Breast and testicular self-examination in primary care

Among a random sample of Michigan family physicians, attitudes about encouraging patients to perform breast and testicular self-examination were very positive. The physicians' self-reported incorporation of such encouragement into their practices was much lower for testicular than breast self-examination. Two hundred seventy-eight randomly selected family physicians in Michigan were surveyed about their beliefs about and professional practices regarding encouraging patients to perform breast self-examination (BSE) and testicular self-examination (TSE). Attitudes were very positive about both techniques. Self-reported incorporation of patient encouragement into professional practice was much lower for TSE than for BSE. The physicians' own personal practices were similarly skewed: female physicians performed BSE for themselves far more regularly than young male physicians did TSE. The barriers they identified to incorporating encouragement into their practices were similar for testicular and breast self-examination, with lack of patient motivation the leading barrier seen.     

Stigma, discrimination, and HIV/AIDS knowledge among physicians in Barbados.

OBJECTIVE: To determine the extent of clinical knowledge of HIV/AIDS that physicians in Barbados have and their attitudes towards persons living with HIV/AIDS. METHODS: In 2000 the Barbados Association of Medical Practitioners conducted a survey in order to assess its members' views on HIV/AIDS issues. Over a two-month period 203 physicians (76% of all those practicing in the country) were interviewed. The survey included physicians working in private practice and the public sector. They were surveyed individually concerning their attitudes towards counseling as well as their clinical knowledge, perception of safe practices, fear of occupational exposure, views on ethical issues, experience treating HIV/AIDS patients, and background with HIV/AIDS continuing education. RESULTS: In comparison to physicians who had graduated in later years, physicians who had graduated in 1984 or earlier had seen fewer HIV/AIDS clients, had lower levels of knowledge about the disease, were more likely to test for HIV/AIDS without informed consent, and were less likely to have ever attended a continuing education training course on HIV/AIDS. Overall, knowledge of the clinical indications of HIV/AIDS was low, and 76% of the physicians did not think they had adequate counseling skills. Over 80% of the physicians were comfortable looking after HIV/AIDS patients. While 95% of the physicians would not release HIV test results without a patient's consent, 33% would test, without consent, a seriously ill patient, and 15% would test without consent a patient upon whom they had to perform an invasive procedure if they perceived the patient to be from a high-risk population such as gay men or commercial sex workers. Only 53% of the physicians had attended an HIV/AIDS in-service training program between 1995 and 1999. CONCLUSIONS: Physician training in Barbados should focus on all aspects of HIV/AIDS care, including clinical and emotional factors. Attendance at such training should be mandatory for public sector physicians, and medical school curricula need to be examined to ensure their HIV/AIDS content is current and comprehensive.     

Physicians' attitudes and beliefs concerning alcohol abuse prevention in adolescents.

BACKGROUND: Primary alcohol abuse-prevention services delivered to adolescents are inadequate, despite the fact that alcohol abuse is a major health problem. Physicians' attitudes and beliefs regarding primary prevention of adolescent alcohol abuse and appropriate onset ages of alcohol use may be useful in understanding why delivery of prevention services is inadequate, but as yet has not been investigated. OBJECTIVES: To examine (1) physicians' attitudes and beliefs regarding alcohol abuse prevention and practice, and (2) correlates of these attitudes and beliefs, including the delivery of primary alcohol abuse-prevention services to adolescents. METHODS: A national, stratified random sample of pediatricians and family practitioners was drawn from the American Medical Association's Masterfile Registry. Inclusion criteria included active medical practice and seeing at least one adolescent per week. The response rate was 63%, resulting in a final sample of 1842 physicians. Participants were queried about their practice, alcohol use, attitudes and beliefs, and delivery of alcohol-related screening and education to adolescents. RESULTS: On average, physicians reported providing alcohol-related screening to 40.3% (standard error [SE]=0.6) and education to 52.0% (SE=0.8) of their adolescent patients. Participants had positive attitudes toward adolescents, believed that prevention was important, and approved of alcohol screening early in adolescence, but did not feel very comfortable about their adolescent alcohol-management skills. Except for ceremonial use, most physicians did not believe in underage drinking. Attitudes and beliefs were significantly related to the delivery of alcohol screening (R(2)=0.34, p < 0.001) and education (R(2)=0.18, p < 0.001). Participants who delivered more screening and education had more positive beliefs in the importance of prevention (beta=0.14 and beta=0.13, respectively; p < 0.001); approved of early alcohol screening (beta=0.29 and beta=0.09, respectively; p < 0.001); and were more comfortable with their alcohol management skills (beta=0.31 and beta=0.28, respectively; p < 0.001). A profile of physicians with positive attitudes and beliefs is presented. CONCLUSIONS: Physician attitudes and beliefs are associated with variations in alcohol screening and education services delivered to adolescents. A better understanding of physicians' attitudes and beliefs can be useful in providing physician education and training aimed at improving primary alcohol-abuse prevention.     

