Does Emphasis on Self-Care Get the Job Done?

Gwen Mayes, JD, MMSc

Disclosures

September 14, 2005

The Kaiser Family Foundation, a nonprofit, private operating foundation dedicated to analyzing healthcare issues, recently released its second national survey of women’s health and their utilization of the healthcare system.[1] Many of the findings offer opportunities for systematic improvements in public health and mental health. For example, mammogram rates reported by women ages 40 to 64 have not improved in the past several years, falling slightly from 73% in 2001 to 69% in 2004. Only 40% of uninsured women older than 40 years had a mammogram in the past year, compared with three quarters of women with private health insurance (74%) or Medicare (73%). Sadly, although impoverished women have access to mammograms through public health clinics through the federal Breast and Cervical Cancer Prevention and Treatment Act,[2] many women do not avail themselves of these services. Many may simply be unaware that they are available.

The Kaiser report also tells us something about the lack of important communication between patients and their physicians. Despite the growth in self-care, self-exams, and unprecedented access to health information in any form, a great number of women are not discussing important health issues with their providers. According to the survey, fewer than half of all women say they have talked to a healthcare professional in the past 3 years about smoking (33%), alcohol use (20%), and calcium intake (43%). Only slightly more than half (55%) talked to their physicians in the past 3 years about diet, exercise, and nutrition.

Equally alarming is the void in communication between young women of reproductive ages and healthcare practitioners regarding important reproductive issues. Among women ages 18 to 44 years, fewer than 1 in 3 (31%) say that they have talked with their doctor about their sexual history and specific issues, such as sexually transmitted infections (28%) and HIV/AIDS (31%), in the past 3 years. Although women of color, particularly African Americans, are at higher risk for HIV/AIDS, fewer than half of African American women (41%) and Latina women (44%) of reproductive age have discussed the topic with a provider in the past 3 years.

One might assume that patient education and self-care have replaced much of the "tough love" doctors dish out in the examining room, but a look at the growing rate of obesity, diabetes, and heart disease in this country tells us otherwise. And the Kaiser survey confirms it. Over half of women (53%) cite healthcare providers as their primary source of health information, much higher than the Internet (15%), friends and family (16%), and books (7%). Even with the tremendous amount of health information available through public means, the doctor's office remains the main place patients turn to for health information.

"Women still turn to their healthcare providers more than any other source for information about their health," says Usha Ranji, coauthor, "Women and Health Care: A National Survey," and senior policy analyst with the Kaiser Family Foundation (personal communication 8/31/05 with Usha Ranji, coauthor, "Women and Health Care: A National Survey and senior policy analysts with the Kaiser Family Foundation in Menlo Park, California). "As a source of information, the Internet was quite low. I think the perception that everyone is going to the Web to get their health information is just not true. They are still looking to their doctor."

So, what's up with the communication gap?

"There's been a renewed interest in health prevention," says Ranji, "so it's surprising that these numbers are so low. But when you think about these topics, they are very personal and intimate both for the patient and the provider." Despite society's fascination with full disclosure and the seemingly unending discussion of personal topics in the media, many topics essential to good health are getting short shrift in the doctor's office.

"These are tough issues to discuss," echoes Robert M. Arnold, MD, Professor of Medicine and Director, University of Pittsburgh Institute for Doctor-Patient Communication (personal communication on 8/30/05 with Robert M. Arnold, MD, Professor of Medicine and Director, University of Pittsburgh Institute for Doctor-Patient Communication). "Doctors weren't talking about these topics years before all of the patient information was made available, and now that there is [information available], there still seems to be a lack of communication. I don't think access to new technology or health information has changed that."

Part of the lack of communication may be due to a perception that someone else is handling the topic. "I also think there is some assumption, particularly in reproductive health, that maybe another doctor is taking care of that," says Ranji. Women's health experts have encouraged integration of reproductive and overall health awareness for years, but the division still remains. Another reason for the gap, according to Arnold, is that physicians may feel that since they raised the issue in the past, there's no need to inquire again.

Both Arnold and Ranji believe the problem partially stems from a lack of time. "The average doctor's visit is 15 to 20 minutes," says Arnold. "There's always more to cover than time allows. It's hard to get everything in that is important to discuss, and it's up to the physician to discern what the patient is willing to change. If a patient says, ‘yeah, I smoke' and doesn't want to quit, then the physician might not want to continue to spend time and effort in talking about smoking cessation. You have to pick and choose those topics that your patient is willing to address."

Lack of time, according to Ranji, means women should do their homework before seeing a doctor. "Things are moving so fast during those few minutes that it's best for the patient to have something written down to remind herself of what needs to be discussed. That way, if the doctor doesn't bring it up, she can." Closely related to time constraints is the matter of reimbursement. Most patients go to the doctor for a specific complaint, and spending time on ancillary preventive measures, while laudable, may not be realistic. "We don't necessarily reimburse for preventive health counseling in this country, and that could possibly have the effect of pushing these topics down on the totem pole. Often it's seen that women are there for something specific, something with a billable code."

Since time is of the essence, whose responsibility is it to bring up sensitive topics -- the patient's or the provider's? "I think it's a question for debate," says Ranji. "I think it's hard because a woman might assume if a physician didn't ask her then maybe it is not that important, whereas the physician might not have asked simply because he or she didn't have time." Add to the mix the sensitive issue of talking about sexual patterns, drug history, and lifestyle behaviors and, not surprisingly, topics of importance are left in the waiting room.

"These findings are disturbing," says Arnold. He advises physicians to improve their skills through continuing education at medical schools and taping sessions with real patients. "I have these sessions taped and then analyzed by a colleague who can give me feedback."

Good patient-provider communication entails give and take. Ranji describes it as a quintessential "chicken and the egg" situation, and both sides share responsibility. But as the Kaiser survey reminds us, despite all the self-education and tutorials available, women still prefer to obtain information about their health from their provider. As such, sensitive topics such as diet, exercise, and sexual habits should not be overlooked or presumed to be covered by someone else.

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