Despite declines in tobacco use over the past 50 years, smoking continues to be a significant public health issue worldwide. Smoking cigarettes remains the leading cause of preventable disease and death in the United States today and causes approximately 443,000 premature deaths in the United States annually (Fiore MC, 2008). Furthermore, smoking is associated with high costs reported as $193 billion in direct healthcare expenditures and productivity (Fiore MC, 2008). Despite the decline in the prevalence of smoking, 20% of adults in the United States still smoke and therefore are in need of smoking cessation counselling (‘Vital signs: current cigarette smoking among adults aged >/ = 18 years–United States, 2005–2010’, 2011). The provider-patient encounter provides an opportunity for smoking cessation counselling to occur. Seventy to eighty per cent of people who smoke visit a healthcare provider at least once a year, thus, providing ample opportunity for smoking cessation counselling to occur. Providing education and counselling to patients who smoke is important to actively engage them in the health decision process and to support their ability to make healthy choices. The US Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence recommends that all healthcare providers offer brief, smoking cessation education and counselling to their patients who smoke (Fiore MC, 2008). In one survey, 68% of patients were screened for tobacco use, however, only 20% of those who smoked report receiving counselling (Thorndike, Regan, & Rigotti, Reference Thorndike, Regan and Rigotti2007). Moreover, less than 10% were offered medication. These scenarios represent missed opportunities for smoking cessation counselling to occur in the provider-patient encounter (Blumenthal, Reference Blumenthal2007; Cummings et al., Reference Cummings, Stein, Hansen, Richard, Gerbert and Coates1989; Milch, Edmunson, Beshansky, Griffith, & Selker, Reference Milch, Edmunson, Beshansky, Griffith and Selker2004; Schnoll, Rukstalis, Wileyto, & Shields, Reference Schnoll, Rukstalis, Wileyto and Shields2006). A documented barrier among practicing licensed physicians to providing smoking cessation counselling to their patients is a lack of adequate training and skills in smoking cessation counselling (Cummings et al., Reference Cummings, Stein, Hansen, Richard, Gerbert and Coates1989; Milch et al., Reference Milch, Edmunson, Beshansky, Griffith and Selker2004; Schnoll et al., Reference Schnoll, Rukstalis, Wileyto and Shields2006). A survey conducted by the Association of American Medical Colleges found that of the approximately 3,000 physicians who responded, 44% reported they were not confident in their ability to motivate smokers to quit; 34% lacked confidence in their ability to make recommendations and 33% lacked confidence in their ability to monitor patient progress (Physician behavior and practice patterns related to smoking cessation: A summary report, 2007). These findings point to barriers among licensed physicians but little is known about the barriers faced by physicians in training.
Physicians in training require special focus because they are a critical component of the healthcare workforce. Resident physicians are more likely to care for younger, non-white, urban, and Medicaid-insured patients and these characteristics mirror those of patients who are more likely to smoke (Zallman, Ma, Xiao, & Lasser, Reference Zallman, Ma, Xiao and Lasser2010). The prevalence of smoking remains highest among persons living below the poverty line, those with less education, and those with less access to care or who are receiving Medicaid benefits (‘Vital signs: current cigarette smoking among adults aged >/ = 18 years–United States, 2005–2010’, 2011). These are the most vulnerable populations in our communities who are at greatest risk of poor health outcomes.
A large body of evidence points to the importance and effectiveness of training of medical residents in the treatment of tobacco use and dependence (Cornuz et al., Reference Cornuz, Humair, Seematter, Stoianov, van Melle and Stalder2002; Cornuz et al., Reference Cornuz, Zellweger, Mounoud, Decrey, Pecoud and Burnand1997; Hymowitz, Schwab, Keith Haddock, Pyle, & Meshberg, Reference Hymowitz, Schwab, Keith Haddock, Pyle and Meshberg2005; Montner, Bennett, & Brown, Reference Montner, Bennett and Brown1994; Scal, Hennrikus, Ehrlich, Ireland, & Borowsky, Reference Scal, Hennrikus, Ehrlich, Ireland and Borowsky2004; Strecher et al., Reference Strecher, O'Malley, Villagra, Campbell, Gonzalez and Irons1991; von Garnier, Meyer, Leuppi, Battegay, & Zeller, Reference von Garnier, Meyer, Leuppi, Battegay and Zeller2010). However, there are no published studies to date that specifically examine barriers to tobacco treatment and counselling from the residents’ perspective. Understanding the barriers that residents encounter in providing smoking cessation counselling to their patients is important for developing targeted educational interventions early on during their training. This study applied qualitative research methods to explore factors that internal medicine residents perceived as barriers or facilitators to providing smoking cessation counselling to their patients. This paper views patient education and counselling by the physician as a type of behavior in which physicians must engage in order to enable their patients to practice healthy behaviours.