Increasing physician involvement In cholesterol-lowering practices: The role of knowledge,attitudes and perceptions

The study evaluated a multifaceted educational intervention systematically designed to increase physician involvement in cholesterol-lowering practices. We hypothesized that knowledge, perceptions and behaviours would be enhanced in participating physicians, compared with controls. Method: Fifty-one family physicians were assigned randomly to three groups; the two experimental groups attended a training workshop, received physician and patient education materials and ongoing consultant support. One experimental group also received a “cuing” intervention. The control group received no interventions. Outcome measures included knowledge and attitude scores, self-efficacy perceptions, and physician dietary counselling behaviour. Measures were taken at pretest, 6 weeks and 15 months later. Results: Intervention group physicians achieved significantly higher knowledge scores than the control group at the six-week test; the differences disappeared at 15 months. Attitudes, self-reported practices and overall self-efficacy scores were similar across groups. Within group variation was highly significant. Physician dietary counselling scores were significantly higher in the intervention groups (p = 0.0001). Some associations were seen among knowledge, attitude, self-efficacy and dietary counselling scores. Conclusion: Physician behaviour change in cholesterol reduction may not depend entirely upon knowledge, attitudes and perceptions. This revised version was published online in June 2006 with corrections to the Cover Date.     

Identifying barriers to hypertension care: implications for quality improvement initiatives.

The role of clinical inertia in the treatment of patients with hypertension was assessed by evaluating health care providers' knowledge, attitudes, and clinical practices regarding hypertension management. A cross-sectional survey was conducted at the Forsyth Medical Group in North Carolina. Participants were physicians (N = 18, 10 sites) and support staff (N = 20, 12 sites), who were surveyed in 2006. Physician and support staff questionnaires consisted of 29 and 15 items, respectively, and were administered by trained interviewers. Though most physicians (94%) cited familiarity with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) guidelines and affirmed that hypertension management guidelines are relevant to their patients, no physicians interviewed routinely document patient hypertension management plans. Although 1 in 3 physicians cited the inability to devote enough time to patients for the discussion of hypertension management, physicians predominantly cited patient- and support-staff- related factors as most important to patients not attaining blood pressure (BP) goal. Patient lifestyle modification (89%), education (67%), and medication compliance (56%) were cited as the most important reasons for uncontrolled BP. Only one-third of physicians believe that clinical staff always obtain accurate BP measurements, and 61% believe that resistant hypertension is a reflection of inaccurate BP measurement. Many support staff claimed to be rushed when measuring patient BP, and 65% recommended BP competency training. Contradictions were evident between provider knowledge of hypertension management standards and how this knowledge is applied in clinical practice. Standardized collection of BP is critical to measuring clinical improvement in hypertension. Results are being utilized to develop clinical improvement initiatives including staff education and competency training.     

