Darer, Jonathan D. MD, MPH; Hwang, Wenke PhD; Pham, Hoangmai H. MD; Bass, Eric B. MD, MPH; Anderson, Gerard PhD
Approximately 125 million North Americans have one or more chronic diseases, accounting for over 75% of health care spending.1–3 More than 80% of persons over the age of 65 have one or more chronic disease, and more than 10% of children in the United States have a chronic condition.3–5 Despite the prevalence and burden of chronic illness, health care delivery in the United States is largely organized and financed around acute illness.6 As a result, current delivery systems are poorly adapted to the needs of patients with chronic conditions.7–12 Quality audits have repeatedly documented that current care delivery systems are unable to adhere to established guidelines in the care of hypertension, diabetes, asthma, frailty, and other chronic conditions.6,13 Medical training may be partly responsible for poor chronic illness care if it has failed to adequately train physicians to care for people with chronic conditions.12,14
To assess physicians’ perceptions regarding the adequacy of training in chronic illness care, we administered a survey of U.S. physicians to determine whether they believed they had received adequate training in ten specific aspects of caring for persons with chronic conditions. We also sought to determine how physicians viewed the effects of their training on their attitudes toward caring for persons with chronic conditions. Because training priorities vary across specialties, we examined whether physicians’ views about the adequacy and effects of their training differed between family physicians, internists, pediatricians, nonsurgical specialists, and surgical specialists.
We compiled a stratified sample of 2,304 U.S. physicians with the objective of including 50% primary care physicians (i.e., family practice, general practice, internal medicine, internal medicine/pediatrics, and pediatrics) and 50% specialists. The sample was drawn from the American Medical Association's (AMA) and American Osteopathic Association's (AOA) Master Files. Primary care physicians were over sampled to facilitate statistical comparisons with specialists. Practice specialty was defined by the self-reported primary specialty in the AMA or AOA database. The practice specialty definition and sampling procedure, designed to generate a nationally representative sample of physicians by gender, age, and geographic region, were the same as adopted by the Physician Survey of the Community Tracking Study.15–17 The sampling weights were computed after adjusting for the probability of nonresponse. The survey had a sampling error of ±3%.
Physicians were eligible if they practiced in the 48 contiguous states or the District of Columbia and currently had 20 or more hours of direct patient contact per week. Physicians were excluded if they were federal or state employees, were residents or fellows in a hospital or academic institution, or had limited or no direct patient contact (e.g., pathologists). The sampling frame consisted of approximately 370,000 U.S. physicians.
The instrument was developed after reviewing the chronic disease and medical education literature.4,6,7,12,14,18–22 Based upon the literature, we defined a chronic condition as “any condition that is expected to last a year or longer, limits what one can do, and may require ongoing care.”2
The instrument was designed to examine several domains including physicians’ demographics, career satisfaction, practice characteristics, the perceived adequacy of medical training regarding representative chronic disease care competencies, and the effect of medical training upon attitudes toward care of persons with chronic conditions. We identified competencies in chronic care by reviewing curricula that address chronic illness, palliative care, and end-of-life care. The competencies were reviewed by two members of the Johns Hopkins School of Medicine faculty, two external expert reviewers, and a panel consisting of representatives from the Association of American Medical Colleges (AAMC), the American College of Physicians–American Society for Internal Medicine Foundation, the American Geriatrics Society, the National Chronic Care Consortium, Clerkship Directors of Internal Medicine, and the Robert Wood Johnson Foundation advisory panel for the national program Partnership for Solutions. Multiple levels of review were used to maximize the face validity of the instrument's content. The targeted chronic disease competencies in this survey represented the general competency areas identified through the review process and were intended to be a representative rather than an exhaustive list of relevant competencies. They were (1) applicable to persons with one or more chronic conditions, (2) not specific to a single disease, and they (3) highlighted the longitudinal, multidisciplinary, and nonbiomedical aspects of chronic illness care. We did not attempt to make the competencies specialty-specific because that would have made it difficult to compare responses between specialties.
Responses to questions regarding the adequacy of training were recorded on a three-point scale (more training than needed, right amount of training, or less training than needed). To minimize social response bias, we included an array of responses such that the neutral response was adequate training. The effects of training on attitudes were also measured on a three-point scale (feeling positive, feeling neutral, and feeling negative).
We contracted a professional survey service (Mathematica Policy Research, Inc.), to conduct the survey between November 2000 and June 2001. Physicians were sent an advance letter describing the study and notifying them that they would be contacted by phone. The interviews lasted approximately 15 minutes. We paid physicians a $25 honorarium to complete the survey.