Methods
This study used a qualitative focus group design. A purposive sample of internal medicine residents was invited via internal email to attend focus groups during one of their primary care block rotations. The groups included residents across all years of training in order to provide a broad perspective of responses. The focus groups were conducted at Weill Cornell Internal Medicine Associates, the adult primary care practice at New York Presbyterian-Weill Cornell Medical Center. The study was approved by the Institutional Review Board of Weill Cornell Medical College. Oral consent was obtained from all participants. A Nurse Practitioner (NP) and certified tobacco treatment specialist (CTTS) who has over 15 years’ experience in smoking cessation counselling and treatment moderated the focus groups. The focus group study was introduced to improve the current smoking cessation curriculum that residents receive. The residents were asked to describe barriers they encounter to providing smoking cessation counselling to their patients, factors that influence their ability to provide smoking cessation counselling, and recommendations that might improve this process.
Data analysis occurred in four steps: data immersion, creation of codes, categorization and identification of themes (Green et al., Reference Green, Willis, Hughes, Small, Welch and Gibbs2007). In the data immersion step, the CTTS audio taped and transcribed all focus groups verbatim and read each transcript line-by-line. The second step was assigning codes to the data. Codes are descriptive labels or tags that represent key concepts that are being conveyed in the data. The CTTS grouped the codes to form general categories and further analyed them to generate themes or interpretation of the data. A second independent reviewer repeated all steps to ensure trustworthiness of data, reviewed the detailed notes of all interviews and the coding process and reanalysed the interviews to determine ‘fit’ into the categories. When there were discordant views regarding the interpretation of findings, raw data was reviewed and placed in new categories until a consensus was reached.
Results
Thirty medical residents in their first through third year of residency participated. The mean age was 28.5 years. The racial distribution of the participants was 10% African American; 40% Indian/Asian American and 50% Caucasian. Two of the residents were former smokers. Four separate focus groups were held at lunchtime four weeks apart with approximately eight different participants in each group. Seven themes emerged as barriers to residents’ providing smoking cessation counselling to their patients: (1) Residents’ perception of their self-efficacy to provide counselling; (2) residents’ perception of their patients’ willingness to stop smoking; (3) residents’ perception of a lack of access to readily available resources; (4) perceived differences in attending physician's recommendations for prescribing medications; (5) a perceived lack of time; (6) a perception of lack of continuous care; and (7) a perception of lack of practical skills in providing counselling.
A lack of self-efficacy or confidence in their ability to provide counselling emerged as a dominant theme. In general, this group of residents perceived that they did not have adequate counselling skills or that they had low comfort level in their ability to provide counselling. Examples of comments supporting these themes included ‘I have no confidence in my counseling skills’. Another resident stated ‘I'm not very good at motivational interviewing’. Another response was ‘Every conversation is different but it would probably be nice if I had more of a game plan’. Another barrier was lack of communication skills and helping patients to set realistic expectations. ‘I find it difficult laying out reasonable expectations’.
The other thematic area of barriers was attributed to patients, such as their readiness to change, the way in which they prioritised smoking, and patients’ fear of withdrawal symptoms. Although these factors were referent to the patient, they were cited as influencing behaviours and attitudes toward providing smoking cessation counselling. Some residents perceived their patients as not being ready to change their behaviour which hampered their own desire to provide counselling. A resident quoted his patient as saying ‘My husband smokes at home and I am not quitting until he quits’. Another resident cited a patient as saying ‘Smoking is the one joy I have in life, why are you trying to take that away’. These sentiments about smoking expressed by their patients led them to believe that their patients were not ready to quit.
Some residents viewed smoking more of a voluntary behaviour. One resident said ‘with smoking. . . that is something they choose to do and you are likely to meet resistance’. Many residents described patient's fear of consequences stemming from smoking cessation as a barrier to providing them with counselling. ‘They (patients) are concerned about withdrawal symptoms’. Cost of nicotine replacement therapy was also raised as a perceived patient barrier. ‘Patients are unwilling to purchase nicotine replacement, but are spending over $12 daily for a pack of cigarettes’. These responses highlight patient-related factors that were cited by residents as factors that hindered their ability to counsel their patients to quit smoking.
