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Preventive actions

Bruce Taylor Seeman Newhouse News Service

Getting screened for cancer is smart. Being tested for diabetes is good, too. Over the long haul, a prudent patient might get checked for early signs of glaucoma and dementia.

Yes, prevention makes sense. But who has the time?

The answer is, not many of us. Our primary care doctors — whom the American Medical Association says spend an average 21 minutes with each patient per visit — have scant opportunities to discuss tactics for avoiding disease.

“Usually, you’re thinking about it on the way home in the car: ‘I should have talked to her about this,’ ” said Dr. Kimberly Yarnall, a Durham, N.C., family medicine specialist. “You’re so behind, and not because you want to be. I hate it.”

This is a big problem in medicine, and the consequences are becoming clearer as more is understood about the high costs of treatment versus sidestepping disease or catching it early.

“About 50 percent of mortality in U.S. adults is linked to a risky behavior,” said Janet Allan, dean of the University of Maryland School of Nursing. “It tells us we need to help people change risky behaviors. Smoking accounts for 400,000 deaths a year. Now, obesity is almost another 400,000. Add risky drinking, risky sexual behavior, and you’re almost up to a million.”

Allan is vice chair of the federal government’s U.S. Preventive Services Task Force, a panel of medical experts that maintains an online directory advising doctors when to recommend preventive screenings, counseling and vaccines for 77 illnesses or other health matters.

The list is growing as science evolves. Several new guidelines were issued this year, including when to screen for oral and testicular cancers, how to prevent low back pain and when to check for alcohol misuse. In April, the guide was made available for doctors’ hand-held computers.

The task force also has issued general prevention guidelines to patients, explaining which tests are most important for men and women and at what ages.

“Have a mammogram every one to two years starting at age 40,” is one recommendation for women. (See www.ahrq.gov/ppip/healthymen.htm or www.ahrq.gov/ppip/healthywom.htm or call 800-358-9295.)

Meanwhile, the Robert Wood Johnson Foundation, a health-oriented philanthropic group, is devoting $9 million in grants to doctors testing ways to help patients avoid sickness by changing day-to-day behavior. The 17 projects currently funded nationwide try to influence patients through counseling from nurses, Internet education and referrals to local groups that specialize in behavior change.

One grant recipient, Dr. Steven Woolf of Fairfax, Va., helped create a Web site ( www.myhealthyliving.net) that encourages patients in four collaborating offices to stop smoking, eat healthy food, get exercise and limit drinking.

In the past, when someone wanted to stop smoking, nurses would pull a pamphlet from a file cabinet and send the patient home with a wish of good luck, Woolf says. Now patients are referred to the Web site, which provides a test to measure addiction, creates a “craving journal” and suggests contacts to local smoking-cessation clinics.

The system offers help when time is short.

“I can get the discussion started, but a lot more is needed than that,” Woolf said. “The solution is getting the patient connected with resources in the community. A few years from now, you’ll look back and say, `What’s the big deal? Everyone is doing this.’ “

LeAnn Reilly, a medical assistant in one of the collaborating offices, said she’s decided to follow one of the Web site tips for those who want to give up smoking: Pick a quitting date in advance.

“Whatever the Tuesday is after the Fourth of July weekend, that’s what I’m going to do,” Reilly said.

A study released last month by the Rand Corp., a nonprofit think tank, suggests the preventive measures used most often are the easiest, such as blood pressure screenings. Less likely are complicated subjects, such as strategies to avoid sexually transmitted diseases or substance abuse.

“Quite frankly, blood pressures are taken by nurses when you come in the door,” said Elizabeth McGlynn, the study’s principal author. Many other matters, she said, “take time for a patient or a doctor to talk.”

Some issues may be passed over because doctors are uncertain how to proceed.

“For blood pressure, there are medications to prescribe,” McGlynn said. “When it comes to things that require health education and counseling, those are areas where doctors have less training, and they may feel less comfortable.”

Last year, a Duke University study published in the American Journal of Public Health suggested that doctors had little hope of providing patients with the recommended array of preventive screening and tests. If they did, the study concluded, it would gobble up more than seven hours of their day.

Yarnall, the study’s lead author, said one way to ease the problem would be to shift some preventive duties to nurses and others who are qualified.

At minimum, she said, patients would be wise to arrive at appointments with firm ideas about how they wish to improve their health.

“If they come in and say, `I’m really serious about exercise,’ or, `I’m really serious about colon cancer,”’ Yarnall said, “that opens the door for a discussion, and we can make a wise decision” about prevention strategies.

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