The independent variable was practice specialty. The main outcome measures were the perceived adequacy of training in ten chronic illness care competencies and the reported effects of training on physicians’ attitudes toward taking care of persons with chronic conditions. Covariates included physicians’ demographics (years since graduation from medical school, race/ethnicity, gender), the proportion of patients in the physician's practice with a chronic condition, and the proportion of patients in the physician's practice in three age categories (<18 years, 18–64 years, or >64 years). Although the survey was originally designed to detect differences between primary care and specialist physicians, the large sample size allowed for retrospective subdivision of physicians into five subgroups while maintaining reasonable statistical power to detect differences across specialties. Primary care physicians were subdivided into family or general practitioners, internal medicine, and pediatrics. Specialist physicians were subdivided into surgical specialists (cardiothoracic surgery, general surgery, neurosurgery, obstetrics and gynecology, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, urology, and vascular surgery) and nonsurgical specialists (allergy, cardiology, dermatology, emergency medicine, endocrinology, gastroenterology, hematology, infectious disease, geriatrics, nephrology, neurology, oncology, physical medicine and rehabilitation, psychiatry, pulmonary and critical care, and rheumatology).
Descriptive analyses were performed for the independent and dependent variables. We used chi-square test statistics for bivariate analyses. Based on the results of bivariate analyses, we constructed multiple logistic regression models to estimate the adjusted percentage of each physician group that reported receiving less training than needed for a given competency or that reported a positive attitude about giving chronic illness care. These analyses adjusted for differences in characteristics of the respondents To adjust for the complex stratified sample design, we used the software package SUDAAN version 8.0 (Research Triangle Institute, Research Triangle Park, North Carolina). All other statistical analyses were performed using SAS, version 8.2 (SAS Institute, Casey, North Carolina) or Stata, version 7 (Stata Corporation, College Station, Texas).
The instrument and implementation protocol were approved by the Johns Hopkins University Bloomberg School of Public Health institutional review board.
Of the 2,304 physicians sampled, 2,237 were located, 1,905 were eligible, and 1,236 (65%) responded. The mean age of respondents was 46.7 years, and the average number of years since graduation from medical school was 19.4. Twenty-six percent of the respondents were female, and 72% were non-Hispanic white. Other respondent characteristics are shown in Table 1.
Respondents were 270 family or general practitioners (65% response), 231 internists (62% response), 129 pediatricians (79% response), 335 nonsurgical specialists (64% response), and 271 surgical specialists (64% response). Response rates did not differ by physicians’ specialty except for a higher rate among pediatricians. Of note, 26% of respondents worked mostly with elderly adults, and 24% of respondents reported that 80–100% of their patients had a chronic medical condition. Most physicians found their careers to be very satisfying (see Table 1).
Adequacy of Training in Competencies for Chronic Illness Care
Most physicians reported that, with respect to the demands of their current practice, they had not received adequate training in the ten chronic care competencies: approaches to educating chronically ill patients (66% of all physicians, range 62–74%), end-of-life care (65%, range 60–67%), coordination of in-home and community services for the chronically ill (65%, range 56–70%), management of geriatric syndromes (65%, range 56–68%), management of psychological and social aspects of chronic illness (64%, range 60–67%), assessment of caregiver and family needs for patients with chronic illness (63%, range 58–72%), chronic pain management (63%, range 60–70%), nutrition in chronic illness (63%, range 49–74%), interdisciplinary teamwork with nonphysician providers for the chronically ill (61%, range 52–70%), and assessment of developmental milestones in chronically ill children (60%, 53–61%).
A majority in all specialty groups reported inadequate training for all ten competencies with one exception (49% of family practitioners felt inadequately prepared to address nutrition in chronic illness). Family practitioners, compared with other physician groups, tended to have the lowest unadjusted percentages reporting inadequate training in competencies.
In multivariate analyses, family practitioners were less likely to report that their training was inadequate for most of the competencies when compared with other specialists (see Table 2). When compared with internists, family practitioners were significantly less likely to respond that their training was inadequate in seven competencies (management of geriatric syndromes, management of chronic pain, nutrition in chronically ill patients, approaches to educating chronically ill patients, assessing the needs of caregivers and families, coordinating services for the chronically ill, and teamwork with nonphysician providers for the care of the chronically ill). Family practitioners also were less likely to report inadequate training on nutrition in chronic illness and coordination of services when compared with pediatricians, on geriatric syndromes and nutrition in chronic illness when compared with nonsurgical specialists, and on geriatric syndromes, nutrition in chronic illness, coordination of services for the chronically ill, and teamwork with nonphysician providers when compared with surgical specialists.
