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- Joshua Schulman-Marcus, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Joshua Schulman-Marcus, Weill Cornell Medical College, Cornell University, New York, New York.
Lifestyle behaviors have long been recognized as major factors in the development or prevention of cardiovascular diseases (1). Poor diet, inadequate physical activity, and smoking contribute substantially to the progression of atherosclerosis and its downstream consequences (2). Recent work suggests that unhealthy lifestyle behaviors also contribute to the burden of atrial fibrillation (3) and heart failure (4). Conversely, healthy lifestyle behaviors may be able to prevent or ameliorate many of the conditions we see on a daily basis.
In this light, one of the essential roles of a cardiologist is to help patients adopt and maintain healthy lifestyle habits. To do so, counseling techniques are generally more effective than education or admonition (5). This is easier said than done; at times, this can be one of the more challenging elements of clinical practice. And yet, it is my observation that most patients positively value a genuine attempt to counsel on lifestyle, even if they do not immediately change behavior. On the other hand, most patients view the omission of this role as a marker of poor physician quality.
Successful lifestyle counseling is both an art and a complex skill. At its core, counseling requires purposeful questioning, listening, and attention to detail (both verbal and nonverbal). Lifestyle is heavily influenced by habits, beliefs, temperament, goals, cultural norms, socioeconomic status, and personal obligations. The sway of each element is dynamic and changes over the life course. Thus, the ability to counsel an individual patient requires illuminating and integrating these facets to help him or her find a unique path to make changes. And even when done well, many patients will still be resistant to actually changing. Breaking long-term habits, however deleterious they may be, is difficult.
Given these challenges, lifestyle counseling sometimes gets overlooked in fellowship. Time is precious in ambulatory clinic, because patients tend to have numerous medical comorbidities requiring complex management and coordination of care. Many also have substantial barriers to behavior change, including limited health literacy, economic stress, cognitive difficulties, or speaking a language other than English. In a diverse population such as in New York, patients’ diets and physical activity patterns may vary widely from my own and one another. In this context, it is easy to fall back on simpler, but generally unsuccessful, techniques such as educating patients about lifestyle. Or sometimes, lifestyle modification is deferred to the next visit, and then deferred again.
Fellows, training programs, and attendings should resist this form of therapeutic inertia. The skill to communicate with patients and families on lifestyle matters is recognized as integral to cardiology training (6). Programs can and should offer opportunities for improvement. At minimum, this may include occasional observation in clinic by a skilled senior cardiologist who can offer tips for improvement. Fellows should be offered the opportunity to work with and get advice from nurse practitioners and other health team members, many of whom have deep experience in counseling patients. Alternatively, fellows can spend dedicated time at a cardiac rehabilitation clinic, where lifestyle change is emphasized as a part of secondary prevention. Ideally, formal instruction of fellows in techniques such as motivational interviewing can be offered (7). Finally, patients should be asked to provide directed feedback, perhaps through the use of anonymous post-visit surveys to minimize reluctance to directly criticize doctors.
Effective lifestyle counseling also requires an awareness of resources to help patients commit to and carry out behavior changes. To this end, each fellowship should provide quick access to a list of preferred resources for smoking cessation, nutritional counseling, exercise, and weight management. Additionally, cardiology fellows can and should curate this list as they hear about success stories from other clinicians and patients. Also, as younger, tech-savvy physicians, we can help make patients (and indeed other cardiologists) aware of emerging Internet and smartphone-based platforms to help sustain adherence to lifestyle changes.
At a more basic level, lifestyle counseling requires patience. It is easy to become disheartened by the slow pace or absence of change. And yet, patients can surprise you, sometimes in dramatic fashion. Recently, a 45-year-old man from the Dominican Republic whom I had not seen in 1 year, came in for a routine visit. When I called his name out in the waiting room, I barely recognized him. He had lost 45 pounds over the past year through improving his diet, cutting back on his drinking, and trying to exercise. As a result, his diabetes, hyperlipidemia, and hypertension had regressed. When I asked him what motivated this change, he said, “It was what you told me! I didn’t want to take medicines, and now I don’t have to.”
