EFFECT OF TRAINING AND A STRUCTURED OFFICE PRACTICE ON PHYSICIAN DELIVERED NUTRITION COUNSELING - THE WORCESTER-AREA TRIAL FOR COUNSELING IN HYPERLIPIDEMIA (WATCH)

We examined the effectiveness of a training program for physician-deli vered 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 Fallen Cli nic) were enrolled into a randomized controlled trial. Physicians were randomized by site into three conditions: (1) usual care, (2) physici an nutrition counseling training, and (3) physician nutrition counseli ng training plus a structured office practice environment for nutritio n management (prompts and the provision of lipid results and counselin g algorithms). A randomly selected 325 patients were given a 10-item p atient exit interview (PEI) assessing whether the physician provided a dvice; assessed past changes, barriers, and resources; negotiated spec ific plans and goals; provided patient materials; referred the patient to a dietitian; and developed plans for follow-up. Condition 3 physic ians demonstrated significantly greater implementation of the nutritio n counseling sequence than did physicians in either of the other two c onditions (P < .0001). Referrals to nutrition services were markedly r educed in condition 2, despite PEI scores no different than those in c ondition 1. Higher PEI scores for patients seen by physicians in condi tion 3 were stable for as long as two years beyond training. Primary c are internists, when provided with both training in counseling techniq ues and a supportive office environment, will carry out patient counse ling appropriately. Training alone, however, is not sufficient and may be counterproductive.