Physicians graduating within the last ten years were less likely to report inadequate training in six competencies when compared with physicians graduating 11–20 years ago, and in eight competencies when compared with physicians graduating more than 20 years ago. Even after adjusting for time from graduation from medical school, the majority of physicians in each specialty felt that they received inadequate training in these competencies (with the exception of management of psychological and social aspects of chronic illness care for pediatricians). For readers interested in details about the relation of other factors to the reported adequacy of training in each competency, additional information is available on request.
Effects of Medical Training on Attitudes toward Chronic Illness Care
Most physicians responded that medical training had a positive effect on their attitudes toward providing care to persons with chronic conditions, including the ability to make a difference in the lives of patients with chronic illness (80%, range 74–85%), the ability to care for chronically ill patients without being able to cure them (70%, range 64–76%), and the ability to influence patient behavior (60%, range 57–64%). Fifty-one percent of all physicians (range 39–60%) responded positively regarding the effect that their medical training had on their feeling regarding care of patients with chronic illness, approximately 40% responded that training had a neutral effect, and 10% reported that training had a negative effect.
In multivariate analyses, family practitioners consistently rated the effect of training on their attitudes more positively than did physicians in other specialties (see Table 3). These differences achieved statistical significance for questions about the effect of training on their attitudes regarding: “taking care of patients with chronic illness” (compared with surgical specialists), “your ability to care for patients even if you can't cure them (compared with surgical specialists),” and “being able to make differences in the lives of patients with chronic illness” (compared with pediatricians and surgical specialists). In the multivariate analyses, physicians who graduated from medical school within the last ten years were more likely than those who graduated 11 to 20 years ago to report a positive attitude regarding “your ability to care for patients even if you can't cure them.” Otherwise, reported attitudes did not differ by time from graduation from medical school. For readers interested in details about the relation of other factors to the reported attitudes, additional information is available on request.
Commentators have generated a growing list of physicians’ competencies that are important to care of people with chronic conditions.19 Despite the concern that many physicians are poorly prepared to address the complex medical and psychosocial needs of persons with chronic conditions,18 few data exist on how well practicing clinicians feel they have been prepared by their medical training to deliver chronic care.
We found that the majority of practicing clinicians in both primary care and specialty fields felt their medical training had resulted in positive attitudes about their ability to care for persons with chronic conditions, but that they had received less training than they felt they needed in a range of specific chronic care competencies. Although this contrasts with recent findings that most graduating residents at academic health centers felt prepared to manage most of the common conditions they would expect to encounter in their specialties,23 it is consistent with the findings that most residents felt less than “very prepared” in specific topics relevant to chronic care, such as pain management, palliative care, and interdisciplinary collaboration. Similar reports exist of high attainment of attitudinal goals but lower attainment of specific competencies in palliative care among graduating medical students.24 Although our study was not designed to assess the adequacy of curricular changes in medical schools in the last three years, a recent survey of medical school course directors found considerable variation in how required courses addressed important chronic care competencies.25 This suggests that training in chronic care competencies may still be inadequate for many physicians.
We did not ask physicians to ascribe deficits in training to particular education stages, but the cumulative data suggest that deficits probably exist at all levels of training. We found that recent medical school graduates, those physicians likely to have entered into practice within the last five to seven years, were more satisfied with their education in chronic care than were older graduates. This finding indicates that some change in the culture of medical education has taken place over the past decade, perhaps as attention has shifted toward ambulatory care settings and competencies, and as new physicians have adjusted their practice expectations to changing patient demographics and practice situations.26–30 The source of physicians’ dissatisfaction with chronic care education may be the result of an academic inertia that is slowly being rectified over time. While the need for better training in chronic care content areas may have been apparent to practicing physicians for some time, educators may have more recently become aware of these gaps in training. However, even adjusting for years since graduation from medical school, we still found that most physicians felt more chronic care education was needed, suggesting that educators still have a long way to go toward preparing new physicians to meet the demands of current practice.
We also found that family practitioners were more likely than other primary care practitioners or specialists to report that their training was adequate in specific competencies and that their training had positive effects on their attitudes toward chronic care. These differences persisted after adjustment for physicians’ characteristics, including prevalence of chronic conditions within practices. A combination of factors may explain this. First, the learning priorities and culture in family practice training may generate more positive attitudes toward and better preparation for providing chronic care compared with surgical specialties and other nonsurgical specialties. Family practice training may emphasize longitudinal care and psychosocial competencies more than other specialties.31 While probably most pronounced during postgraduate training years, these differences may begin as early as medical school, to the extent that specific schools are more likely to produce graduates who go on to choose family practice as a specialty.32 Training differences may amplify differences in the preexisting characteristics of those who choose family practice compared with those who choose other specialties.