Factors influencing antibiotic prescribing in China: an exploratory analysis

OBJECTIVES: China has very high rates of antibiotic resistance and a health care system that provides strong incentives for over-prescribing. This paper describes the findings of a qualitative study in a province of southern China that seeks to assess knowledge, attitudes, and practices in relation to the use of antibiotics. METHODS: Semi-structured interviews with patients and health workers at provincial, county, township, and village level. Interviews used four probes (common cold, cough, mild diarrhoea and tiredness) where antibiotics were not indicated, supplemented by questions on knowledge, attitudes, and practices. These data were supplemented by two focus groups, with medical students and pharmacists, and discussions with participants at a national conference on antibiotic use. RESULTS: Coughs and diarrhoea are almost universally treated with antibiotics, while the cold is normally treated with antivirals instead or as well. Many physicians are aware that the cold is usually self-limiting but believe that they can speed recovery and that they are responding to patient expectations. Most physicians and many patients are aware of the phenomenon of antibiotic resistance, although it is often seen as a property acquired by the patient and not the micro-organism. Physicians face financial incentives to prescribe, with profit splitting with pharmaceutical suppliers. Sales profits form a major part of a hospital's income. National guidance on use of antibiotics is fragmentary and incomplete. CONCLUSION: The misuse of antibiotics poses considerable risks. Effective action will require a multi-faceted strategy including education, based on an understanding of existing beliefs, the replacement of perverse incentives with those promoting best practice, and investment in improved surveillance. Much of this will require action at national level.     

GPs' strategies in intercultural clinical encounters

BACKGROUND: In North America and Europe, patients and physicians are increasingly likely to come from non-Western cultural backgrounds. The expectations of these patients may not match those of physicians. OBJECTIVE: To identify strategies used by GPs with patients from cultures other than their own. METHODS: We conducted a qualitative inductive study based on 25 semi-structured interviews with family physicians practising in Montreal, Canada. We elicited physicians' strategies when dealing with patients from a cultural background different from their own. We began by asking physicians to describe an encounter they found difficult and one they found easy. RESULTS: Physicians reported three types of strategies: (i) insistence on patient adaptation to local beliefs and behaviours; (ii) physician adaptation to what he or she assumed patients wanted; and (iii) negotiation of a mutually acceptable plan. Individual physicians did not adopt the same strategy in all situations. Their choice of strategy depended on the topic. When dealing with issues they felt deeply about, such as the autonomy of women, many physicians insisted on patient adaptation. Physicians used a patient-centred model of care, but had no framework to elicit information about patients' culture. CONCLUSIONS: A patient-centred model of care enables physicians to consult effectively despite a wide range of cultural differences between themselves and their patients. However, their lack of a conceptual framework for addressing cultural difference prevents systematic data collection and consideration of challenges to respect for individual autonomy. Physician training should include the provision of an explicit conceptual framework for approaching patients from a different culture.     

Cancer Screening and Haitian Immigrants: The Primary Care Provider Factor

Background: Haitian immigrants, among the fastest growing immigrant communities in the United States, have low cancer screening rates. Several patient barriers have been identified and associated with low screening rates but little is known on provider barriers for cancer screening. To address this gap, we assessed the cancer screening practices, attitudes, and beliefs of primary care providers serving the Haitian community. Methods: We surveyed a random sample of physicians serving first generation Haitian immigrants in New York City, identified through their zip codes of practice. Participants completed a questionnaire to assess their beliefs, attitudes and practices surrounding cancer screening, and their perceptions of patient barriers to screening. Results: 50 of 87 physicians (58%) consented to participate in the study. Cancer site-specific and overall cancer screening scores were created for breast, cervical, and colorectal cancer screening. 75% of providers followed breast cancer screening guidelines, 16% for cervical cancer, and 30% for colorectal cancer. None of the providers in the sample were following guidelines for all three cancer sites. Additionally, 97% reported recommending digital rectal exam and PSA annually to patients 50 years or older with no family history, and 100% to patients over 50 years old with family history. Conclusions: The reported practices of providers serving the Haitian immigrant community in New York City are not fully consistent with practice guidelines. Efforts should be made to reinforce screening guideline knowledge in physicians serving the Haitian immigrant community, to increase the utilization of systems that increase cancer screening, and to implement strategies to overcome patient barriers.     

