The Practices of General and Subspecialty Internists in Counseling about Smoking and Exercise

KENNETH B. WELLS, MD, MPH, CHARLES E. LEWIS, MD, SCD, BARBARA LEAKE, PHD, MARY KAY SCHLEITER, PHD, AND ROBERT H. BROOK, MD, SCD
Abstract: We compared the practices of subspecialists and general internists in counseling about smoking and exercise, using data from a study of recent graduates of United States training programs in internal medicine. Information on the characteristics of physicians and their clinical practices was obtained from self-report questionnaires. The internists most likely to counsel smokers regardless of the presence or absence of diseases associated with smoking are cardiologists, pulmonary specialists, nephrologists, and generalists trained in a primary care residency funded by the Robert Wood Johnson Foundation or Health Resources Administration. Most

internists practice tertiary prevention by counseling a high percentage of smokers with heart or lung disease. Rheumatologists counsel a higher percentage of all patients with poor exercise habits but a lower percentage of such patients with heart disease than do other internists. The differences in counseling related to training are not explained by different levels of involvement as a primary care physician. Rather, these differences appear to reflect training and subspecialty-specific priorities for counseling. (Am J Public Health 1986; 76:1009-1013.)

Introduction During the last decade, general internal medicine has emerged as a distinct clinical "specialty," differentiated from other internal medicine subspecialties by its emphasis on primary care activities, especially preventive services. Beginning in 1973, primary care residency programs in general internal medicine were fostered by grants from the Robert Wood Johnson Foundation (RWJF), the Health Resources Administration (HRA), and other sources. These programs were developed partly in response to a decline in the number of practicing generalists during the 1960s and the assumption that subspecialists would not consistently provide primary care services. However, there have been few empirical studies of this assumption; existing studies have used different research methods and reached opposite conclusions. 13 Aiken, et al, using data from the Mendenhall study,4 concluded that subspecialty internists are a major source of primary care services.2 Spiegel, et al, concluded that, depending on the definition of a primary care physician, only a small proportion of patients use subspecialists as their primary care physician.3 Both sets of investigators urged future investigators to compare the practices of generalists and subspecialists in providing primary care services, especially health maintenance activities. Although a number of previous studies have described how physicians counsel patients, they either did not focus on differences between generalists and subspecialists or they were conducted prior to the 1970s, when the current concept of the general internist reemerged.5-'4 In this article, we evaluate the practices of general and subspecialty internists in counseling patients about cigarette smoking and regular exercise, using data from the Physician Practice Study.'5
Address reprint requests to Kenneth B. Wells, MD, MPH, Assistant Professor of Psychiatry, UCLA Neuropsychiatric Institute, School of Medicine, and Senior Researcher, Rand Corporation, 1700 Main Street, Santa Monica, CA 90406. Dr. Lewis is Professor of Medicine and Chief of the Division of General Internal Medicine and Health Services Research, UCLA Department of Medicine, School of Medicine; Dr. Leake is Senior Statistician, UCLA School of Public Health and School of Medicine; Dr. Schleiter is Professor, Department of Anthropology and Sociology, Albion College; Dr. Brook is Professor of Medicine and Public Health, UCLA, and Senior Researcher, Rand Corporation. This paper, submitted to the Journal October 2, 1985, was revised and accepted for publication February 14, 1986.
C 1986 American Journal of Public Health 0090-036/86$1.50

