the early portion of this decline was due to changes in lifestyle, specifically decreased smoking prevalence and serum total cholesterol levels in the general population.23Goldman L Cook EF The decline in Ischemie heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle.Ann Intern Med. 1984; 101: 825-836Crossref PubMed Scopus (413) Google Scholar More recent the decline in coronary heart disease has continued and is due to both improved treatment and risk factor profiles.24Rosamond WD Chambless LE Folsom AR et al.Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994.N Engl J Med. 1998; 339: 861-877Crossref PubMed Scopus (715) Google Scholar, 25Hunink MG Goldman L Tostcson ANA et al.The recent decline in mortality from coronary heart disease, 1980-1990: the effect of secular trends in risk factors and treatment.JAMA. 1997; 277: 535-542Crossref PubMed Google Scholar, 26McGovem PG Pankow JS Shahar E et al.Recent trends in acute coronary heart disease: mortality, morbidity, medical care, and risk factors.JV EnglJ Med. 1996; 334: 884-890Crossref PubMed Scopus (630) Google Scholar Cancer mortality in the United States increased 6% from 1970 to 1994, and new treatments had little overall effect during this time.27Bailar III, JC Gomik HL Cancer undefeated.N Engl J Med. 1997; 336: 1569-1574Crossref PubMed Scopus (405) Google Scholar Declines in the mortality from some cancers during this period were probably the result of primary (decreased lung cancer mortality in men due to reductions in smoking prevalence) and secondary (decreased cervical cancer mortality in women secondary to increased screening with the Papanicolaou test) prevention activities. Based on this overall lack of decline in cancer mortality, it was suggested the national approach to cancer control should be realigned to emphasize and support prevention much more than current efforts.27Bailar III, JC Gomik HL Cancer undefeated.N Engl J Med. 1997; 336: 1569-1574Crossref PubMed Scopus (405) Google Scholar The associations of certain behaviors and risk factors with specific diseases and injuries have become more clear in recent years. Moreover, there has been increasing recognition of the potential of preventive activities to improve the health of the population. However, what evidence exists that preventive services are effective in decreasing morbidity and mortality and improving the quality of life? In 1975 Frame and Carlson6Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 1 : selected diseases of respiratory, cardiovascular, and central nervous systems.J Fam Pract. 1975; 2: 29-36PubMed Google Scholar, 7Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 2: selected endocrine, metabolic, and gastrointestinal diseases.J Fam Pract. 1975; 2: 123-129PubMed Google Scholar, 8Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 3: selected diseases of the genitourinary system.J Fam Pract. 1975; 2: 189-194PubMed Google Scholar, 9Frame PS Carlson SJ A critical review of periodic health screening using specific screening criteria, part 4: selected miscellaneous diseases.J Fam Pract. 1975; 2: 283-289PubMed Google Scholar systematically reviewed screening in the periodic health examination with use of specific criteria. They found that many traditional tests and procedures could not be justified, and it was not necessary to perform others annually. They presented a screening flow sheet outlining recommendations and intervals for screening tests. In 1979 the Surgeon General's Report reviewed the state-of-the-art up to that time on health promotion and disease prevention.28Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. US Dept of Health, Education, and Welfare, Washington, DC1979Google Scholar This report outlined a strong case for more attention to disease prevention and health promotion in many different areas. Also, in a 1979 landmark study, the Canadian Task Force on the Periodic Health Examination used specific criteria with regard to the quality of data to evaluate individual components of the periodic health examination.10Canadian Task Force on the Periodic Health Examination The periodic health examination.Can Med Assoc J. 1979; I21: 1193-1254Google Scholar Similar to the Canadian Task Force, the evidence supporting the clinical effectiveness of preventive services was again reviewed by the US Preventive Services Task Force and published in 1989 in the Guide to Clinical Preventive Services,11US Preventive Services Task Force Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Williams & Wilkins, Baltimore, Md1989Google Scholar which was updated with the publication of the second edition in 1996.29US Preventive Services Task Force Guide to Clinical Preventive Services. 