Primary prevention in general practice - views of German general practitioners: a mixed-methods study.

BACKGROUND: Policy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners' (GPs) attitudes toward primary prevention. METHODS: Mixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention. RESULTS: Most respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs' health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of "health policing". GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions. CONCLUSIONS: The mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.

Evaluating the use of prostate-specific antigen as an instrument for early detection of prostate cancer beyond urologists: results of a representative cross-sectional questionnaire study of general practitioners and internal specialists.

OBJECTIVES: The aim of this cross-sectional study was to evaluate the value of prostate-specific antigen (PSA) testing as a tool for early detection of prostate cancer (PCa) applied by general practitioners (GPs) and internal specialists (ISs) as well as to assess criteria leading to the application of PSA-based early PCa detection. METHODS: Between May and December 2012, a questionnaire containing 16 items was sent to 600 GPs and ISs in the federal state Brandenburg and in Berlin (Germany). The independent influence of several criteria on the decision of GPs and ISs to apply PSA-based early PCa detection was assessed by multivariate logistic regression analysis (MLRA). RESULTS: 392 evaluable questionnaires were collected (return rate 65%). 81% of the physicians declared that they apply PSA testing for early PCa detection; of these, 58 and 15% would screen patients until the age of 80 and 90 years, respectively. In case of a pathological PSA level, 77% would immediately refer the patient to a urologist, while 13% would re-assess elevated PSA levels after 3-12 months. Based on MLRA, the following criteria were independently associated with a positive attitude towards PSA-based early PCa detection: specialisation (application of early detection more frequent for GPs and hospital-based ISs) (OR 3.12; p < 0.001), physicians who use exclusively GP or IS education (OR 3.95; p = 0.002), and physicians who recommend yearly PSA assessment after the age of 50 (OR 6.85; p < 0.001). CONCLUSIONS: GPs and ISs frequently apply PSA-based early PCa detection. In doing so, 13% would initiate specific referral to a urologist in case of pathological PSA values too late. Improvement of this situation could possibly result from specific educational activities for non-urological physicians active in fields of urological core capabilities, which should be guided by joint boards of the national associations of urology and general medicine.

German GPs' willingness to expand roles of physician assistants: a regional survey of perceptions and informal practices influencing uptake of health reforms in primary health care.

BACKGROUND: Many countries with shortages in health personnel are introducing task shifting in primary health care. GPs' attitudes and practices strongly affect task shifting and the expansion of the roles of physician assistants (PAs). OBJECTIVE: To assess, in a German state with shortages of health personnel, the overall willingness of GPs to delegate home visit tasks to PAs and to elicit their perceptions of barriers to and benefits of such delegation and the current practice of informal delegation. METHODS: Postal self-administered anonymous survey of all practicing GPs in the rural state of Mecklenburg-Vorpommern. Main outcomes were GPs' willingness to delegate in home visit tasks to a properly trained PA, perceived barriers to and benefits of home visit delegation and current practice of informal delegation. Using multinomial logistic regression, associations were identified among outcome variables, and characteristics of the GPs and of their practices. RESULTS: Response rate was 47%. Responders (500) were comparable to all GPs in the state (1096); 48% of practitioners are willing to delegate home visits tasks to PAs. The main barrier to delegation was the related costs of PAs' training (34%), and the main benefit that it 'saves the GP's time' (67%). The 46% of practitioners who are informally delegating home visit tasks were significantly more likely be younger [odds ratio (OR) and 95% confidence interval (CI)] [OR = 0.96 (0.93-0.99)] and female [OR = 1.70 (1.12-2.58)]. CONCLUSION: The increasing proportion of women in family medicine might favor task shifting in General Practice.

A qualitative study on patients' and physicians' visions for the future management of overweight or obesity.

