The art and complexity of primary care clinicians' preventive counseling decisions: Obesity as a case study

PURPOSE: Studies have often shown low rates of preventive counseling in primary care, and interventions aimed at improving counseling rates have had disappointing results. Using obesity as a case study, we looked for factors that influence clinicians' decisions to include preventive counseling in the brief primary care encounter. METHODS: A sequential, mixed methods study was conducted among clinicians in RIOS (Research Involving Outpatient Settings) Net, a Southwestern US practice-based research network. Thirty primary care clinicians participated in in-depth interviews or analytic focus groups, and 75% of 195 network members responded to a survey used to estimate the frequency of factors influencing decisions to undertake preventive counseling. RESULTS: Clinicians described a complex set of factors that influence decisions to provide preventive counseling for obesity. These can be grouped into 2 sets of factors: (1) relatively stable factors that "set the stage" for the encounter, such as the clinician's life values, definitions of success, and the availability of community resources; and (2) factors that are more dynamic, exerting their influence "as the door opens" into the examination room. These factors include the patient's agenda and receptivity to the proposed counseling, as well as the presence of teachable moments. Clinician, patient, and external factors are found in both groups. CONCLUSIONS: Clinician decisions to include obesity and other types of preventive counseling in the brief encounter reflect the art and complexity of management of the encounter. Future efforts to enhance the delivery of preventive counseling will need to move beyond linear models of behavior change to recognize this complex environment.