2nd ed. Williams & Wilkins, Baltimore, Md1996Google Scholar Set criteria were used to evaluate the quality of evidence regarding the effectiveness of screening and counseling interventions to prevent 70 different illnesses and conditions. A major principle finding of the US Task Force was that interventions that address patients' personal health practices are vitally important. Implicit in this is that patients must assume greater responsibility for their own health, and therefore physicians need to be prepared to help them in this effort by providing counseling and appropriate resources. Another finding was that clinicians must take every opportunity to deliver preventive services, especially to persons with limited access to care. However, clinicians should be selective in ordering tests and procedures and even providing certain preventive services. Some tests that have traditionally been performed as part of the periodic health examination are of unproven effectiveness. Other tests such as certain screening tests are expensive or could even lead to harm from further diagnostic tests or treatment. By outlining the quality of evidence for different interventions, the Guide to Clinical Preventive Services can help physicians determine, in conjunction with the patient, which screening procedures and counseling services to provide after taking into consideration that patient's profile of risk factors. The evidence for the physical examination components of the periodic health examination has been reviewed.30Oboler SK LaForce FM The periodic physical examination in adults.Ann Intern Med. 1989; 110: 214-226Crossref PubMed Scopus (87) Google Scholar For many routine components there was little supportive evidence. However, no evidence is not the same as negative evidence, and there may be particular individuals who benefit from the discovery of important physical findings despite little evidence of a significant overall effect in a population. The effect of patient education and counseling was determined in a meta-analysis of 74 studies.31Mullen PD Simons-Morton DG Ramirez G et al.A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors.Patient Edite Couns. 1997; 32: 157-173Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar A beneficial effect was found for all behavior groups, including smoking and alcohol misuse, nutrition and weight control, and other preventive behaviors. Certain preventive interventions, such as mammographic screening for breast cancer, are cost-effective.32Lindfors KK Rosenquist CJ The cost-effectiveness of mammographie screening strategies.JAMA. 1995; 274: 881-884Crossref PubMed Scopus (127) Google Scholar Programs promoting smoking cessation during pregnancy, use of bicycle safety helmets, and immunizations are all estimated to save money—up to $14 for every dollar spent in the case of some immunizations.33Salcher D Hull FL The weight of an ounce.JAMA. 1995; 273: 1149-1150Crossref PubMed Scopus (6) Google Scholar Currently, most physicians practice some aspects of preventive medicine although there is wide variability and, in general, preventive medicine is underutilized in most practices. Studies have shown physicians' recommendations for screening tests, immunizations, and health promotion assessment and counseling fall short of meeting expert guidelines.34Schwartz JS Lewis CE Clancy C Kinosian MS Radany MH Koplan JP Internists' practices in health promotion and disease prevention.Ann Intern Med. 1991; 114: 46-53Crossref PubMed Scopus (176) Google Scholar, 35Lewis CE Disease prevention and health promotion practices of primary care physicians in the United States.Am J Prev Med. 1988; 4: 9-16PubMed Google Scholar, 36McPhee SJ Richard RJ Solkowitz SN Performance of cancer screening in a university general internal medicine practice.J Gen Intern Med. 1986; 1: 275-281Crossref PubMed Scopus (211) Google Scholar, 37McPhee SJ Bird JA Implementation of cancer prevention guidelines in clinical practice.J Gen Intern Med. 1990; 5: SH6-S122Google Scholar, 38Taira DA