Training Doctors to be Competent in Behavior Counseling

The American Heart Association 2020 impact goals clearly established the link between individual health behaviors and cardiovascular health¹. A subsequent statement has advocated for intensified attention by practitioners to provide behavioral treatment strategies in patient encounters. The approach recommends applying five steps known as the 5As: (1) assess the risk behavior, (2) advise change, (3) agree on goals and an action plan via shared decision making, (4) assist with treatment, and (5) arrange follow-up.² Additionally, practitioners are urged to incorporate motivational interviewing techniques using open-ended questions and partnering with patients to develop mutual goals for change.² Finally, the importance of a public health approach to healthy behavior is recognized. The current scientific statement by Hivert et al, reinforces this approach, but specifically advocates for structured and comprehensive training during medical school to improve the ability of physicians to provide effective lifestyle counseling. The authors provide valuable suggestions for the content and structure of such a curriculum that addresses nutrition, physical activity and smoking cessation. They also urge that cultural, gender and age-related concerns are included in the approach to individual patient encounters.³

To make the case for their recommendations, the authors outline significant gaps in most current medical school curricula related to training in behavior counseling. Although they acknowledge that such training should be provided across the continuum of medical education, from medical school through residency and practice, this statement primarily promotes comprehensive training within the medical school curriculum. An alternative approach may be to introduce concepts within medical school, but provide longer and more focused training during the years of residency training. Given the demands on student time for all aspects of medical education during medical school and the fact that some students will not select a specialty that will require direct patient counseling, providing counseling training and practice during residency may be the preferable approach. Rather than engage medical school deans and licensing bodies, the AHA may consider advocating such enhanced training with the Accreditation Council for Graduate Medical Education (ACGME) and the relevant Residency Review Committees (RRCs) and Certification Boards of the American Board of Medical Specialties (ABMS). To establish the most effective approach for developing physicians who are both competent and confident in behavioral counseling, well-designed research studies should be undertaken. Opportunities exist to demonstrate effective ways to train faculty, establish a culture of expectation that counseling will occur, define time-efficient and cost-effective interventions, and track impact through changes in patient behavior and clinical outcomes.

AHA and cardiovascular leaders must continue to advise behavior change among patients at risk for cardiovascular disease to achieve further reductions in the prevalence and severity of cardiovascular disease. Partnerships with medical schools, residency programs as well as public health agencies are required. Elements of the training curricula outlined in this statement will be applicable across the training spectrum. What has been suggested to produce lasting changes in physician behavior requires: (1) demonstrating a gap between current behavior and optimal behavior, (2) addressing gaps in knowledge and performance within the practice environment, and (3) reinforcing change over time until the new behavior is well established4. How each entity will implement these elements should be based on evidence from reliable research findings. Until such findings are available, training opportunities should be offered and outcomes tracked for patients, providers and trainees.