Gaps Exposed Between Primary Care Physicians and Patients

Survey finds overemphasis on physical health and treatment compared to underlying components of health such as diet and environmental factors.

There is a gap between what primary care physicians (PCPs) discuss with their patients and several core elements of health, a recent survey found.

The survey, which was conducted by The Harris Poll on behalf of Samueli Integrative Health Programs, features responses from more than 2,000 adults. The data shows a disconnect between what PCPs are discussing with their patients and many underlying determinants of health.

The survey found 74% of conversations between PCPs and their patients were focused on physical health, but discussions of other key health factors were far less frequent:

• Diet: 44%
   
• Sleep: 40%
   
• Mental health: 36%
   
• Importance of being healthy: 20%
   
• Environment such as domicile: 13%
   
• Spiritual health: 10%
   
• Non-medication approaches to health such as massage: 10%

Wayne Jonas, MD, executive director of Samueli Integrative Health Programs at H&S Ventures in Alexandria, Virginia, and a practicing family physician, presented the survey data during an online press conference this week. He said PCPs are not discussing enough of the underlying factors and social determinants that account for about 80% of health, including education, employment, income, family and social support, and community safety.

"Unfortunately, fewer than half were discussing core determinants of health that we know are in the 80% of what produces good health. For example, diet and sleep habits were discussed by only 44% and 40%, respectively, during office visits. Even fewer—only 20%—talked about why it was important to be healthy; in other words, what aligns in your life goals and your health goals," he said.

The survey's finding on PCP discussions with patients about behavioral health were striking, said Jonas, former director at the Office of Alternative Medicine for the National Institutes of Health.

"Mostly alarmingly, even though a large portion of the population suffers from mental health conditions such as depression and anxiety, only about a third of the conversations with doctors engaged in these psychological conditions."

The survey also showed PCPs were out of sync with the topics that many patients want to discuss, Jonas said.

"We found that for many of these areas, people did want to have these conversations with their doctor. About 45% said they wished they talked about their life goals—what matters to them and how it aligns with their health goals. Surprisingly, even more younger adults—those 18 to 24—indicated they wanted to talk about the behavioral determinants of health with their doctors more than they did."

Promoting broader discussions
 

Jonas acknowledged that the volume-driven, fee-for-service payment model prevalent in PCP offices is ill-suited for broader discussions about health with patients.

"This is a major problem and one that I hear all the time. I struggle with it myself in my own practice—finding enough time to address what matters to the patient about chronic conditions and management of chronic conditions. … What we really need to do is restructure how we do primary care—especially for chronic diseases—to allow more time for conversations."

Jonas said he has found ways to spend more time with his patients, with transformative impact.

"A lot of chronic pain patients are referred to me. They have had many visits and they have spent 20 minutes getting pills and procedures several times. No one has sat down with them and asked how they can be empowered to improve their own pain and lives, and how they can set up a team to manage their care themselves. If we do that, oftentimes we can break the cycle of dependency on continued medical care that occurs in the 20-minute visit."

Broadening discussions about health with patients is a crucial part of shifting to value-based care, Jonas told HealthLeaders before the press conference.

"Physicians need to make time to address what is of value to patients. It's a shift in our thinking. This could be as simple as integrating a few questions into a routine office visit to evaluate those aspects of a patient's life that facilitate or detract from healing. Doing this can help our healthcare system transition to a value-based care model and directly impact goals like the Triple Aim."

Medical education
 

Jonas also told HealthLeaders that changes are required in medical education to improve the quality of primary care.

"Medical education is lacking in key areas that are fundamental to a patient's health. … The key areas that need to be added to most office visits are behavioral and lifestyle, social and emotional, and mental and spiritual. Medical training sharply limits the ability of physicians to make healing their primary mission, and the current model of care does not allow for much time to capture the personal, social, behavioral, and environmental factors that contribute to most chronic diseases."

Nutrition and prevention should be enhanced in medical education curriculums across the country, he said.

"Medical students receive minimal education on nutrition, yet we know that diet influences a great deal of a person's health and risk for developing disease. Our medical training needs to expand outside of the realm of diagnosis and treatment and focus on prevention as well."