Safran DG Seto TB Rogers WH Tarlov AR The relationship between patient income and physician discussion of health risk behaviors.JAMA. 1997; 278: 1412-1417Crossref PubMed Scopus (118) Google Scholar Physicians who are younger, residency trained, generalists, subspecialists within their specialty, in a group practice, and experienced with the US Preventive Services Task Force guidelines are more likely to perform recommended preventive services.34Schwartz JS Lewis CE Clancy C Kinosian MS Radany MH Koplan JP Internists' practices in health promotion and disease prevention.Ann Intern Med. 1991; 114: 46-53Crossref PubMed Scopus (176) Google Scholar39Czaja R McFall SL Wamecke RB Ford L Kaluzny AD Preferences of community physicians for cancer screening guidelines.Ann Intern Med. 1994; 120: 602-608Crossref PubMed Scopus (78) Google Scholar40Stange KC Fedirko T Zyzanski SJ et al.How do family physicians prioritize delivery of multiple preventive services?.J Earn Pract. 1994; 38: 231-237Google Scholar In general, community physicians agree with the screening guidelines of the American Cancer Society, and screening practices are increasing.411989 survey of physicians' attitudes and practices in early cancer detection.CA Cancer JCIin. 1990; 40: 77-101Crossref PubMed Scopus (194) Google Scholar42Lane DS Messina CR Current perspectives on physician barriers to breast cancer screening.J Am Board Earn Pract. 1999; 12: 8-15PubMed Google Scholar In clinical practice screening Pap tests are recommended to patients at relatively high rates.36McPhee SJ Richard RJ Solkowitz SN Performance of cancer screening in a university general internal medicine practice.J Gen Intern Med. 1986; 1: 275-281Crossref PubMed Scopus (211) Google Scholar43Centers for Disease Control and Prevention Trends in cancer screening—United States, 1987 and 1992.MMWR Morb Mortal Wkly Rep. 1996; 45: 57-61PubMed Google Scholar Yet, there is large variability in performing screening tests for colon cancer.411989 survey of physicians' attitudes and practices in early cancer detection.CA Cancer JCIin. 1990; 40: 77-101Crossref PubMed Scopus (194) Google Scholar Mammograms and clinical breast examinations are often not obtained at recommended intervals, although the percentage of women who have received recent screening with mammography and clinical breast examinations is clearly increasing.43Centers for Disease Control and Prevention Trends in cancer screening—United States, 1987 and 1992.MMWR Morb Mortal Wkly Rep. 1996; 45: 57-61PubMed Google Scholar, 44Fox SA Murata PJ Stein JA The impact of physician compliance on screening mammography for older women.Arch Intern Med. 1991; 151: 50-56Crossref PubMed Scopus (235) Google Scholar, 45Centers for Disease Control and Prevention Self-reported use of mammography among women aged greater than or equal to 40 years—United States. 1989 and 1995.MMWR Morb Mortal Wkly Rep. 1997; 46: 937-941PubMed Google Scholar In contrast, some screening tests are performed routinely although they are not indicated.39Czaja R McFall SL Wamecke RB Ford L Kaluzny AD Preferences of community physicians for cancer screening guidelines.Ann Intern Med. 1994; 120: 602-608Crossref PubMed Scopus (78) Google Scholar46Clasen CM Vemon SW Mullen PD Jackson GL A survey of physician beliefs and self-reported practices concerning screening for early detection of cancer.Soc Sci Med. 1994; 39: 841-849Crossref PubMed Scopus (27) Google Scholar and others are performed more frequently than recommended.47Woo B Woo B Cook F et al.Screening procedures in the asymptomatic adult: comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice.JAMA. 1985; 254: 1480-1484Crossref PubMed Scopus (214) Google Scholar There has been an increase in the proportion of physicians who believe that most health-promoting behaviors are important and that physicians should be educating patients about health-related risk factors.48Wechsler H Levine S Idelson RK et al.The physician's role in health promotion revisited-a survey of primary care practitioners.N Engl J Med. 1996; 334: 996-998Crossref PubMed Scopus (153) Google Scholar However, assessment of health behaviors and health promotion counseling vary according to the health habit. Most physicians ask about smoking habits, although fewer spend significant time counseling patients t
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