Lifestyle Discussions During Doctor-Older Patient Interactions: The Role of Time in the Medical Encounter

Marcia G. Ory, PhD, MPH; B. Mitchell Peck, PhD; Colette Browning, PhD; Samuel N. Forjuoh, MD, DrPH

Abstract

Context: Although physician influence can be especially powerful with older adults, relatively little is known about how primary care physicians (PCPs) interact with their patients regarding lifestyle issues.
Objective: To document the length of time that PCPs discuss lifestyle issues with their older patients and to examine patient, physician, and contextual correlates.
Design: Descriptive and multivariate analysis of videotapes of physician-patient encounters.
Setting: Medical encounters from 3 primary care ambulatory settings.
Patients: There were 116 ongoing medical encounters with patients aged 65 years or older.
Main outcome measures: Total time spent in physical activity (PA) discussions and total time spent discussing PA, nutrition, and smoking during the medical encounter.
Results: Very little time was spent in lifestyle discussions. On average, PA was discussed for less than a minute (58.28 seconds) and nutrition for slightly less than 90 seconds (83.11 seconds). Only about 10% of the average 17-minute, 22-second encounter was spent on physical activity, nutrition, or smoking topics. Physician supportiveness score (beta = 8.92, P ≤ .001) and the number of topics discussed (beta = 106.39, P ≤ .001) were significantly correlated with the length of all lifestyle discussion. Lifestyle discussions were also more likely to occur during longer visits.
Conclusion: There is a critical need for additional training of primary care providers on how to discuss lifestyle issues in the most time-efficient but effective manner to achieve positive behavior change associated with improved health outcomes. There is also a need for the institutionalization of policies to encourage more lifestyle discussions.

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Independent Variables: Patient, Physician, and Contextual Characteristics of the Doctor-Older Patient Encounter Sample
Sample Characteristics (N = 116)	Percent or Averageof Sample
Patient Characteristics
Age
Average	73.6 years
65-74 years	62.5%
75-84 years	27.7%
≥ 85 years	9.8%
Gender
Female	55.8%
Male	44.2%
Race/Ethnicity
White (non-Hispanic)	87.6%
Black/Hispanic	12.4%
Education
College graduation or more	31%
Less than college graduation	69%
SF-36 Physical Functioning Scale score
Average	62.4 points
Physician Characteristics*
Age
Average	49.4 years
< 50 years	61.9%
≥ 50 years	38.1%
Gender
Male	80.7%
Female	19.3%
Race/Ethnicity
White (non-Hispanic)	92.1%
Black/Hispanic	7.9%
Geriatric Training
No	74.6%
Yes	25.4%
Physician ADEPT Supportiveness Score
Average	17.7 points
Contextual Characteristics
Site of Care
Academic medical center	36%
Managed care clinic	58.8%
Inner city private practice	5.3%
Length of Patient-Physician Relationship
Average	6.27 years
≤ 1 year	30.3%
> 1 and ≤ 3 years (median)	22.9%
> 3 and ≤ 10 years	28.5%
> 10 years	18.3%
Presence of Companion
Yes	19.3%
No	80.7%
Number of Topics Discussed
One (PA alone)	35.3%
More than one	64.7%
Reason for visit
Acute	15%
Nonacute	85%
Length of Visit
Average	17 minutes, 22 seconds

*n = number of doctor-patient encounters, not individual physicians.