Survey of physician diagnostic and treatment practices for patients with acute diarrhea in Guangdong province, China

Although international clinical guidelines generally recommend performing bacterial stool culture in patients with acute diarrhea and fever and discourage routine antibiotic prescribing, clinical practice varies. Understanding practice patterns can help health officials assess the sensitivity of laboratory-based enteric infection surveillance systems and the need to improve antibiotic prescribing practices. We surveyed physicians in Guangdong province, China, to measure their practices for patients with acute diarrhea. A standardized questionnaire was used to interview physicians working in hospitals participating in a Salmonella surveillance system in Guangdong, China. The questionnaire asked physicians about their routine practice for patients with diarrhea, including how they managed the last patient they had seen with acute diarrhea. We calculated the odds ratio and 95% confidence interval for factors associated with ordering a stool culture and for prescribing antibiotics. We received surveys from 237 physicians across 22 hospitals in Guangdong. For the last patient with diarrhea whom they had evaluated, 134 (57%) reported ordering a stool culture. The most common reasons for not ordering a stool culture included that it takes too long to receive the result, that the patient is not willing to pay for the test, and that the patient's illness was too mild to warrant testing. Most physicians prescribed at least one medication for the last patient with diarrhea whom they had evaluated. Of the 237 physicians surveyed, 153 (65%) prescribed antibiotics, 135 (57%) probiotics, and 115 (49%), a gastric mucosal protective drug. In conclusion, physicians in Guangdong, China, reported high rates of ordering bacterial stool cultures from patients with diarrhea, possibly associated with their hospital's participation in a special surveillance project. The high rate of antibiotic prescribing suggests that efforts to promote judicious antibiotic use, such as physician education, are needed.     

Family practitioners' attitudes and knowledge about irritable bowel syndrome: effect of a trial of physician education

BACKGROUND: Primary physicians care for most patients with irritable bowel syndrome (IBS), but data on their attitudes and knowledge about the disorder are limited to research in the UK. OBJECTIVE: The purpose of the present study was to assess US family practitioners' attitudes and knowledge about IBS and determine the effect of a single education class on these measures. METHODS: In a large health maintenance organization (HMO), a baseline group of family practitioners twice completed a questionnaire on attitudes and knowledge about IBS, 3 months apart. A class group completed it pre-class, immediately post-class and 3 months post-class. RESULT: Thirty-five physicians ranked IBS among five chronic, painful syndromes as highest in difficulty satisfying patients, tied with headache for highest in difficulty in practice strategy decision, second in time required, and fourth in diagnostic confidence and satisfaction in caring for patients. IBS and heartburn had widely separated rankings in all five attitudes. The correct answer rate on seven of 13 knowledge questions was <50%, and a majority did not identify the Rome II symptom criteria as typical and lacked other important knowledge. Of the 30 class physicians, the knowledge scores (mean +/- SD; maximum possible, 13) of 29 increased from 5.59 +/- 1.84 pre-class to 10.21 +/- 1.76 immediately post-class (P < 0.0001); 3 months later, the scores were lower (8.93 +/- 0.36) than post-class (P < 0.0001), but still higher than pre-class (P < 0.0001). Their attitude rankings were nearly identical pre-class and 3 months later (P > 0.05). In the 19 baseline physicians, IBS attitude rankings and knowledge scores did not change significantly over 3 months (P > 0.05). CONCLUSION: These US family practitioners had attitudes about IBS patients and lacked knowledge that could interfere with patient care. A single class improved short-term knowledge but had little effect on attitudes about IBS.     

Physician compliance with mammography guidelines: barriers and enhancers.

