Physician training for patient-centered nutrition counseling in a lipid intervention trial

BACKGROUND: We examined the effect of a 3-hr training program on physicians' lipid intervention knowledge, attitudes, and skills. The program teaches physicians skills to conduct a brief dietary risk assessment and provide patient-centered counseling to enable patients with elevated lipids to change their dietary patterns. METHOD: The training is part of a randomized trial of lipid-lowering interventions, the Worcester Area Trial for Counseling in Hyperlipidemia. Primary care internists practicing in a health maintenance organization (HMO) were assessed, before and after training using questionnaires and audiotapes to document changes in knowledge about diet, attitudes about intervention, reported nutrition intervention practices, and counseling and assessment skills. Physicians also rated the value that they thought the training program had to them. RESULTS: After completion of the program the physicians' use of dietary counseling steps, as assessed by blinded evaluation of audiotaped physician-patient interactions, significantly increased (mean pre = 5.4, mean post = 9.2; t = 9.9; P < or = 0.001). In this regard, there were instances in the use of 7 of the 14 specific counseling steps. Physicians also demonstrated increases in self-perceived preparedness as measured by a 5-point scale (mean pre = 3.2, mean post = 4.0; t = 4.25; P < 0.001), confidence in having an effect (mean pre = 3.3, mean post = 3.9; t = 3.16; P < 0.01), perception that materials were available to aid intervention (mean pre = 2.7, mean post = 4.0; t = 5.29; P < 0.001), and perception that they have access to a nutritionist (mean pre = 3.5, mean post = 4.0; t = 2.63; P < 0.01). They rated the value of the program between very good and excellent. CONCLUSION: Results of this 3-hr educational program indicate that physicians in an HMO are responsive to the teaching of specialized skills deemed important for promoting health behavior change in their patients.     

Willingness to perform euthanasia. A survey of physician attitudes

BACKGROUND: In the United States, few studies have examined important variables in physician attitudes toward the practice of euthanasia, such as the patient's underlying disease, mental capacity, and age, and the physician's specialty and religion. We administered a case-based survey to analyze the impact of such specific variables on physician attitudes toward the practice. METHODS: A four-section survey solicited (1) physician responses to three hypothetical cases in which patients requested euthanasia; (2) physicians' general opinions about euthanasia and how its legalization might affect them personally and professionally; and (3) demographic information. Analysis focused on physicians' characteristics as they related to their responses to the various aspects of euthanasia elicited in the survey. Univariate and multivariate analyses, using logistic regression, were performed. RESULTS: Completed and analyzable surveys were returned by 740 physicians. We found that physicians felt more comfortable with euthanasia requests from nondecisional, nonterminal patients who had left advance directives than they did with requests from decisional patients suffering from grave illnesses or injuries, or from decisional patients who had early signs of a progressive but nonlethal neurologic disease. We also found that physicians' specialties and religions correlated with their responses to the hypothetical cases and with their generalized attitudes toward euthanasia. CONCLUSIONS: Given the disparity in responding physicians' attitudes toward euthanasia, along with the fact that values based on religious affiliation or profession may underlie many physicians' opposition to the practice, we conclude that if euthanasia is to be legalized, safeguards protective of patients and physicians must be incorporated.     

Eyeball position in Graves orbitopathy and its significance for eyelid surgery

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.     

Wellness Promotion in Persons With Disabilities: Physicians' Personal Behaviors, Attitudes, and Practices.

Objective: To examine physicians' attitudes, personal wellness behaviors, and wellness promotion practices with their patients who were living with a disability. Design and Participants: A 20-item survey was mailed to 1,200 physicians from a national stratified random sample. Responses were received from 417 physicians (34.8% response rate). Results: Physicians who reported engaging in high levels of wellness promotion with their patients with disabilities rated wellness promotion as more important and reported feeling more competent and responsible. Several barriers and incentives to wellness promotion were reported. Conclusions: Physicians' attitudes and perceived competencies may influence their wellness promotion activities with their patients with disabilities. Medical training modules and other methods may increase physicians' wellness promotion activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preferences of physicians and their patients for end-of-life care

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.     