Methods
Sample and Design

The Physician Practice Study (PPS) is a study of the practice characteristics of recent graduates of residencies in family practice and general internal medicine, and fellowships in six subspecialties of internal medicine.'5 This paper reports data from the PPS on the internists only, grouped as follows: * internists who completed at least one year of an RWJF- or HRA-funded primary care residency (primary care general internal medicine group (PC-GIM)); * internists who completed a "traditional" residency in internal medicine (traditional general internal medicine group (T-GIM)); * internists who completed fellowship training in cardiology, pulmonary medicine, gastroenterology, nephrology, rheumatology, or hematology/oncology. The sample for the PC-GIM group was all participants in an RWJF- or HRA-funded residency during 1976-77. The population for the T-GIM and subspecialty group was all internists in the appropriate specialties who had participated in the National Study of Internal Medicine Manpower (NaSIMM). The NaSIMM used a random sample of all internal medicine residents and fellows in the six subspecialties in US training programs during 1976-77.16 The response rate in NaSIMM was 77 per cent. In 1981, attempts were made by telephone to locate all internists in the original study populations to determine eligibility for the PPS. Internists were eligible to participate if they were in the clinical practice of medicine in 1981 and if they were practicing in the field of medicine in which they had trained in 1976-77, e.g., those trained in general internal medicine who still practiced general internal medicine. Of the 1,229 internists in the original sample, 91 per cent were contacted by phone; of those contacted, 56 per cent were eligible to participate. Most of those who were ineligible had participated in a traditional internal medicine program and subsequently received subspecialty training, and thus were not practicing general internal medicine in 1981. Instrument All eligible physicians were asked to complete a questionnaire which included an eight-item measure of the physician's practices in counseling about smoking (i.e., stopping or reducing smoking) and exercise (i.e., increasing regular
1 009

AJPH August 1986, Vol. 76, No. 8

WELLS, ET AL.
TABLE 1-Primary Care General Internal Medicine Ornbtaion by Type of Training
Percentage of Internists

(95% confidence interval)

Primary Care Physician for 2 75 Per Cent of Patients - 75 Per Cent of Practice Time Spent in General Internal Medicine

Physician Group

Numbera
449 86 158 200 29 37 41 32 33 23

Yes
52 74 (10)

Yes
50 91 (19) 87 (5) 4 (9) 0 3 10 3 0 8

All Groups Primary Careb Generalist Traditional Generalist

Subspecialists Cardiology Pulmonary Medicine Hematology/Oncology Gastroenterology Rheumatology Nephrology

65 (7) 29 (6) 28 32 49 6 15 39

aThe table excludes data on five subspecialists for whom the subspecialty type was not recorded and one intemist who did not respond to either item. bPnmary Care refers to programs funded by the Robert Wood Johnson Foundation or Heafth Resources Administration.

exercise such as walking, biking, or swimming) during the preceding month."4 For each habit, the items measure: * the indications for routine counseling, in terms of the percentage of all patients and of those with specific clinical syndromes (e.g., heart disease) who are counseled; * the general aggressiveness of counseling style, in terms of the tendency of the physician rather than the patient to initiate counseling and the frequency and duration of counseling sessions, and; * the specific techniques used (e.g., face-to-face counseling, pamphlets). Our analyses use scores on individual counseling items and on global scales for each habit. The global scales consist of simple sums of the items for each habit (Cronbach's alpha exceeds 0.80 for each scale). As a partial test of the validity of the counseling questionnaire, we compared item responses on the questionnaire to data from log-diaries, completed by 53 per cent of the eligible physician sample. On the log-diaries physicians simply indicated whether or not they counseled each patient seen over a three-day period about smoking and/or exercise. Physicians with higher scores on the global counseling scales derived from the questionnaire items were more likely to indicate that they counseled on the log-diary. The questionnaire also included information on the physician's demographic characteristics, board certification, participation in a primary care residency, and practice characteristics.
Statistical Analyses To assess the effect of training and specialization on counseling practices while controlling for other factors, we performed analysis of covariance and least-squares multiple linear regressions with the physician demographic, training, and practice characteristics as independent variables, and counseling items and global scales as dependent variables. We contrasted each group of generalists with cardiologists, pulmonary specialists, and nephrologists (combined) and with hematologists/oncologists, gastroenterologists, and rheumatologists (combined). A sensitivity analysis indicated that our conclusions about the differences between generalist
1010

