The research team included 6 members representing a broad range of perspectives, including family medicine, health services research, epidemiology, psychology, anthropology, and sociology. We used an iterative analysis and interpretation process that evolved over time as the team became more familiar with the data.19 Two immediate objectives were identified: (1) to develop a classification system that could be used to describe how physicians address smoking cessation, and (2) to identify factors that may enhance or impede the degree of adherence to the clinical smoking cessation guideline.2 First, the team selected 18 encounters for reading and discussion by all research team members. For each of these encounters, one team member read the narrative out loud, and then the team discussed at length their understanding and assessment of what had taken place. Narrative data from the chart audit and physician interviews were considered as the discussion proceeded. During these discussions, preliminary schemes for classifying and assessing the encounters were developed.
The team was then divided into 3 groups of 2, and each group was assigned approximately 10 encounters for reading and for further development of the initial schemes. To ensure that each group member’s evaluation was independent, each member wrote a description and evaluation of each encounter without having read what the other member had written. The classifications and evaluations were then shared with the other member and the entire research team. Multiple team discussions were used to address differences in interpretation and to identify salient patterns within the data.
After discussing the initial 48 encounters, the remaining 43 encounters were analyzed. The same process of intragroup blind review was followed, and at this point, a nearly complete list of patterns and other important features seen within the encounters was established. Analysis and discussion by the entire research team led to agreement on the classification and evaluation of each of the 91 encounters.
To test the possibility that a single observer may introduce observer bias, the research team analyzed 51 additional clinical encounters with 9 family physicians in 5 different practices by a different research nurse. The 3 teams used the same blinded iterative process. These encounters were reviewed, looking for new patterns of smoking cessation counseling or confirmation of the patterns previously identified.
Results
We observed between 2 and 7 encounters of 20 family physicians in 7 practices Table 1. Five clear patterns were discernable according to the level of tobacco counseling and the type of visit. They represent a hierarchy that ranges from optimal smoking cessation counseling during visits when it was appropriate, to visits during which other agendas were appropriately given higher priority, to deficient missed opportunities. No additional patterns of interaction of smoking cessation counseling were identified among the 51 additional encounters audited.
In nearly half of the visits physicians either followed recommendations (21%), or competing priorities within the encounter reasonably overrode tobacco counseling (24%). In the other encounters tobacco cessation counseling fell short of recommendations, including visits among patients being seen for acute respiratory illnesses or other smoking-related illnesses. This failure often occurred despite the presence of a reminder system that identified the patient as a smoker. In 9% (8 cases) the physicians explicitly told the observing research nurse that they would not address tobacco with a specific patient because of a preconception that the patient would not respond.
Patterns of Tobacco Counseling
Good counseling
Good quality cessation counseling occurred in 21% of the encounters, during which physicians offered appropriate brief interventions depending on patients’ willingness to quit at that visit. Three levels of intervention were discernible within this first pattern. The 5A’s occurred when patients requested help, emphatically said “yes” when asked if they were interested in quitting, or when they responded positively to the physician’s description of pharmacologic options to help quit smoking. Patients were offered only 3A’s if they indicated they were not ready to quit by explicitly saying so or by staying quiet after an inquiry about their willingness to quit. Eleven physicians (55%) had at least 1 encounter with a smoker in which the physicians demonstrated good quality smoking cessation intervention, indicating that they had the knowledge and skill to provide recommended smoking cessation strategies.
Competing demands
Another common pattern was when a smoking cessation agenda was appropriately overridden by higher priorities. This occurred in 24% of the encounters. These were visits during which the physician-patient interaction was less straightforward than simply history taking, diagnosis, and treatment. In 10 encounters the top priority was alleviation of acute pain. Examples included abdominal pain, chest pain, back pain related to pyelonephritis, and severe rib pain after trauma. During 6 encounters patients were experiencing psychological distress, including anxiety attack, anger, a hypomanic breakdown, and depression. In some encounters it became clear that higher-priority competing demands took precedence as a result of a patient-driven agenda (eg, a discussion about care from multiple consultants or a lengthy discussion about multiple medications) or a physician-driven agenda (eg, a first visit for a patient with a complex medical problem squeezed into an acute visit time slot). In reviewing these encounters, the research team agreed that the competing priorities were appropriately important to reasonably not expect discussion of tobacco cessation.