BACKGROUND: The management of obesity with its associated morbidity and mortality is a growing problem in primary care practices. Despite numerous recommendations in response to this challenge, weight management interventions still yield poor results. This is partly due to a discrepancy between physicians' and patients' understanding of the problem and possible solutions. OBJECTIVE: This study analyses patients' and physicians' visions for the future management of obesity. METHODS: Qualitative in-depth semi-structured interviews were performed. Physicians and patients were asked about their individual needs, experience and views regarding the management of obesity. Fifteen GPs and 15 overweight patients participated in this study. Interviews were transcribed and submitted to qualitative content analysis. RESULTS: The investigation reveals a high level of agreement between the two groups with regard to communication requirements for successful care. Both groups stressed the need for multimodal care concepts inside and outside of GP practices. Both also addressed the current overburdening of outpatient care structures in dealing with the management of obesity. CONCLUSION: Options should be developed for closer cooperation between GPs and support facilities inside and outside practices.

Locus of control, self-efficacy and attribution tendencies in obese patients - implications for primary care consultations.

BACKGROUND: To examine health- related locus of control, self- efficacy and attribution tendencies in obese patients and to discuss their impact on primary care consultations. MATERIAL/METHODS: 123 patients, showing a BMI >25 kg/m(2) and following a health Check up, rated questionnaires regarding health-related locus of control, self-efficacy and attribution tendencies concerning obesity. Physical health parameters like BMI, level of cholesterol, blood pressure and existing cardiovascular co morbidities were assessed by GPs. Statistical analysis were conducted using SPSSv16.0. RESULTS: Patients scored comparable to a norm- population on self- efficacy and the three dimensions of health related locus of control. Physical health parameters did not explain variance. Patients named mainly behavioral causes for their overweight; those with a BMI >30 kg/m(2) tend to attribute their bodyweight to genetically origins. CONCLUSIONS: In order to conduct individual tailored consultancies it is necessary to explore the individual beliefs and attitudes of patients of concern. It is suggested that locus of control and self- efficacy are obligatory issues to discuss in preventive encounters with these patients. GPs should be trained in techniques like motivational interviewing in order to encourage patients to take responsibility for their health and thus increase treatment outcome.

Perception of stress and quality of life in overweight and obese people--implications for preventive consultancies in primary care.

BACKGROUND: The increasing prevalence of obesity requires especially primary health care providers to act. General Practitioners (GP) in particular have the opportunity to motivate patients in early risk stages to follow weight reduction programmes before manifestation of associated diseases. In order to conduct preventive consultancies it is necessary to explore the individual physical and mental health status of patients. Aim of this study was to examine quality of life and perceived level of stress in overweight and obese patients treated in primary care. MATERIAL/METHODS: 123 patients, following a health Check up realized by their GP, rated self- reported questionnaires regarding quality of life and perceived level of stress (SF-12, PSS). Following descriptive analysis, differences in dependent variables related to BMI, sex and age were tested using ANOVA and regression analysis (SPSSv15.0). RESULTS: Restrictions in all parameters of mental health for overweight and obese patients in primary care were shown. Especially patients with a BMI above 30 kg/m2 reported a decreased level of quality of life. CONCLUSIONS: Health care providers should be aware of cumulative restrictions in mental health of their overweight patients. The findings provide essential implications for all health care professionals in primary care doing preventive consultancies with obese clients.

[Computer-based health care research in the competence network inflammatory bowel disease. Handling of bowel diseases in general practice]. / Computergestützte Versorgungsforschung im Kompetenznetz "Chronisch-entzündliche Darmerkrankungen": Umgang mit gastroenterologischen Erkrankungen in der hausärztlichen Praxis.

BACKGROUND: Consultations due to most different bowel diseases and abdominal symptoms are common in primary care. However, little is known about the concrete situation in the general practitioner's office so far. In this study, practitioners involved in the actual treatment of patients with bowel diseases document their medical strategies by the use of an internet-based data entry system. Hence, with the support of an internet-based data collection tool, health care research has started to break new ground. METHODS: Following the programming of a digital data collection system and the installation of a nationwide research network of general practitioners interested in this matter, participating physicians communicated anonymised data on medical care of patients with various abdominal problems and intestinal/bowel diseases to the principal study investigators for 12 months, thereby using a computer-based data entry system (via internet). RESULTS: Within the 12 months of observation, 94 general practitioners documented 1,584 patient contacts by using the new data collection system. Accordingly, the most frequent reasons for consultation were abdominal pain (39%) and a change in stool habits (28%), each over a period of > 21 days. Women reported abdominal pain more often than men. Furthermore, the willingness to cooperate with specialists (hospitalization, referrals) was high among participating physicians, in reference to abdominal problems, thereby not demonstrating gender specificity. In the majority of cases, computer-assisted data entry took place outside regular consultation hours, and physicians frequently documented more than one patient within one session. CONCLUSION: High numbers of hospitalizations and specialist referrals, as shown in this study, points toward a high intensity of medical attendance necessary for patients with unspecific symptoms of the bowel or related abdominal problems. Computer-assisted data entry systems, however, represent a challenging yet still realizable way of data collection. This procedure should be brought forward for future projects in health care research.