and subspecialty internists are similar whether we group nephrologists with cardiologists and pulmonary specialists or with other subspecialists. Results Physician Characteristics Of the 628 internists eligible to complete the questionnaire, 455 did so (a response rate of 72 per cent). The analytic sample includes 89 primary care track generalists, 166 traditionally-trained generalists, and 211 subspecialists; the latter group consists of 30 cardiologists, 32 gastroenterologists, 42 hematologists/oncologists, 25 nephrologists, 39 pulmonary specialists, 33 rheumatologists, and five subspecialists whose subspecialty was not recorded. The mean age of responding internists is 37 years. Most are male (89 per cent) and White (89 per cent). These internists spend an average of 40 hours per week in direct patient care activities. Thirty-five per cent of their patients are of low socioeconomic status and 11 per cent of high socioeconomic status (as defined by the internist). Of all physicians studied, 86 per cent are board certified in internal medicine; 70 per cent of subspecialists are board certified in a subspecialty of internal medicine. Those in the PC-GIM group spent an average of 2.5 years in a primary care residency. Of the subspecialists, 5 per cent had participated in a primary care program prior to subspecialty training.
Primary Care/General Internal Medicine Orientation

General internists (both PC-GIM and T-GIM groups) perceive themselves as the primary care physician for more than twice the proportion of their patients as do subspecialists (Table 1). General internists spend almost all of their practice time in general internal medicine activities while subspecialists spend very little of their time in these activities (Table 1). As shown in Table 1, the percentage of patients for whom subspecialist physicians perceive themselves to be the primary care physician is highest for hematology/oncology (49 per cent); intermediate for cardiology, pulmonary medicine, and nephrology (32-28 per cent); and lowest for gastroenterology and rheumatology (6-15 per cent).
AJPH August 1986, Vol. 76, No. 8

HEALTH HABIT COUNSELING OF INTERNISTS

TABLE 2-Aggressiveness of Counseling about Smoking and Exercise for Intemists Who Counsel
Percentage of lntemistsa Who Counsel Smoking Exercise
(N = 394) Yes
15
57

Counseling Practice
Counsels only during initial visit 8 Counsels less than 2 minutes/visit Counseling initiated only when an immediate health hazard

(N

Yes

429)

61

36

47

aThe table excludes intemists who do not counsel; for each habit, the sample size vanes slightly by item due to missing data.

Counseling Practices

Across all physicians, only 3 per cent state they never counsel about smoking, while 12 per cent never counsel about exercise. When they counsel, these internists rely on face-to-face techniques. For each habit, over 90 per cent discuss the risks and benefits of change, suggest specific steps, and 66 per cent explore feelings about the habit. A lower percentage talk with family members about the habit (55 per cent for smoking; 37 per cent for exercise). Less than half present pamphlets (even for smoking) refer to outside agencies or use other office personnel for counseling. The pattern of techniques used for counseling is similar for generalists and subspecialists. As shown in Table 2, among internists who counsel, 8 to 15 per cent counsel only during an initial visit, depending on the habit; 57-61 per cent counsel less than two minutes per visit; 36-47 per cent initiate counseling only when the habit presents an immediate health hazard. Regarding smoking, internists are oriented more toward tertiary prevention than primary prevention (Table 3). For example, 82 per cent counsel more than 75 per cent of smokers with chronic lung disease, but only 52 per cent counsel more than 75 per cent of all their patients who smoke. Only 15 per cent of respondents counsel most of their patients with poor exercise habits about regular exercise such
TABLE 3-Smoking Counseling by Traininga