BACKGROUND: Primary care physicians are increasingly the gatekeepers to clinical preventive services including mammography utilization. Moreover, lack of physician recommendation is a major reason for patient failure to obtain screening. A study was designed to examine the attitudes, beliefs, and practices with regard to breast cancer screening as self-reported by primary care physicians. The variables associated with compliance or lack of compliance with screening guidelines are emphasized. METHODS: One hundred sixteen primary care physicians practicing in two New England communities responded to a mailed survey. The survey included questions on attitudes and beliefs about breast cancer screening, as well as questions about perceived barriers and actual screening practices. RESULTS: Fifty-seven percent of the respondents reported ordering annual mammograms for their female patients aged 50 to 75 years. An additional 21 percent reported ordering biannual mammograms for women in this age group. Strongly associated with ordering annual mammograms were beliefs in the benefits of mammography and the perception of community consensus regarding breast cancer screening. A strong positive association of practicing in a group setting and mammography guideline compliance was documented. Middle-aged physicians in solo practice reported the poorest screening compliance. CONCLUSIONS: The level of physician compliance with the standard of annual mammography screening is low (57 percent). The three most important determinants of annual screening suggest ways to improve physician compliance: improve physician attitudes about the benefits of mammography, build further on the medical community's consensus regarding the appropriateness and importance of the annual guidelines, target the poorest compliers with special messages or programs.     

Predictors of physicians' attitudes toward sharing information with patients and addressing psychosocial needs: a cross-sectional study in Greece

Sharing information with patients and addressing their psychosocial needs are recognized as fundamental practices of patient-centered physicians. Our study explored predictors of physicians' patient-centered attitudes and yielded a better understanding of the relative influences of job satisfaction, employment status, specialty, previous communication skills training, and sociodemographic factors. Physicians who participated in 13 identical workshops offered throughout Greece were invited to complete a battery of anonymous questionnaires (demographics, job satisfaction scale, Patient-Practitioner Orientation Scale-Sharing subscale, and Physician Belief Scale). Prediction models were used to identify predictors of patient-centered attitudes. In total, 400 fully completed questionnaires were returned (response rate 79.8%). Job satisfaction, previous training in communication skills, younger age and lower socioeconomic status were predictors of positive attitudes toward sharing information with patients. Job satisfaction, previous training in communication skills, and stronger religious beliefs were predictors of higher psychosocial orientation. Job satisfaction and training in communication skills should be ensured in the effort to develop and maintain patient-centered attitudes in physicians. Religious beliefs, age, and socioeconomic status should be taken into consideration in the effort to help physicians become aware of their biases.     

Racial attitudes,physician–patient talk time ratio,and adherence in racially discordant medical interactions

Physician racial bias and patient perceived discrimination have each been found to influence perceptions of and feelings about racially discordant medical interactions. However, to our knowledge, no studies have examined how they may simultaneously influence the dynamics of these interactions. This study examined how (a) non-Black primary care physicians' explicit and implicit racial bias and (b) Black patients' perceived past discrimination affected physician–patient talk time ratio (i.e., the ratio of physician to patient talk time) during medical interactions and the relationship between this ratio and patients' subsequent adherence. We conducted a secondary analysis of self-report and video-recorded data from a prior study of clinical interactions between 112 low-income, Black patients and their 14 non-Black physicians at a primary care clinic in the Midwestern United States between June, 2006 and February, 2008. Overall, physicians talked more than patients; however, both physician bias and patient perceived past discrimination affected physician–patient talk time ratio. Non-Black physicians with higher levels of implicit, but not explicit, racial bias had larger physician–patient talk time ratios than did physicians with lower levels of implicit bias, indicating that physicians with more negative implicit racial attitudes talked more than physicians with less negative racial attitudes. Additionally, Black patients with higher levels of perceived discrimination had smaller physician–patient talk time ratios, indicating that patients with more negative racial attitudes talked more than patients with less negative racial attitudes. Finally, smaller physician–patient talk time ratios were associated with less patient subsequent adherence, indicating that patients who talked more during the racially discordant medical interactions were less likely to adhere subsequently. Theoretical and practical implications of these findings are discussed in the context of factors that affect the dynamics of racially discordant medical interactions.     