Diagnostic work-up of rectal bleeding in general practice.

BACKGROUND: GPs have many patients with gastrointestinal discomfort. Among bowel-related complaints, the sign of rectal bleeding is of particular importance in patients aged 50 years and above, as it can be an early sign for serious bowel diseases such as colon carcinoma. Despite many guidelines offered to GPs for screening and early detection of colorectal carcinomas, there is very little information about the actual diagnostic approach to the sign of rectal bleeding. AIM: The aim of the study was to collect data concerning treatment strategies used by GPs who treat patients presenting with rectal bleeding. DESIGN OF STUDY: Prospective data collection. SETTING: General practices in Germany. METHOD: Over the course of a year, GPs recorded their treatment strategies in patients presenting with rectal bleeding and associated symptoms. Using a digital practice patient file, physicians participating in the study were able to continuously transmit data electronically to the researchers of the study about diagnostics, referrals, hospital admissions, and final diagnoses. RESULTS: During the course of 1 year, 94 participating physicians collected data on 1584 patients. Information about treating rectal bleeding was recorded for 422 patients; 60% of the patients were referred to specialists in internal medicine or gastroenterologists for further diagnostics. A colonoscopy was the most frequently performed diagnostic procedure (46.2%). Twenty-two per cent (n = 93) of the patients--54 of them aged 50 years and above--were exclusively treated by their GP without conducting a colonoscopy or cooperating with specialists. For these patients, GPs diagnosed less severe diseases like haemorrhoids or other proctologic diseases. CONCLUSION: By using a study that allows GPs to transmit electronically their findings and data, it is possible to draw a picture of treatment strategies of GPs in patients presenting with rectal bleeding. The high percentage of patients who received medical treatment in consultation with specialists underscores the significance of the sign of rectal bleeding in general practice. The need for further diagnostic measures in patients who have been treated exclusively by GPs has to be discussed.

[Perception of continuous medical education by primary care physicians]. / Wahrnehmung von Fortbildungsangeboten aus Sicht von Hausärzten: Eine qualitative Befragung von Allgemeinärzten und hausärztlich tätigen Internisten aus Berlin.

The enormous increase of specific medical knowledge has become a growing challenge also for general practitioners (GPs) in their daily routine. In this study, GPs practising in Berlin were asked about their experience with Continuous Medical Education (CME). The evaluation of this survey may help planning future qualification courses. Thirty GPs from Berlin (14 females, 16 males) participated in a qualitative survey and were interviewed about their experience with and the use of CME programmes offered. The interviews performed were summarised, structured, and analysed according to the qualitative analysis of content by Mayring. The GPs considered lack of time to be the general impediment to their further professional development. The patient-oriented communication with specialised colleagues during working hours was considered an important tool of CME. Traditional educational means, for example professional journals, were appreciated because of their flexible use in terms of time and location. Due to the lack of time, GPs may favour types of CME that can be used flexibly. The implementation of professional medical networks between GPs and specialty consultants may have a major impact on future CME programmes.

[Statements of general practitioners on cooperation with specialists and a future health care system]. / Hausärztliche Sicht zur Kooperation mit Spezialisten und Visionen zukünftiger VersorgungsstrukturenEine qualitative Befragung von Allgemeinärzten und hausärztlich tätigen Internisten aus Berlin.