Lifestyle counseling is rarely this simple, but I offer this story to illustrate 3 points. First, patients sometimes remember lifestyle discussions more than any other part of a clinical encounter. Second, it’s important for us to remain encouraging rather than take a fatalistic attitude. Third, that on occasion, helping a patient prevent heart disease can feel as gratifying as taking care of a myocardial infarction.
In this coming era of “precision” cardiology, it’s important to remember that we already have the opportunity to offer personalized medicine. Effective lifestyle counseling requires considering the patient as a complete individual, rather than an algorithm or “iPatient” (8). Excellence in such a skill should be nurtured in fellowship and beyond. Indeed, I still feel I have much to learn in this regard, and true excellence will require a lifelong commitment to improvement. It is worthwhile, though, when I consider my potential to positively influence patients and their health. It may not always be easy or timely, but the rewards are abundant.
- Pamela B. Morris, MD ()
RESPONSE: The Necessity of Developing Lifestyle Counseling Skills
After nearly 30 years of practice in preventive cardiology and cardiac rehabilitation, like Dr. Schulman-Marcus, I continue to be regularly amazed by the capacity of patients to make meaningful lifestyle changes when they are approached with patience and sensitivity to individual and cultural lifestyle preferences, as well as socioeconomic factors. Changes in diet, physical activity, and tobacco use for cardiovascular disease (CVD) risk reduction are difficult, and multiple attempts at modification are often required for patients to succeed. Cardiologists must continue to provide support and resources for behavioral change without judgment, and provide this care with consistent emphasis on the critical importance of the patient’s efforts.
Despite the demonstrated benefits of healthy lifestyle habits on CVD event reduction, the majority of fellowship programs do not meet American College of Cardiology/Core Cardiovascular Training Statement (ACC/COCATS) training recommendations for CVD prevention and lifestyle counseling. Although all competencies in CVD prevention have been identified as Level I (required for all fellows), training programs tend to prioritize imaging, interventional cardiology, and electrophysiology procedural experience over education in best practices in preventive cardiology. Clinical rotations in “softer” areas of practice, such as cardiac rehabilitation and prevention, are often considered to be convenient times for vacation or coverage for colleagues during procedure-based rotations that depend upon fellows-in-training (FIT) for daily workflow. Many programs lack faculty and cardiovascular team members with expertise in obesity and weight management, sleep medicine, diet and nutrition counseling, smoking cessation counseling, cardiac rehabilitation, exercise physiology and exercise prescription, as well as the psychosocial aspects of CVD risk reduction. Though lifestyle guidelines focusing on nutrition, weight management, and physical activity have recently been updated, fellows may not be adequately trained to implement these evidence-based recommendations and to use effective motivational interviewing and counseling strategies to encourage patient compliance and success in making sustained lifestyle changes.
The ACC has recently formed the Prevention of Cardiovascular Disease Section and the Population Health Policy and Health Promotion (PHPHP) Committee to support a new paradigm and focus on prevention. The Prevention of CVD Section has formed lifestyle workgroups concentrating in the areas of nutrition, tobacco cessation counseling, cardiac rehabilitation, and physical activity, as well as cardiometabolic health and management of complex dyslipidemias. The Digital Strategy workgroup is tasked with providing educational resources for effective CVD prevention in clinical practice to our trainees and members. The PHPHP Committee recently held a 2-day retreat to define the ACC’s potential impact on cardiovascular health at a population level. During his keynote lecture, Dr. Valentin Fuster echoed the concerns of Dr. Schulman-Marcus, emphasizing the important fact that “CVD is a behavioral issue,” strongly related to diet, physical activity, and smoking habits.
As stated by Dr. Schulman-Marcus, excellence in lifestyle counseling must “be nurtured in fellowship and beyond,” if we are to successfully impact the future cardiovascular health of patients. It is our responsibility as educators of this new generation of cardiologists to serve as role models and mentors in preventive cardiovascular medicine and to provide them with the necessary counseling skills to support heart-healthy behavioral changes by patients. We welcome FIT members to the Prevention section and seek your help to promote the importance of fellowship training in lifestyle counseling and CVD risk reduction.
- 2015 American College of Cardiology Foundation
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