as running, swimming, or walking; 56 per cent of physicians counsel most of their patients with heart disease about exercise (Table 4). Of those who ever counseled about smoking, 10 per cent never counseled about exercise. Effects of Training As shown in Table 3, about 9 per cent of hematologists, gastroenterologists, and rheumatologists (combined) do not counsel any patients about smoking compared to 0-2 per cent of other internists. While almost 90 per cent of cardiologists, pulmonary specialists, and nephrologists counsel almost all smokers with heart disease, about 65 per cent of hematologists, gastroenterologists, and rheumatologists do so. Internists who counsel a high percentage of all smokers, regardless of disease, are most likely to be generalists trained in a primary care residency (PC-GIM) and cardiologists, pulmonary specialists, and nephrologists. As demonstrated in Table 3, about two-thirds of these internists counsel most of their patients who smoke, compared to less than half of traditionally trained generalists or subspecialists in the hemeGI-rheum group. Rheumatologists and subspecialists in the cardiologypulmonary-nephrology group counsel a higher percentage of patients about regular exercise than do all generalists combined or the hematologist/gastroenterologist group (Table 4). Rheumatologists are less likely than each of the other groups of internists to limit their counseling to patients whose poor exercise represents an immediate health hazard, yet, they are less likely to counsel their patients with heart disease about exercise than are any of the other groups of internists (Table 4). All of the differences in counseling among groups in internists noted above remain or become more marked when we use ANOCOVA to control for per cent of patients for whom the internist thinks he is the primary care physician or multiple regression techniques to control for several physician and practice characteristics. Table 5 illustrates the regression results for the global smoking counseling scale, which represents the general intensity of counseling efforts. Rheumatologists, gastroenterologists, and hemeoncologists counsel less intensely about- smoking than do other internists, even after controlling for the per cent of patients for whom the internists is the primary care physician, board certifica-

Group
All Internists

Ever Counsels %
97 (2)

Counsels > 75% of all Smokers (Primary Prevention) % (95% confidence interval)
52 (5) 63 (10) 48 (8) 51 (7) 63 (10)
41

Counsels > 75% of Smokers with Heart Disease (Tertiary Prevention) %

82 (4) 89 (7) 83 (6) 77 (6)
90 (6)

Primary Care Generalist Traditional Generalist All Subspecialists Cardiologist, Pulmonary Specialist and Nephrologist Heme/Oncologist, Rheumatologist and Gastroenterologist

100 (t2)c 98 (2) 94 (3)

98 (3)
91

(5)

(9)

65 (9)

8The sample size (N = 441) varies slightly by item due to missing data. The table excludes 5 subspecialists with specialty type not recorded and 9 intemists who did not answer these items. bPrimary care refers to programs funded by the Robert Wood Johnson Foundation or Health Resources Administration. c(Calculated for a proportion of .99).

AJPH August 1986, Vol. 76, No. 8

1 011

WELLS, ET AL.
TABLE 4-Exercise Counseling by Training
Counsels > 75% of all Patients with Poor Exercise Habits (Primary Prevention) % (95% confidence interval) Counsels > 75% of Patients with Heart Disease and Poor Exercise Habits (Tertiary Prevention) %

Group
All Internists Primary Care Generalist Traditional Generalist All Subspecialists

Ever Counsels %

88 (3) 93 (5) 88 (5) 86 (5)

15 (t3) 8 (6) 13 (5) 19 (6) 16 (8) 7 (6) 33 (16)

56 (5) 65 (10) 58 (8) 50 (7) 62 (10) 42 (11) 34 (16)

Cardiologist, Pulmonary Specialist, Nephrologist Hematology/Oncologist,

93 (5)

Gastroenterology
Rheumatologist

76 (10) 88 (9)

"The sample size (N = 443) varies slightly by item due to missing data. The table excludes 5 subspecialists for whom the subspecialty type is missing; and 7 intemists who did not answer these items. bPnmary care generalists were trained in programs funded by the Robert Wood Johnson Foundation or Health Resources Administration.