Multivariate Models: Influence of Patient, Physician, and Contextual Characteristics on the Length of Lifestyle Discussions
Characteristic	Description	Physical Activity Discussion (1-second change)	All Lifestyle Discussion (1-second change)
		beta(95% CI)	beta(95% CI)
Patient Age(1-year change)	Linear	-1.65 (-4.33, 1.04)	-1.34 (-6.87, 4.18)
Patient Gender	Female compared to male	-7.55 (-38.04, 22.94)	36.94 (-25.33, 99.21)
Patient Race	White compared to non-white	-24.61 (-74.86, 25.64	-30.67 (-98.19, 36.85)
Patient Education	College educated compared to less than college	6.98(-40.64, 54.60)	53.84(-37.94, 145.63)
Patient SF-36 Physical Activity Score(1-point change)	Linear	-0.38 (-0.85, 0.09)	0.53(-0.15, 1.21)
Physician Age (1-year change)	Linear	-0.47(-2.15, 1.22)	-0.31(-4.59, 3.97)
Physician Gender	Female compared to male	-23.15 (-52.51, 6.22)	-52.40(-149.95, 45.16)
Physician Race	White compared to non-white	5.75(-52.29, 63.80)	-57.59 (-151.96, 36.78)
Physician Geriatric Training	Has training compared to does not have training	-6.21 (-36.11, 23.68)	-57.75 (-129.02, 13.53)
Physician ADEPT Supportiveness Score(1-point change)	Linear	1.50(-0.96, 3.97)	8.92(3.05, 14.78)^‡
Length of Doctor-Patient Relationship(1-year change)	Linear	-1.03(-2.48, 0.42)	-3.35 (-7.38, 0.67)
Companion Present	Has companion compared to does not have companion	30.84 (-16.11, 77.79)	-12.00 (-98.86, 74.85)
Number of Topics Discussed	> 1 compared with only 1 (PA)	10.42 (-16.27, 37.10)	106.39 (51.14, 161.64)*
Reason for Visit	Acute compared to non-acute	-30.92 (-63.85, 2.00)	-62.74(-146.56, 21.08)
Length of Visit	Linear	0.02(-0.01, 0.06)	0.07(-0.01, 0.16)
Constant		187.53(-20.42, 395.49)	-94.46(-505.54, 316.62)

*P ≤ .001
n = 107
Note: All variables entered simultaneously and clustered on doctor identifier.
CI = confidence interval

Logistic Regression of Patient, Physician, and Visit Characteristics on All Lifestyle Discussion Length, Dichotomized
All Lifestyle Discussion (> 1 Minute vs ≤ 1 Minute)
Characteristic	Referent	OR (95% CI)
Patient Age	5-year increase	1.26 (0.82, 1.95)
Patient Gender	Male	2.76 (0.82, 9.28)
Patient Race	Non-white	0.59 (0.16, 2.16)
Patient Education	Less than college educated	1.39 (0.56, 3.43)
Patient SF-36 Physical Activity Score	5-point increase	1.05 (0.97, 1.13)
Physician Age	5-year increase	0.92 (0.66, 1.26)
Physician Gender	Male	0.24(0.03, 1.78)
Physician Race	Nonwhite	0.37 (0.02, 7.41)
Physician Geriatric Training	Does not have training	0.70(0.17, 2.93)
Physician ADEPT Supportiveness Score	5-point increase	1.30 (0.64, 2.63)
Length of Doctor-Patient Relationship	1-year increase	0.95 (0.89, 1.02)
Companion Present	No	0.83(0.34, 2.05)
Number of Topics Discussed	One topic discussed (PA)	4.44(1.31, 15.02)*
Reason for Visit	Nonacute	0.21 (0.02, 1.73)
Length of Visit^‡	60-second increase	1.12 (1.00, 1.25)*

*P ≤ .05
n = 107
Note: All variables entered simultaneously and clustered on doctor.
Note: 95% CI lower bound is 1.0046.
CI = confidence interval

Difference in Means of Length of Physical Activity Discussion, Length of All Lifestyle Discussion Combined, and Total Visit Time Compared Across Sites
	Academic Medical Center	Inner City Private Practice	Managed Care Organization
	n = 41	n = 6	n = 67
	Mean (SD)	Mean (SD)	Mean (SD)
Physical Activity Discussion, seconds	82.61^a(91.53)	50.00^a,b(69.62)	45.37^b(60.91)
All Lifestyle Discussion, seconds	196.83^a(189.49)	58.67^a,b(76.48)	93.55^b(163.55)
Total Visit Time	1417.71^b(462.49)	762.50^a(378.28)	852.21^a(371.60)

Note: Groups bearing same letters are not significantly different from one another at P ≤ .05.
SD = standard deviation

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Lifestyle Discussions During Doctor-Older Patient Interactions: The Role of Time in the Medical Encounter

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