Residents perceived a lack of readily available resources such as pamphlets or visual aids with information for both providers and patients as a barrier. Several residents made suggestions for the type of smoking cessation material that should be available. ‘We should have brochures and stuff in the rooms’. Residents felt there were no resources for providers or for patients, or at least they were unaware of any resources that are fairly accessible. ‘I needed to know the options of what is out there. . . like a little cheat sheet’. Other residents wanted more evidence based guidelines. ‘The treatment modalities, the pros and cons from a provider standpoint. . . if those were available in each room so I could just go right to the different options and show them in a . . . visual manner what the choices are that would kind of make the conversation easier to have from a provider standpoint’.
Depending on where they are in their training, some residents are not yet licensed and therefore unable to prescribe medications. ‘Since many of us can't prescribe yet and have to rely on the attending (supervising physician) for prescriptions . . . it's like a barrier’. Another resident stated ‘I think that most of the attendings are comfortable prescribing patches and gum but when it comes to the meds, there are different criteria. Sometimes it's hard if they don't agree’. One resident described the discrepancy between what the patients wanted and what was recommended as a barrier to providing counselling and treatment. An example was demonstrated by this ‘whenever a patient comes in and says I'm smoking and I want to quit, they always say I want Chantix or Wellbutrin. I've actually run into a lot of resistance from the supervising attending prescribing those medications’. These responses illustrated the sentiment that some residents perceived a lack of support for prescribing medications by their supervising physician.
An overwhelming majority of residents cited time constraints as a barrier. High patient volumes coupled with the medical complexity of patients were considered a major time limiting factor. Some of the comments included, ‘Don't really have time to discuss all these different interventions: Zyban, the patch and gum and . . . so on’. Residents found it challenging to provide both smoking cessation counselling as well as address other medical co morbid conditions in the allotted time frame. ‘They come in with lots of co morbidities’ and ‘If you have an hour to sit there with them and they have no other medical issues . . . then maybe’.
Traditionally, residents rotate in short intervals throughout the year. This was perceived as being ‘discontinuous care’, thereby introducing another barrier to counselling. For example, one resident stated ‘We don't see patients frequently enough’; ‘We don't have available dates at appropriate junctures’. The sense that they are unable to follow up their patients was also stated ‘It's hard. . . my own ability to follow-up . . . or maybe they see someone else when they come in’. ‘They're just kind of out there and I don't really know what's going on’. Residents also felt that they did not have adequate skills set in providing counselling. For example a resident stated ‘Like smoking and a lot of other things we have talks about, you know you talk about it but when it comes to the practical application, you don't get to do it’. This was summarised by a resident as ‘I don't know, sometimes I don't know what to talk to them about? What does counselling for smoking cessation consist of; we all know smoking is bad but what does counselling consist of, like what do you say that you would walk away from a patient and say that was a good counseling session?’
Discussion
This study identified barriers to the provision of smoking cessation counselling from the perspective of physicians in training. While some of the themes identified were similar to what has been identified among fully-licensed physicians, this study highlighted barriers that were unique to physicians in training. As stated earlier, many lacked confidence in their ability to counsel patients. The reason for this lack of self-efficacy in their ability was a lack of practical skills in counselling. This is not uncommon among physicians in training. While all providers are aware of the health risks of tobacco use, physicians in training admit they do not feel prepared to help patients stop smoking. In a study of physician barriers to providing smoking cessation services, providers felt ill prepared in pharmacotherapy, counselling and information on culturally specific cessation training (Blumenthal, Reference Blumenthal2007). Powers et al. found that almost two thirds of students in 12 medical schools reported no teaching about tobacco cessation and cultural competency and one third reported no experience with tobacco cessation counselling persons of various races and ethnicities (Powers et al., Reference Powers, Zapka, Biello, O'Donnell, Prout and Geller2010).