tion status, and demographic characteristics. As shown in Table 5, other factors equal, internists with many high income patients counsel less intensely about smoking than those with fewer high income patients. Only one factor other than training is independently related to counseling in the multivariate analyses for both smoking and exercise. The more the internist perceives himself to be the primary care physician, the more he counsels. For example, of internists who think they are the primary care physician for 0-25 per cent of their patients, 11 per cent never counsel about smoking, as opposed to 0 per cent of those who think they are the primary care physician for 75-100 per cent of their patients. Finally, although the relationship of training and practice characteristics to counseling is clearly important, the percentage of variation in counseling that these characteristics
TABLE 5-Regression Results for the Intensity of Couneling Efforts about Smokinga Variable Name (Scoring; Mean; Standard Deviation)

explain is small (5-15 per cent across regressions). Obviously other factors also affect counseling practice.
Discussion We found that internists who are most likely to counsel a high percentage of all smokers can be divided into two groups that cross the specialty-generalist distinction: generalists trained in a primary care residency funded by the Robert Wood Johnson Foundation or the Health Resources Administration, and cardiologists, pulmonary specialists, and nephrologists. Simply put, those who perform the most counseling about smoking specialize in organ systems that are adversely affected by smoking or have received special primary care training. On the average, all groups of internists were less likely to counsel about exercise than about smoking. This may reflect the fact that there is greater controversy about the value of regular exercise, relative to the value of reducing cigarette smoking, in lowering cardiovascular risk. Rheumatologists, who treat many patients with limitations in physical functioning, counseled the highest percentage of patients with poor exercise habits. This finding is probably not entirely explained by the rheumatologist's recommendations for range-of-motion exercises, as the items specifically referred to activities such as running, walking, or swimming. Nevertheless, rheumatologists were less likely to counsel heart disease patients about exercise than were other internists. Some subspecialists may be relatively less responsive to indications for counseling involving disorders of organ systems outside the focus of their training/practice. Our results could partly reflect self-selection of training programs. For example, internists who believe it is valuable to counsel about smoking may be more likely to select cardiology than gastroenterology as a subspecialty. It should also be noted that the population for this study consisted of respondents (72 per cent) to an earlier national survey of

Coefficient
13.699 0.356

Standard Error

Trainingb

Intercept Board Certified in Internal Medicine (0-1; 0.87; 0.34) Per Cent of Practice High Income Patients (0-100; 10.3; 9.5) Per Cent of Patients, Primary Care Physician (0-100; 61.9; 36.3) Male (0-1; 0.89; 0.31) White (0-1; 0.90; 0.30) Year of Birth (19 44.2; 5.6)

0.627 0.023

-0.047 0.034
-0.276 0.789

0.007
0.706 0.726 0.060
0.924 0.649 0.622

0.059
1.242 1.650 -1.474

PC-GIMc

Cardiology-Pulmonary-Nephrology
Pheumatology GI-Home

aRegular least-squares linear regression; the dependent variable is giobal measure of the intensity of counseling about smoking; the mean is 18.9 and standard deviation is 4.6. bThe omitted group is traditional general intemal medicine.

NOTE: The sample size is 401, due to mission data.

cPC-GIM = general intemists trained in a primary care track residency.

internists. The differences among groups of internists could also reflect differences in practice case mix. For example, rheumatologists could see relatively fewer patients with severe heart disease. Nevertheless, each group of internists reported that they treat patients who do not have diseases related to smoking and exercise-i.e., patients who are appropriate for primary prevention. Subspecialists could be
AJPH August 1986, Vol. 76, No. 8

1012

HEALTH HABIT COUNSELING OF INTERNISTS

less likely to counsel such patients if they do not see themselves as the primary care physicians. However, we obtained the same differences among groups when we controlled for the internist's level of involvement as a primary care physician. Among subspecialists, hematologists/oncologists thought they were the primary care physician for the highest percentage of patients. Yet they counseled less about health habits than did several other subspecialty groups. These physicians see many terminally ill patients and thus may be less concerned about preventing future illnesses. Our conclusions about the differences among groups of internists in preventive counseling practices are unlikely to be due to methods artifacts such as a tendency to overreport counseling practices, for two reasons. First, a large number of physicians reported low levels of counseling. Second, we found a positive association between the self-report counseling scores and log-diary reports of counseling, supporting the validity of the self-report measure. Our findings help clarify the direction of future research on the relative contribution of specialists and generalists to the provision of primary care. First, we found that subspecialists are so heterogeneous in counseling that they cannot be meaningfully compared on this dimension as a single group to generalists. Second, different groups of specialists have priorities for preventive counseling that reflect the particular needs of their clinical populations. Future studies should target the assessment of counseling to these priorities. Our training and practice variables explained a relatively small proportion of the variation in smoking and exercise counseling. In a previous study, 17 we explained a much larger proportion of the variance by including measures of physicians' attitudes toward counseling and their own personal health practices (e.g., smoking). Differences among groups of internists in such personal characteristics (not measured in the current study) could partly explain differences in their counseling practices; in our previous work, however, clinical training was not strongly correlated with either physicians' attitudes about counseling or their personal health practices. Our results suggest that there is room for improvement for all groups of internists-particularly in counseling oriented to primary prevention. The differences we observed among groups of internists may point to one solution to this