A methodology for assessing the professional development needs of nurses and midwives in Indonesia: paper 1 of 3

Background

The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States.

Methods

This is a secondary data analysis of the 1996–1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week.

Results

Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs.

Conclusion

There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.     

The Construction of HIV/AIDS in Indian Newspapers: A Frame Analysis

Sharing information with patients and addressing their psychosocial needs are recognized as fundamental practices of patient-centered physicians. Our study explored predictors of physicians' patient-centered attitudes and yielded a better understanding of the relative influences of job satisfaction, employment status, specialty, previous communication skills training, and sociodemographic factors. Physicians who participated in 13 identical workshops offered throughout Greece were invited to complete a battery of anonymous questionnaires (demographics, job satisfaction scale, Patient–Practitioner Orientation Scale-Sharing subscale, and Physician Belief Scale). Prediction models were used to identify predictors of patient-centered attitudes. In total, 400 fully completed questionnaires were returned (response rate 79.8%). Job satisfaction, previous training in communication skills, younger age and lower socioeconomic status were predictors of positive attitudes toward sharing information with patients. Job satisfaction, previous training in communication skills, and stronger religious beliefs were predictors of higher psychosocial orientation. Job satisfaction and training in communication skills should be ensured in the effort to develop and maintain patient-centered attitudes in physicians. Religious beliefs, age, and socioeconomic status should be taken into consideration in the effort to help physicians become aware of their biases.     

Survey of HIV/AIDS knowledge and attitudes of Kuwaiti family physicians

OBJECTIVES: This study aimed to explore Kuwaiti family physicians' attitudes and knowledge about HIV/AIDS. METHODS: One hundred and sixty-two Kuwaiti family physicians (95 females and 67 males) from all four health catchment areas have completed a 30-item self-administered questionnaire to measure HIV/AIDS-related attitudes and knowledge. RESULTS: Knowledge was lacking in areas dealing with HIV-related neuropsychiatric complications and other issues concerning HIV/AIDS, special populations and range of normal sexuality. The majority of physicians expressed negative attitudes toward homosexuality and about AIDS patients in general. Eighty-three per cent of Kuwaiti family physicians would opt out of treating AIDS patients. More than half of the physicians would avoid coming into social contact with HIV-seropositive persons. No significant difference was found for the total knowledge and attitude scores for gender. CONCLUSION: The results of this survey revealed that even in the second decade of the AIDS epidemic, some Kuwaiti family physicians continue to have a lack of proper knowledge about HIV and harbour negative attitudes toward AIDS patients. There is a need to promote an AIDS education early in the medical internship training years which addresses many underlying socio-cultural factors.     

Knowledge,Attitudes, and Beliefs Regarding Weight Gain During Pregnancy Among Hispanic Women

Pregnancy weight gain may be a risk factor for the development of obesity highlighting the importance of identifying psychosocial risk factors for pregnancy weight gain. The goal of this qualitative pilot study was to evaluate knowledge, attitudes and beliefs regarding weight gain during pregnancy among predominantly Puerto Rican women, a group with higher rates of obesity as compared to non-Hispanic white women. We conducted four focus groups stratified by level of acculturation and BMI. Women reported receiving advice about pregnancy weight gain predominantly from nutritionists and family members rather than from their physicians. The majority of overweight/obese women reported that they had not received any recommendations for weight gain during pregnancy from physicians. Pregnancy weight gain advice was not consistent with the 1990 Institute of Medicine Guidelines. Overall, attitudes towards weight gain recommendations differed by weight status, whereas feelings and dietary beliefs about weight gain differed according to level of acculturation. Our findings inform behavior change strategies for meeting pregnancy weight gain recommendations.