Ockene I S, Hebert J R, Ockene J K, Merriam P A, Hurley T G, Saperia G M
Department of Medicine, University of Massachusetts Medical School, Worcester 01655, USA.
Am J Prev Med. 1996 Jul-Aug;12(4):252-8.
We examined the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with a structured office practice environment for nutrition management, on physicians' counseling practices. Forty-five primary care internists and 1,278 of their patients in the top quarter of the cholesterol distribution at a central Massachusetts health maintenance organization (the Fallon Clinic) were enrolled into a randomized controlled trial. Physicians were randomized by site into three conditions: (1) usual care, (2) physician nutrition counseling training, and (3) physician nutrition counseling training plus a structured office practice environment for nutrition management (prompts and the provision of lipid results and counseling algorithms). A randomly selected 325 patients were given a 10-item patient exit interview (PEI) assessing whether the physician provided advice; assessed past changes, barriers, and resources; negotiated specific plans and goals; provided patient materials; referred the patient to a dietitian; and developed plans for follow-up. Condition 3 physicians demonstrated significantly greater implementation of the nutrition counseling sequence than did physicians in either of the other two conditions (P < .0001). Referrals to nutrition services were markedly reduced in condition 2, despite PEI scores no different than those in condition 1. Higher PEI scores for patients seen by physicians in condition 3 were stable for as long as two years beyond training. Primary care internists, when provided with both training in counseling techniques and a supportive office environment, will carry out patient counseling appropriately. Training alone, however, is not sufficient and may be counterproductive. Medical Subject Headings (MeSH): hypercholesterolemia, diet therapy, coronary disease, health behavior, primary health care, medical education, managed care programs.
我们研究了一项针对医生提供营养咨询的培训计划的有效性，该计划单独实施以及与结构化的营养管理办公室实践环境相结合时，对医生咨询实践的影响。在马萨诸塞州中部一家健康维护组织（法伦诊所）中，45名初级保健内科医生及其胆固醇分布处于前四分之一的1278名患者被纳入一项随机对照试验。医生按地点随机分为三种情况：（1）常规护理；（2）医生营养咨询培训；（3）医生营养咨询培训加上结构化的营养管理办公室实践环境（提示以及提供血脂结果和咨询算法）。随机抽取325名患者进行了一项包含10个项目的患者出院访谈（PEI），以评估医生是否提供了建议；评估过去的变化、障碍和资源；协商具体计划和目标；提供患者资料；将患者转介给营养师；以及制定随访计划。与其他两种情况中的医生相比，第3组医生在营养咨询流程的实施方面明显更为出色（P <.0001）。尽管第2组的PEI评分与第1组无异，但转介到营养服务的情况在第2组中显著减少。第3组医生诊治的患者的PEI评分在培训后的长达两年时间里都保持稳定。当提供咨询技术培训和支持性办公室环境时，初级保健内科医生会适当地对患者进行咨询。然而，仅靠培训是不够的，而且可能会适得其反。医学主题词（MeSH）：高胆固醇血症、饮食疗法、冠心病、健康行为、初级卫生保健、医学教育、管理式医疗计划。