BACKGROUND AND PURPOSE: Ideas of general practitioners (GPs) could be of value for the restructuring of the German ambulant health care system. The way managed care is seen by GPs is of particular interest. The aim of this study was to record opinions of GPs, working in Berlin, in regard to several aspects of their daily work. METHODS: 14 female and 16 male GPs from Berlin participated in a qualitative survey. These 30 GPs were interviewed about their attitude toward cooperation with specialized colleagues and their opinions on a future medical care system. The interviews performed were summarized, structured and analyzed according to the qualitative content analysis by Mayring. RESULTS: From the GPs' point of view, ambulant cooperation is facilitated by knowing specialized colleagues, by staying in close contact to them via telephone and by being able to arrange short-term appointments with these specialists. A closer cooperation with specialists in a network as well as an advanced use of digital information systems for accessing patients' data were considered to be vital elements for a future health care system. CONCLUSION: An important reason for choosing the cooperation with specialists is to find quick comprehensive treatment strategies for patients. It may be concluded that ambulant managed care of patients could be optimized with the creation of medical networks.

GPs' attitudes, objectives and barriers in counselling for obesity--a qualitative study.

BACKGROUND: Increasing prevalence of obesity worldwide requires providing support for many patients. GPs in particular, as long-term supervisors of patients, are asked to deliver care to those affected. OBJECTIVES: This qualitative study aimed at identifying GPs' perspectives on counselling overweight and obese patients. METHODS: To that end, semi-structured interviews were conducted in Berlin with GPs regarding their objectives and barriers in overweight care. Fifteen GPs participated; interviews were audio taped, transcribed and analysed using qualitative content analysis. RESULTS: Analysis showed a differentiated pattern of medical and psychosocial objectives in obesity treatment. Overall, it was seen that GPs wanted to play a relatively passive role in treatment of obesity. In particular, motivating patients was a key goal of primary care consultations; at the same time patients' lack of motivation was a main barrier to successful treatment. CONCLUSIONS: Care for obese patients is perceived as ineffective and frustrating. Recommended solutions include further education to improve GPs' communication techniques, e.g. to trigger patients' motivation.

Home visit delegation in primary care: acceptability to general practitioners in the state of Mecklenburg-Western Pomerania, Germany.

BACKGROUND: Shortages and maldistribution of primary care physicians (PCPs) are affecting many countries today, including in Germany. As has been suggested, the ensuing problems might be alleviated by delegating some medical tasks to physicians' assistants (PAs). This was tried in three regions of the German state of Mecklenburg-Western Pomerania under a pilot project entitled AGnES (Arztentlastende gemeindenahe E-Health-gestützte Systemische Intervention, i.e., a community-based, e-health-assisted, systemic intervention to reduce physicians' workloads). We conducted a survey of all practicing PCPs in the state to assess their overall attitude toward the delegation of home visit tasks, and to determine what they would prefer as the job description and type of employment contract for a PA who would be hired to assist them. METHODS: All PCPs practicing in Mecklenburg-Western Pomerania were asked in a quantitative survey about their willingness to delegate home visits, their perceived barriers to and benefits of home visit delegation to a qualified assistant, the skills they would require of a PA who would be hired to carry out home visits, and their preferred type of employment contract for the PA. RESULTS: 47% of the PCPs (515/1096) responded to the survey. 46% of the respondents were already informally delegating home visit tasks to qualified PAs. Female PCPs were more likely to do so (odds ratio [OR] 1.70), as were PCPs practicing in rural areas (OR 1.63) and those working in individual practice (OR 1.94). Most PCPs were in favor of delegating home visits to qualified PAs (77%). Main advantages were seen in reducing physicians' workloads (70%) and in increasing their job satisfaction (48%). 34% of PCPs said they would not cover the cost of training PAs. CONCLUSION: Acceptance of home visit delegation among PCPs in the state of Mecklenburg-Western Pomerania is high, mainly among the younger physicians. Perceived barriers and benefits of delegation of home visits to qualified PAs should be taken into account in the design of future health-care reforms, so that practice in rural areas can be made more attractive for the incoming generation of PCPs.

Motivational interviewing and shared decision making in primary care.