Epidermoid carcinoma of the thyroid

BACKGROUND: Dermatologists' attitudes toward independent electrolysis practice by nonphysicians has historically ranged from the critical to the praiseworthy. It is hypothesized that dermatologists' attitudes toward independent electrolysis practice by nonphysicians is related to physicians' perception of licensing requirements for independent nonphysician electrologists (INE). METHODS: Nine hundred and thirty-seven fellows of the American Academy of Dermatology (AAD) residing in the Southern United States were anonymously surveyed about independent electrolysis practice by nonphysicians. The results of the survey were analyzed using the Pearson chi-square test. RESULTS: Dermatologists who perceived that licensing was required for INE were significantly more likely to refer patients to INE for hair removal (P = 0.001) and prescribe EMLA cream (lidocaine 2.5% and prilocaine 2.5%) to patients requesting it for electrolysis performed by INE (P = 0.001). However, those dermatologists who had electrolysis services available in their practice settings (15.1%) were significantly less likely to refer patients to INE (P = 0.001) and to prescribe EMLA cream to patients seeking electrolysis from INE (P = 0.034). Only 5.7% of responding dermatologists supported the use of hair removal lasers by INE. CONCLUSION: Dermatologists' attitudes toward INE generally appear to be positively related to perceived licensure requirements for INE, but these positive attitudes do not extend to independent laser use by nonphysician electrologists for hair removal.     

Physicians'' experiences and beliefs regarding informal consultation

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.     

Physician perspectives on the ethical aspects of disability determination

OBJECTIVE: To evaluate physician's attitudes and responses to the ethical conflicts involved in certifying patients for welfare disability. DESIGN: A mailed questionnaire survey that used case scenarios and general questions. SETTING: Massachusetts. PARTICIPANTS: A random sample of 347 internists and family practitioners and a convenience sample of 100 neighborhood health center physicians from three large cities (NHC sample). The response was 53% and 76%, respectively. MEASUREMENTS AND MAIN RESULTS: Physician responses to case scenarios representing difficult decisions about patient requests for welfare disability determination and general questions about the welfare disability system. Physicians reported a willingness to exaggerate clinical data to help a patient they thought deserving of welfare disability benefits (39% random sample; 56% NHC sample). Physicians did not report confidence in their ability to determine who was disabled as measured by a visual analog scale (4.4 cm random sample, 4.6 cm NHC sample; 0 = very confident, 10 = very uncertain). They did feel burdened by their participation in welfare disability determinations when compared with other administrative chores as measured on a visual analog scale (2.8 cm random sample, 2.5 cm NHC sample; 0 = more burdensome, 10 = less burdensome). Eighty-two percent of the random sample physicians and 86% of the NHC sample physicians thought that filling out a disability form could adversely affect the physician-patient relationship, and 62% of physicians in each sample thought that it represented a conflict of interest. Eighty percent of physicians in both samples thought that it would be better if an independent group of physicians were designated to determine disability. CONCLUSIONS: Physicians perceive an ethical bind as they try to satisfy the conflicting demands of patients and the welfare disability system. They will frequently decide in favor of their patient's interests. This has implications for welfare policy planners.     

Physician's attitudes toward the ill aged and nursing homes

A survey of physicians in private practice (exclusive of pediatricians) was conducted in a medium sized suburban city in the New York metropolitan area, to determine whether physicians' attitudes toward the ill aged and nursing homes were predictors of the quality of medical care available to area nursing home patients. Questionnaires were circulated to 302 practitioners. Of the 28 percent who responded, 32 percent were psychiatrists, 15 percent primary care physicians and 8 percent orthopedists. Physicians felt competent to manage the ill aged, although 50 percent had had no significant degree of exposure to geriatric medicine in their medical education, and 70 percent of the primary care group had had none. Primary care and older physicians were more likely to treat patients in nursing homes. Almost 40 percent viewed the nursing home as a place to die. Although 85 percent studied that physicians should be involved in the nursing home displacement process, only 21 percent believed that they continued to be in charge of their patients after placement. The findings demonstrate generalized medical disinterest in the care of ill aged patients in institutions. The persons responsible for awarding government grants and those involved in planning medical school curricula should pay more attention to the needs of the chronically ill aged.     

Femoral and lateral femoral cutaneous nerve block for muscle biopsies in children

OBJECTIVE: Unintentional injuries are the number one cause of death for infants. Many of these injuries could be prevented if parents took additional safety precautions. In this study physicians' and parents' perspectives regarding the part that physicians play in educating first time parents about child safety issues were compared. METHODS: All pediatricians and family physicians in London, Ontario were surveyed by mail (68% return rate) regarding their practices, attitudes, and beliefs related to parent education about child safety issues. A sample of 114 first time mothers, including 38 each with 6, 12, and 18 month old infants, completed a telephone interview. All parents had physicians who had returned questionnaires. RESULTS: There was good correspondence between parents' and physicians' judgments about the safety issues most often covered, and what role physicians should adopt regarding parent education about child safety issues. In addition, they both agreed that parents seldom seek out safety information by asking questions. Relative to parent reports, however, physicians significantly overestimated the time they spent on safety issues and the degree of their direct involvement in communicating this information. The best predictor of time spent by physicians on safety issues was their rating of the importance of assuming the role of parent educator. The best predictor of parents asking questions about child safety was their rating of the adequacy of physicians' responses to previously asked questions. CONCLUSIONS: The results suggest that both physicians and parents contribute to undermine communication about child safety during well-baby visits.     

