Physician Attitudes May Hamper Assessments of Patients' Risk Status
Nine in 10 primary care physicians surveyed in Pennsylvania in 1998 said that they are comfortable discussing issues related to sex with their patients, but fewer than one-third believed that their counseling helps reduce risky behavior among their patients.1 Furthermore, although virtually all respondents thought that physicians should routinely counsel teenage patients about sexually transmitted disease (STD) prevention, only about three in five considered themselves responsible for ensuring that their young female patients receive proper STD prevention services. Female doctors, those working in clinics and physicians who felt adequately trained in STD care had more positive STD-related attitudes than others.
The survey was mailed to a randomly selected sample of 1,054 primary care physicians, of whom 541 returned the questionnaire. Roughly half (53%) of respondents were male; most were older than 40 (67%) and white (87%). Thirty-four percent were obstetrician-gynecologists, 28% family practitioners, 24% pediatricians and 14% internists. The majority (62%) were in group practices; the rest were solo practitioners (24%) or worked in clinics (13%).
When asked if their medical education had adequately prepared them to offer STD care, only 52% of participants replied that it had. The proportion was higher (71%) when the question referred to postgraduate training, but it varied considerably by specialty--from 47% among pediatricians to 90% among obstetrician-gynecologists. Higher proportions of doctors younger than 40 than of older physicians considered their STD training adequate.
Respondents were asked to rate the extent to which they agreed with nine statements reflecting attitudes toward providing STD services; possible responses ranged from one (strongly disagree) to five (strongly agree). When the researchers dichotomized the responses (agree vs. disagree), they found that 89% of physicians felt comfortable discussing sex-related issues with their patients. Nonetheless, only 45-46% enjoyed seeing patients with concerns about STDs or were confident that they diagnosed most female patients' STDs; only 30% thought that their counseling had a positive influence on patients' behavior.
Ninety-four percent of physicians agreed that counseling adolescents about STD prevention should be a routine practice, but only 57% considered themselves responsible for ensuring that their young female patients received STD prevention services. A substantial minority (29%) thought that chlamydia was too uncommon among their patients to warrant screening of sexually active teenage women. Nearly half of respondents indicated that time pressures were a barrier to providing effective STD prevention services and counseling; one-quarter said that financial reimbursement difficulties impeded service provision.
Significantly higher proportions of female than of male respondents reported agreement with five of the nine attitudinal items (comfort in discussing sex-related issues, confidence in detecting female patients' STDs, effectiveness of counseling, physicians' responsibility for routine counseling and personal responsibility for female patients). Moreover, when the researchers calculated summary attitude scores and used multivariate analysis to examine their relationships with physician characteristics, they found several significant associations. Scores were elevated (indicating more positive attitudes) among female doctors, physicians employed by clinics and respondents who considered their medical school or postgraduate training in STD care adequate. Compared with family practitioners, obstetrician-gynecologists had higher scores, and pediatricians had lower scores.
Finally, the investigators examined physicians' counseling and risk assessment practices, and how these practices related to attitudes regarding STDs. Questionnaire responses revealed that the large majority of physicians (74-88%) usually counseled 15-25-year-old patients about STD transmission and prevention, and asked them about their sexual activity, condom use and STD history. Fewer than half (42-47%) typically asked these patients about their lifetime number of sexual partners or sexual orientation. Respondents who reported these practices had significantly higher summary attitude scores than those who did not.
While acknowledging their study's limitations--particularly its limited generalizability--the researchers point to a number of important findings. Medical education and training, they comment, should give increased emphasis to STD care, "to influence future attitudes and behaviors." More generally, they conclude that "interventions to improve physicians' confidence and sense of responsibility for STD prevention could lead to improved STD-related practices."
1. Ashton MR et al., Primary care physician attitudes regarding sexually transmitted diseases, Sexually Transmitted Diseases, 2002, 29(4):246-251.