problem: each subspecialty group could be encouraged to take the lead in developing educational programs to improve preventive counseling in their area of interest (e.g., cardiologists and heart disease, rheumatologists and exercise). Our findings for counseling about smoking by generalists trained in primary care programs suggest that special training programs may indeed enhance the level of preventive medicine practiced by internists.
REFERENCES
1. Scheffler RM, Weisfeld N, Ruby G, et al: A manpower policy for primary health care. N Engi J Med 1978; 298:1058-1062. 2. Aiken LH, Lewis CE, Craig J, et al: The contribution of specialists to the delivery of primary care. N Engi J Med 1979; 300:1363-1370. 3. Spiegel JS, Rubenstein LV, Scott B, Brook RH: Who is the primary physician? N Engl J Med 1982; 308:1208-1212. 4. Mendenhall RC, Girard RA, Abrahamson S: A national study of medical and surgical specialties: I. background, purposes, and methodology. JAMA 1978; 240:848-852. 5. Boucot KR, Mausner JS: Smoking among members of the Philadelphia County Medical Society. Philadelphia Med 1964; 60:711-712. 6. Green D, Horn P: Physicians' attitudes toward their involvement in smoking problems of patients. Dis Chest 1968; 54:180-181. 7. Thomas N: Smoking attitudes of New Haven County physicians: a survey. Connecticut Med 1968; 32:902-905. 8. California Medical Association, Bureau of Research and Planning: The smoking study: a report of the attitudes and habits of California physicians with respect to cigarette smoking. California Med 1968; 109:339-344. 9. Coe R, Brehm HP: Preventive Health Care for Adults: A Study of Medical Practices. New Haven: College and University Press, 1972. 10. Coe R, Brehm HP: Smoking habits of physicians and preventive care practices. HSMAA Health Rep 1971; 86:217-221. 11. Bourke GJ, Wilson-Davis K, Thornes RD: Smoking habits of the medical profession in the Republic of Ireland. Am J Public Health 1972: 62:575-580. 12. Noll CE: Health professionals and the problems of smoking and health: report 3-physicians' behavior, beliefs, and attitudes toward smoking and health. Chicago: National Opinion Research Center, University of Chicago, 1969. 13. Wechsler H, Levine S, Idelson RK, Rohman H, Taylor JO: The physician's role in health promotion-a survey of primary care practitioners. N EngI J Med 1983; 308:97-100. 14. Wells KB, Ware JE Jr, Lewis CE: Physicians' practices in counseling patients about health habits. Med Care 1984; 22:240-246. 15. Schleiter MK, Taylor AR: Physician Practice Study Final Report: First Level Analysis. Chicago: University of Chicago, 1982. 16. Tarlov AR, Weil PA, Schleiter MK, Association of Professors of Medicine Task Force on Manpower: National Study of Internal Medicine Manpower: I Residency Training 1976-1977. Ann Intern Med March 1978; 88:413-420. 17. Wells KB, Lewis CE, et al: Do physicians preach what they practice?a study of physicians' health habits and counseling practices. JAMA

1984;252:2846-2848.

AJPH August 1986, Vol. 76, No. 8

1013