Familial occurrence of a del(Xp-) chromosome: pitfall in karyotype/phenotype correlation

PURPOSE: To examine the attitudes of physicians practicing in New Mexico toward gay and lesbian medical students, house officers, and physician colleagues. METHOD: In May 1996, the authors mailed a questionnaire with demographic and attitude questions to 1,949 non-federally employed physicians practicing in New Mexico. The questionnaire consisted of questions dealing with medical school admission, residency training, and referrals to colleagues. The response rate was 53.6%. RESULTS: Of all the responding physicians, 4.3% would refuse medical school admission to applicants known to be gay or lesbian. Respondents were most opposed to gay and lesbian physicians' seeking residency training in obstetrics and gynecology (10.1%), and least opposed to their seeking residency training in radiology (4.3%). Disclosure of homosexual orientation would also threaten referrals to gay and lesbian obstetrician-gynecologists (11.4%) more than to gay or lesbian physicians in other specialties. CONCLUSION: Physicians' attitudes toward gay and lesbian medical students, house officers, and physician colleagues seem to have improved considerably from those reported previously in the literature. However, gay men and lesbians in medicine continue to face opposition in their medical training and in their pursuit of specialty practice.     

Medical views of psychological consultation.

A questionnaire was mailed to 500 physicians in a five-state rural region in an effort to obtain their views, concerns, and attitudes about the utility of psychological consultations. The 500 physicians were randomly selected in equal numbers per state from national directories of internal medicine physicians and family practitioners. Of the 500 physicians surveyed, 139 (28%) responded by completing and returning the questionnaire. The results suggest that physicians generally view psychological consultations as helpful and necessary; however, they expressed concern about what training psychologists received as consultants. Physicians also expressed strong concern about the perceived lack of feedback from psychologists during and after consultations. The implications of the return rate and results are discussed. Recommendations to establish greater credibility and to improve interactions between physicians and psychologists are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Letter: Random thoughts on abortion attitudes

Comments on a paper of physicians' attitudes toward abortion are presented. The reasons for approval of abortion which show about 80% citing medical or psychiatric and only 60% citing social reasons or a woman's right to do with her body what she wants support the belief in the sexist attitudes of physicians. Disbelief is voiced toward the 1 physician who feels a woman cannot become pregnant from incest or rape, and towards the physician who believes a woman's mental health is unthreatened by an unwanted pregnancy. The author wonders if there were differences between male and female physicians sampled.     

Effects of information on attitudes toward and interpersonal acceptance of persons who are deaf.

225 undergraduates completed measures of authoritarianism and attitudes toward persons with disabilities before reading sketches that contained information about deaf target persons labeled as deaf or labeled and described as deaf. Measures of acceptance of the target person and attitudes toward persons who are deaf were then taken. Results indicate partial support for the prediction that information affects attitudes toward persons who are deaf but no support for the prediction that information also affects interpersonal acceptance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Skills that Iowa family physicians desire in a new physician partner

BACKGROUND AND OBJECTIVES: The importance of specific skills in primary care continues to be debated. As a result, there is not consensus on which skills need to be stressed during residency training. Our project asked community-based family physicians to rate the importance of specific skills in a new family physician partner. METHODS: Data were collected through a cross-sectional survey of all active members of the Iowa Academy of Family Physicians. Participants were surveyed by mail, using a list of 83 skills pertinent to primary care. Physicians were asked to rate the importance of a new member of their practice having the individual skills on this list. RESULTS: A total of 546 family physicians (67%) completed questionnaires. Fourteen skills (seven cognitive and seven psychomotor) were reported to be "essential" or "very important" by at least 80% of the physicians. A total of 43 skills were rated as "essential" or "very important" by at least 50% of responding family physicians. Many of the hospital-based procedural skills, particularly those used in an intensive care setting, were rated as less important. The importance ratings of many skills were associated with the physicians' ages, size of their primary hospitals, and availability of other medical specialties. CONCLUSIONS: Family physicians tended to rate office-based procedural skills, counseling skills, and management skills as "essential or very important" to their practices. These rating might be used to guide residency training in family practice.     

Effect of erythromycin on feeding intolerance in very low birth weight infants: a preliminary observation

The objective of the study was to measure the change in physicians' attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p < .005) and less for quality improvement (first survey 85% vs second survey 67%, p < .008) over time. These findings may create a barrier to physicians' adoption of practice guidelines.     