Attainment of competence in communication and interpersonal skills is a requirement for accreditation of residency programmes and certification by the American Board of Internal Medicine (ABIM) (Duffy et al., Reference Duffy, Gordon, Whelan, Cole-Kelly, Frankel and Buffone2004). Additionally, the US Preventive Health Service Task Force (USPSTF) strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products (USPSTF, 2009). Screening, Brief Intervention and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to early intervention and treatment services through universal screening for persons with substance use disorders and those at risk (Babor et al., Reference Babor, McRee, Kassebaum, Grimaldi, Ahmed and Bray2007; Madras et al., Reference Madras, Compton, Avula, Stegbauer, Stein and Clark2009). The addition of SBIRT training to residency programme has been shown to greatly improve counselling skills and confidence in these skills (Tetrault et al., Reference Tetrault, Green, Martino, Thung, Degutis and Ryan2011). It has also been demonstrated that knowledge and confidence in working with patients for promoting smoking cessation as well as other behavioural change can be improved by brief (1-2 hour) training sessions, including brief web-based intervention (Pederson, Blumenthal, Dever, & McGrady, Reference Pederson, Blumenthal, Dever and McGrady2006; Roman, Borges, & Morrison, Reference Roman, Borges and Morrison2011).
Implementation of US Public Health Service guidelines for smoking cessation also is less than optimal. An important aspect of residency training would be to provide instruction on incorporating the 5 As: Ask, Advise, Assess, Assist and Arrange in the allotted time. Residents for the most part seemed unaware of this approach: ‘I know about the stages of change: precontemplative, etc. but I don't know what the 5 As are’. This can be achieved through role play where residents are presented with standardised patients or their own patients. This group indicated a preference for using real patients. As one resident said ‘there are enough patients of our own that smoke that you don't really need to set up fake patients’.
While many residents admitted they were not familiar with the evidence based approved pharmacotherapy, most felt the supervising physicians were familiar with these therapies. The supervising physician often serves as a reminder to the resident. For example one resident said ‘To be honest my attending(supervisors) are the ones that usually bring it up, my attendings are pretty good about it’. Supervising attendings can set the stage for provision of smoking cessation counselling by establishing it as the norm in provider-patient encounters in which a patient is identified as a current smoker. The supervising physicians can also provide recommendations regarding the appropriate pharmacotherapy for smoking cessation.
The residents perceived there was a lack of readily available resources such as pamphlets or visual aids with information for both providers and patients. Following the focus group project, a group of residents created their own patient education handout as well as a provider resource that are available on the internal medicine residency website and can be downloaded as needed. The focus group project also increased awareness of the CTTS and counselling services available within the practice.
A unique barrier to this group was the perception of lack of continuity in care. Due to constraints placed on them by their training programme, the residents are often not in clinic for several weeks and are unable to follow-up on their own patients. Patients are then seen by other providers or are lost to follow-up altogether. In the outpatient setting patients often present with acute illness so counselling or providing health education is not appropriate or possible. Scheduling of clinic sessions and inpatient responsibilities often preclude adequate follow-up of outpatients. This may pose an additional challenge to following up the impact of any counselling effort. As with other providers, time is a factor for medical residents; in addition to the 20 minutes allotted for the actual office visit, the residents must then present their patients to the supervising physician, which often adds an additional 20 and 30 minutes to the visit.
This study has some limitations. The participants were a small group (N = 30) of non randomly selected subjects from one training programme, so their responses may not be representative of medical residents training elsewhere. However, it is important to recognise that the purpose of a focus group study is not necessarily to find information that can be generalised. The hallmark of focus groups is in the use of group interaction to produce data and insights that might not be accessible without the interaction of a group (Morgan, Reference Morgan1997). It allows the researcher to examine responses in depth and perhaps generate new information. These results are similar to findings in multiple other studies of healthcare providers and the provision of smoking cessation services.
Conclusion
This study confirms that medical residents face similar barriers to other providers in the provision of smoking cessation services, but face additional barriers that are specific to their training. Barriers to smoking cessation counselling and treatment identified by these residents include several modifiable factors such as lack of self-efficacy and skills in counselling which can be addressed through training. Resident education should include patient centered approaches such as shared-decision making to engage patients in the decision-making process. Training programmes should also be restructured to allow for improved continuity in care. Not withstanding these limitations, the implications of these findings are important since residents are likely to see patients who fit the demographic of smokers. In order to provide improved rates of smoking cessation counselling and eventually decrease the prevalence of smoking in the population, barriers to physician-based counseling must be addressed early on in their training. These findings can inform the development of targeted educational material that can help residents better communicate tenets of smoking cessation counselling thus increasing the number of smokers who receive counselling.
All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline.
Acknowledgements
We wish to thank Judy Tung, MD, Medical Director of Weill Cornell Internal Medicine Associates for her support of this project.
Funding/Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of Interest
None.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
