BACKGROUND: Although primary care physicians understand the importance of preventive services for patients with multiple risk factors (MRF) for coronary heart disease, physician intervention is limited. This study investigated (1) physicians' views of challenges faced in managing patients with MRF; (2) the counseling and management methods they utilize; and (3) possible strategies to enhance MRF intervention in the primary care setting. METHODS: Two focus groups were conducted with primary care physicians from varying settings to gain insight into these issues noted above. Each group was co-facilitated by a physician and a behavioral scientist using a previously developed semistructured interview guide. The group discussions were tape recorded and subsequently transcribed. Transcripts were analyzed using the constant comparative method for analysis. RESULTS: Physicians are challenged by knowledge limitations (contribution of individual risk factors to overall risk); limited support (guidelines, materials, and staff); and logistic difficulties (organizational issues, time limitations). Their approach to MRF management tends to be highly individualized with an initial preference for lifestyle change interventions rather than prescription of medications with some qualifying circumstances. Physicians favored a serial rather than a parallel approach to MRF intervention, starting with behaviors that the patient perceives as a priority. Proposed solutions to current challenges emphasize physician education and the development of innovative approaches that include physician assistance and a team approach. CONCLUSIONS: Physicians are aware of and sensitive to the complexity of MRF management for their patients and themselves. However, future MRF interventions will require nonphysician staff involvement and increased systems support.

This article describes the results of a three-hour training program that teaches residents a patient-centered counseling approach to smoking cessation, emphasizing questioning and exploring feelings, rather than providing information. Fifty internal medicine and family practice residents affiliated with a university medical center were assessed before and after training using questionnaires and videotape documenting changes in their knowledge about smoking, attitudes concerning intervention, and intervention skills. The residents showed a significant increase in knowledge and perceived themselves as having significantly more influence on their patients who smoke after completion of the training program. Counseling skills improved significantly in the use of questions and exploring feelings as judged by blind evaluation of videotapes. The results of this three-hour training program suggest that physicians in training are responsive to the teaching of specialized skills deemed important for promoting health behavior changes in their patients.

Individuals do not benefit equally from attempts to change their lifestyles in an effort to lower their risk for disease or to improve their quality of life. A change in one lifestyle behavior may cause an increase in another risk factor and reduce the benefits of the anticipated change. The social environment exerts pressures and makes available resources that also influence the benefits and costs of a particular health behavior change. These pressures and resources vary depending on the individual and his or her social context. This article uses the target behavior of smoking as an example of a lifestyle change and considers the benefits and costs that interventionists need to be aware of if they are to effectively facilitate health behavior change. This approach requires the identification of resources at different levels of the environment (e.g., family, community, institutions) that may influence the cost/benefit ratio. Such an analysis is appropriate whether one is considering a model of individual behavior change or a public health model that seeks to intervene at the community-wide level to promote health and reduce disease risk among a large segment of the population. Specific recommendations based on this approach are offered and it is concluded that both individual and public health approaches are necessary to achieve optimal health behavior change in our population and to optimize the cost/benefit ratio of such change for all individuals.