OBJECTIVE: The aim of this study was to assess general practitioners' (GP) readiness to involve obese patients in therapy decision making and to determine whether they integrate motivational interviewing techniques. METHODS: Fifty-eight preventive Check-up 35 encounters with overweight and obese patients in primary care were audio recorded in 12 GP practices. The use of motivational interviewing techniques was rated with the Behavior Change Counseling Index (BECCI). The involvement in medical decisions was rated with the Observing Patient Involvement Scale (OPTION). RESULTS: OPTION and BECCI scores were low (means=0.71 and 1.65), indicating minimal implementation of shared decision making and motivational interviewing in preventive encounters with these patients. GPs used more motivational interviewing for patients with a BMI>30 kg/m(2) than for those with a BMI<30 kg/m(2). Female GPs had significantly higher shared decision making scores, indicating that they prefer to involve patients in medical decisions. GPs differed significantly in their use of both approaches. CONCLUSIONS: Shared decision making and motivational interviewing, though known to be successful strategies in lifestyle counseling, are rarely used during obesity encounters in our sample of German GPs. PRACTICE IMPLICATIONS: GPs should be sensitized and trained in the application of these methods.

[Check up 35: what benefits do general practitioners in Brandenburg see?]. / Die Gesundheitsuntersuchung: Welchen Nutzen sehen Brandenburger Hausärzte?

INTRODUCTION: The so-called "Check up 35" is a structured preventive examination to be conducted by primary care providers. Recent interviews have shown that expectations with regard to this examination vary among physicians; some of them expressed doubt that the consultation is useful at all. The aim of this study was to representatively examine Brandenburg's family physicians' attitudes towards this "Check up". METHODS: 50% of the family physicians listed in the data base of the Association of SHI Physicians were randomly selected to receive a mail questionnaire (n=748). Participation in the study was voluntary, the questionnaires were evaluated anonymously. The physicians were asked about both content and assumed benefit of consultations. RESULTS: The questionnaire was answered by 37% of the physicians (n=274). In 2008, 40 "Check ups" were conducted every three months. 96% of the physicians amended the standard programme with additional preventive examinations - most frequently serum creatinine measurements. In most of the respectively rated categories, they appreciate the usefulness of the examination. In contrast, they take a rather sceptical attitude towards the en bloc standard programme. DISCUSSION: The study shows that many family physicians are very critical of the "Check up 35"; in particular, this applies to the range of scheduled examinations. There are considerable variations in the individual shaping of the consultation process among the physicians. They use the "Check up" as a tool for individual prevention instead of limiting it to the reduced standardised screening as intended.

Innovative strategy for implementing chronic heart failure guidelines among family physicians in different healthcare settings in Berlin.

AIMS: The aim of this study was to improve drug therapy for chronic heart failure (CHF) patients. METHODS AND RESULTS: This prospective interventional pilot study was performed with cross-sectional comparative analysis before and after the intervention. Usual pharmacotherapy was observed for 8 months in two different outpatient healthcare settings in Berlin [11 family physicians from individual GP (IGP) practices and 12 working in a medical care centre (MCC)]. Medical care centres provide a novel structure for outpatient care and have recently been introduced in Germany. The subsequent intervention entailed implementation of heart failure guidelines via a computer-based reminder system, followed by renewed cross-sectional observation of prescription behaviour for 1 year. Family physicians recruited patients, assessed CHF severity according to the NYHA class, and referred patients for echocardiography. The study included 190 patients in the baseline phase and 209 in the intervention phase. Longitudinal follow-up was performed in 172 cases. Echocardiography was ordered by 94.6% of MCC-physicians and 79.9% of IGP's. Undermedication was observed in both settings. Guideline-based beta-blocker therapy was prescribed for 46.3% of patients (44.8% of IGPs and 48.5% of MCC-GPs). Prescription improved by 12.3% after the intervention. There were marked deficiencies in the prescription of aldosterone antagonists (35%) for severe heart failure, which improved to 44.2% after the intervention. CONCLUSION: The problem of inadequate implementation of evidence-based therapy for CHF was partially overcome by using the reminder system, which provided participating physicians with short guideline recommendations during the intervention phase.