In addition to giving greater attention to specific competencies, family practice training may provide more realistic expectations of actual practice conditions than does training in other primary care specialties. For example, the vast majority of internal medicine residency training time is spent in inpatient settings, despite recent trends to incorporate more ambulatory care experiences. A disparity in training settings may still exist in pediatrics residencies.28 Inpatient settings may not adequately prepare internists and pediatricians for the realities and practice demands of the outpatient setting, such as difficulties in coordination of community-based services. Moreover, emphasizing acute care may lead physicians to rely on an intensity of diagnostic testing and treatment that may not be appropriate in the chronic care setting, and that they may find frustrating, unrewarding, or both. Improving chronic care education may require switching to a more longitudinal framework, across different settings and over time. For example, some programs have incorporated home visits to help students learn to manage chronic conditions in nonacute settings.19
We could not account fully for patient case-mix differences. This may explain some of the differences in attitudes and perceived adequacy of preparation between physician groups. Although earlier smaller studies comparing patient case-mix found no significant differences in case mix between internal medicine and family practice,33 the Medical Outcomes Study found consistent interspecialty differences. Family practice patients had higher functional status and were less likely to have one or multiple chronic conditions than were general internal medicine, cardiology, or endocrinology patients.34 Even given similar prevalence of chronic conditions among family practice patients compared with medicine and pediatrics patients, internists and pediatricians may see patients with unmeasured differences in the complexity of illness (more comorbidity or greater severity).34 Higher disease burdens may result in higher care burdens, less career satisfaction, and a greater sense that medical training was not adequate preparation for practice.35–39 However, for case-mix differences to explain our findings they would have to be disproportionate to case-mix differences in patients seen during training. Otherwise, we would expect that greater exposure to more complicated patients during training would better prepare internists and pediatricians for practice.
The strengths of this study were the use of a representative national sample of clinical practice physicians, a relatively high response rate for this population, and adjustment for demographic and practice characteristics. Despite these strengths, our study had several limitations. First, because the mean of years beyond medical school training for respondents was 19, recall bias may have artificially raised or lowered ratings of training adequacy and effects on attitudes. Second, little is known about the relation between perceived adequacy of training in competencies and actual performance measured by patient outcomes or adherence to quality indicators. By bringing attention to concerns about the perceived adequacy of training in chronic care, this study may help promote future work examining this relationship. Third, responders may have been more or less likely than nonresponders to answer positively regarding the effect of their chronic care training. However, our response rate was 65%, which compares favorably to other large physician surveys.40–43 It is unlikely that selection bias significantly affected our results because response rates were similar across physician groups. It is difficult to assess whether responders would be more or less likely to answer positively regarding the effect of their chronic care training. Fourth, it is possible that perceived adequacy of training is related to physicians’ satisfaction with practice in more than one way, but we could not sort that out in this cross-sectional survey. Fifth, we included only ten competencies relevant to chronic care. Differences between specialties may be attenuated or more dramatic for other chronic care competencies, such as managing pharmacologic issues or assessing functional abilities. Although the responses were relatively consistent in rating training adequacy both within and between specialty groups for the competencies we included, the instrument was discriminating enough to reveal a number of significant differences in ratings between the physician groups. In addition, the responses varied across items for each of the physician groups: the adjusted percentage reporting less training than needed for specific items ranged from 45% to 81% (see Table 2), and the adjusted percentage feeling positive about specific items ranged from 34% to 84% (see Table 3). Finally, as discussed earlier, we adjusted for the reported percentage of patients in each physician's practice with chronic illness, but we were unable to account for other differences in case mix between specialties.
In conclusion, most practicing physicians, regardless of specialty, reported that medical training had a positive effect on their attitudes toward care for people with chronic conditions but was inadequate preparation for many chronic care competencies. Our results suggest that medical educators at all levels should reassess curricula for content on chronic care. Although medical school may be the most appropriate setting to introduce or modify chronic disease curricula for a broad physician audience, medical students are only likely to learn the basics of chronic disease care. Because each medical and surgical specialty has unique demands with respect to patients with chronic conditions, residency and fellowship programs will need to reevaluate chronic care education to enable practitioners to be more confident in their clinical skills.
This project was supported by the Partnership for Solutions, a National Program of the Robert Wood Johnson Foundation. Dr. Darer was supported by grant 5-T32-PE10025 from the Health Resources and Services Administration. Dr. Pham was supported by grant T32 HL07180 from the National Heart, Lung, and Blood Institute.
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