Impact of sonography on the diagnosis and treatment of acute lower abdominal pain in children and young adults

OBJECTIVE: Our purpose was to evaluate the impact of sonographic data on clinical physicians' diagnostic confidence and their treatment of children and young adults with acute lower abdominal pain. SUBJECTS AND METHODS: Senior surgical and emergency department staff completed questionnaires before and after abdominal sonography was performed on 94 of 101 consecutive children and young adults with acute lower abdominal pain, pelvic pain, or both. Physicians who were unaware of sonographic data stated the most likely diagnosis and their level of confidence in their diagnosis and then formulated clinical plans. After they were given sonographic data, physicians again stated the most likely diagnosis, estimated their level of confidence, and formulated revised treatment plans. RESULTS: Sonographic data resulted in revised clinical diagnoses in 52% of the patients. Overall, the gain in diagnostic confidence for the entire study population was 33% (95% confidence interval [CI], 27-38%; p < .0001). The impact on the physicians' confidence was greater in those children and young adults whose diagnoses changed after sonography (mean increase in physicians' confidence, 48.3%; 95% CI, 47-75%). In patients whose diagnoses were not changed after sonography, the mean increase in physicians' confidence was 17.6% (95% CI, 11-24%; p < .0001 [analysis of variance]). Physicians used sonographic data to change initial treatment plans in 43 patients (46%). Of these 43 patients, a lower intensity of care was given to 30 patients (70%) and a higher intensity to 13 patients (30%). CONCLUSION: Sonographic data frequently changed initial clinical diagnoses, thus increasing diagnostic confidence and changing clinical treatment decisions in the setting of acute lower abdominal pain in children and young adults.     

Diagnosis and treatment of prostatitis in Canada

OBJECTIVES: There is a general consensus among physicians that the present management of chronic prostatitis is dismal. We undertook a survey of Canadian primary care physicians (PCPs) and urologists to determine the degree and source of frustration and to analyze present practice patterns in this disease. METHODS: Five thousand PCPs and all 545 Canadian urologists were asked to complete a comprehensive computer-assisted telephone survey that explored practice characteristics, attitudes, and diagnostic and treatment strategies in the management of prostatitis. Randomization of attribute banks, adherence to questionnaire routing, validation by on-site monitoring, and possible bias were addressed. RESULTS: Completed interviews were obtained from 10% of PCPs and 28% of urologists. PCPs see on average 3.5 (median 2) patients with prostatitis per month and urologists see on average 21.8 (median 11) patients with prostatitis per month. All physicians experience significantly more frustration in treating prostatitis than they do in treating patients with benign prostatic hyperplasia (BPH) and prostate cancer, and they perceive that prostatitis affects patients' quality of life significantly more than BPH and almost as much as prostate cancer. The degree of frustration and unhappiness in dealing with prostatitis is driven by a lack of confidence and comfort in their ability to accurately diagnose and subsequently rationalize treatment. Most PCPs and urologists continue to employ steps in addition to history and physical examination to establish a diagnosis but only a few PCPs and a third of urologists use specific lower urinary tract cultures. Physicians tend to use trimethoprim or trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone as their usual first line therapy for chronic prostatitis. The most commonly used therapeutic strategy (40%) for chronic prostatitis was TMP-SMX as first line therapy and a fluoroquinolone as second line therapy. CONCLUSIONS: There is widespread frustration, discomfort, and lack of confidence in both PCPs' and urologists' perceived ability to manage prostatitis. Physicians have expressed a desire for a better understanding of this disease, simpler and clearer diagnostic guidelines, and more rational treatment strategies.     

Factors affecting primary care physician participation in Medicare

OBJECTIVES: This study investigates the levels of participation and the relative association of economic and noneconomic factors on primary care physician participation in the Medicare program. METHODS: Demographic information, participation in Medicare, and attitudes toward both the Medicare program and Medicare patients were collected in a written survey mailed to half the primary care physicians in Iowa. Ordinary least squares and logistic regression analyses were conducted to determine factors associated with the percentage of Medicare patients in a practice and the acceptance of all new Medicare patients, respectively. RESULTS: Two thirds of physicians were accepting all new Medicare patients, whereas 16% were accepting no new Medicare patients. Factors associated with having a higher percentage of Medicare patients in a practice were as follows: (1) a larger proportion of Medicare recipients in the county, (2) practice as a general internal medicine physician, (3) more years in practice at the current location, (4) greater enjoyment treating elderly patients, (5) less concern about having too many Medicare patients, and (6) a stronger belief that the Medicare program respects their professional judgment. Physicians less concerned about having too many Medicare patients in their practice and physicians in counties with a higher percentage of Medicare patients were significantly more likely to accept all new Medicare patients. CONCLUSIONS: These results suggest that as Medicare reforms are discussed, careful consideration of the impact of these reforms on noneconomic issues is important to ensure adequate physician participation and access for elderly patients through the Medicare program.