[Are there any differences in guideline adherence to pharmacotherapy of heart failure between individual GP practices and Medical Care Centres (MCCs)?]. / Leitliniengerechte Pharmakotherapie bei herzinsuffizienten Patienten--Gibt es Unterschiede der Behandlung durch Hausärzte in Einzelpraxen und in Medizinischen Versorgungszentren?

BACKGROUND: Chronic heart failure is one of the most important cardiovascular diseases. Patients with this common disease are primarily treated by general practitioners (GPs). Previous research showed deficits in drug therapy. Ambulatory care in Germany is changing; new structures for medical care (Medical Care Centres) have been registered since 2003. It was of interest to evaluate medical procedures of these new structures and compare them to the one applied in traditional single practices. Aim of this study was to investigate compliance with guidelines regarding drug therapy of chronic heart failure performed by GPs working in two different outpatient settings. METHODS: A prospective observational study was conducted. Over a period of eight months medical pharmacotherapy in individual practices and a Medical Care Centre (MCC) was compared. To ensure comparability in both settings GPs treating randomly selected patients were asked to recruit patients with heart failure, encode their NYHA class and conduct echocardiography to verify the diagnosis. RESULTS: 241 heart failure patients were enrolled by general practitioners (137 in individual practices and 104 in MCCs). GPs working in MCCs performed more diagnostic echocardiographies than physicians in individual practices. ACE inhibitors/sartans, beta blockers and diuretics were prescribed less often than recommended in the guideline. DISCUSSION: The hypothesis of insufficient adherence to guideline recommendations for pharmacotherapy of ambulatory heart failure patients was confirmed. However, the prescribing behaviour for pharmacotherapy of heart failure among the physicians in Berlin was better than among their European colleagues. There were only minor differences in drug prescription between the 11 GPs from single practices and the 12 GPs working in an MCC.

Counseling overweight in primary care: an analysis of patient-physician encounters.

OBJECTIVE: The aim of this study was to assess general practitioners' (GPs') and patients' practices and attitudes regarding overweight encountered during preventive counseling talks. METHODS: Twelve GPs audiotaped their preventive counseling talks with overweight patients, including the assessment of individual risk profiles and further medical recommendations. Fifty-two dialogues were transcribed and submitted to qualitative content analysis. RESULTS: Dietary advice and increased physical activity are mostly discussed during talks. Recommendations appear to be more individual if patients are given the chance to reflect on causes of their overweight during counseling talks. CONCLUSIONS: A dialogue approach affects the strength and quality of weight loss counseling in primary care. However, physicians and overweight patients rarely agreed on weight loss goals during the physician-patient talks. PRACTICAL IMPLICATIONS: Patient centeredness, particularly the integration of patients' perceptions towards weight management, might be an important step towards improving weight counseling in primary care.

[Overweight patients in primary care: how family physicians utilize medical check-up examinations for risk counselling. Content analysis of check-up counselling talks between physicians and patients]. / Ubergewichtige Patienten in der Hausarzt- praxis: Wie wird die Gesundheitsuntersuchung zur Risikoberatung genutzt? Eine qualitative Analyse von Arzt-Patient-Gesprächen.

BACKGROUND: The number of overweight patients in Germany has been continuously increasing during the past years. The so-called "check-up 35" consultation presents primary care providers with an opportunity for preventive counselling talks with the respective individuals. In this qualitative study we analysed family physician encounters. We were particularly interested in the way in which the subject matter was addressed and the risk counselling performed by the physicians when confronted with overweight patients. METHODS: Twelve physicians audio-taped their final check-up dialogue with 52 overweight or obese patients (BMI > or = 25 kg/m2). The interviews were transcribed, and a content analysis was conducted using the established method developed by Mayring. RESULTS: Physicians used direct or more often indirect strategies to address overweight in counselling talks that were most often initiated by their patients. They largely addressed this topic while communicating laboratory results. Some obese patients did not receive any advice on health risks. In the encounters analysed the physicians did not employ standardized risk counselling tools. CONCLUSIONS: The reasons for addressing overweight indirectly and the lack of standardized risk counselling with obese patients are carefully discussed.