Putzer, Gavin J. MD, MPH; Koro-Ljungberg, Mirka PhD; Duncan, R. Paul PhD; Dobalian, Aram PhD, JD
* Bioterrorism agents may cause mass casualties, resulting in significant morbidity and mortality, societal disruption, and long-term human and economic hardship.
* This study used a qualitative methodology with semistructured physician interviews from federally designated rural areas followed by grounded theory methods for data analysis.
* The findings of this study suggest that some rural physicians in Florida believe that they are inadequately prepared from a cognitive, clinical, expectation, and/or simulation perspective for public health emergencies such as bioterrorism events.
* Preparedness initiatives, policies, and disaster management can be implemented effectively only if physicians are aware of the possibility of bioterrorism, suspect and recognize an event when it occurs, notify authorities promptly upon suspicion of such an event, and institute appropriate medical management.
Human-induced emergencies (eg, the terrorism events of September 11, 2001 and the 2001 anthrax attacks) have raised awareness of the nation’s vulnerability to large-scale emergencies. To moderate the risks and magnitude of public health emergencies deriving from such events, the United States has made emergency preparedness a priority for governmental agencies and physicians. Although much of the aftermath of these events has resulted in an increased focus on these agencies specifically in urban areas,1–3 it has become clear that such a focus also is necessary in rural areas4; however, scant attention has been given to preparing rural physicians for emergencies,5,6 despite the fact that many experts agree that the risks such incidents would pose to human health appear equally great in rural and urban areas.5,7–9
Emergency preparedness among rural physicians is a significant issue for the nation given that roughly 80% of US land is classified as rural and 25% of the population lives in rural areas.10,11 Adequate emergency preparedness in rural communities depends on coordinated efforts among health institutions and professionals; however, rural facilities tend to have less capacity and resources as well as less epidemiological surveillance capacity than do their urban counterparts. For example, there are fewer physicians on a per capita basis in rural settings than in metropolitan settings.1,12 Furthermore, in comparison to urban communities, which typically have several hospitals, many rural communities have a single hospital as the nucleus of health planning.13,14 National policy changes have encouraged hospitals to downsize capacity in an effort to contain costs and, as a result, rural hospitals lack surge capacity.13,15 Rural physicians are more likely than urban physicians to provide care outside their specialty areas.12,16 Thus, if emergency-related resources and specialty physicians in rural areas are lacking, rural readiness for emergencies may be compromised.
A few studies explain that the present generation of physicians believe that they are unprepared in both their knowledge base and confidence levels to address bioterrorism and its consequences.17–20 Previous research has underscored this point by showing that community clinicians often are the first to identify bioweapon victims yet remain inadequately prepared clinically to address such events.1,2,4,5 An Internet-based survey among Florida community health professionals suggested that only one-third were adequately prepared from a clinical perspective for a bioterrorism incident.21 This suggests a need to educate clinicians on the signs, symptoms, and reporting mechanisms of bioterrorism-related diseases. Previous reports provide evidence of both knowledge gaps and high levels of interest in bioterrorism-related training among physicians2,17,19; thus, a need exists to improve bioterrorism preparedness.17,18 The objective of the present study was to provide a greater understanding of rural physicians’ preparedness for a bioterrorism event. This study presents a conceptual model for understanding the preparedness of physicians for such emergencies. We believe that the presented model can illustrate some areas of questions, concerns, and future studies, stimulating ideas regarding how to improve the preparedness of rural physicians in responding to bioterrorism events.
Qualitative research studies have become more prevalent in health research and medicine.22,23 Denzin and Lincoln note that qualitative researchers make sense and interpret phenomena in ways in which participants bring meaning to the phenomena.24 Furthermore, qualitative research uses field or documentary/historical research styles, and the sampling is driven not by a need to generalize or predict, but rather by a need to create new interpretations.22 Crabtree and Miller ask how researchers should select a sample from a larger pool for closer scrutiny.22 They support ways in which one can have confidence that the sample chosen is appropriate and adequate.22 Patton suggests that qualitative research “typically focuses in depth on relatively small sample sizes, even single cases (n = 1), selected purposefully.”25 Patton states that “the validity, meaningfulness, and insights generated from qualitative inquiry have more to do with the information-richness of the cases selected and the analytical capabilities of the researcher than with sample size.”25
This study used a qualitative approach incorporating key informant interviews. Florida was considered an appropriate location given that it was the initial site of the 2001 anthrax attacks and half of the state’s counties are rural. The university institutional review board approved the study.
Purposeful sampling was used to ascertain the representativeness of the settings and the individuals. Purposeful sampling guides researchers to choose particular participants because they are believed to represent or feature processes, phenomena, or experiences of interest.26,27 Six interviews were conducted in five federally designated rural counties. The participants were selected based on specialty (primary care), location (rural), and setting (health department). Representative settings were selected that identify what is typical regarding rural physicians’ perceptions of and beliefs about a bioterrorism event.
Semistructured interviews were conducted in 2004–2005. Each interview was conducted by the same two investigators in person for 30 minutes. To assess physician professional preparedness, the following questions were posed:
1. Can you describe the likely medical conditions following a bioterrorist attack?
2. Can you describe the likely mental health conditions?
3. How would you monitor patients’ care?
4. How would you monitor patients’ mental health care?
5. Have you had an opportunity to learn about bioterrorism agents?
6. How important is it for physicians to receive bioterrorism training?
The interview data were transcribed verbatim in preparation for a rigorous data analysis. Grounded theory method was used to analyze the data.28 Transcripts were checked for accuracy and then coded. The coding process proceeded from the specific to the general by beginning with particular pieces of data (open codes) and continuing toward the development of a meaningful whole (conceptual model). Sentences and occasionally paragraphs formed our smallest unit of analysis. We followed Strauss/Corbin’s and Charmaz’s process for coding: open, selective, and theoretical.29,30 The codes were constantly compared with each other to develop an inductive and data-based conceptual model that illustrated participants’ experiences of preparedness. Codes were developed by one coder, but the codes and emerging model were continuously reviewed by another qualitative researcher. The interviews were ceased after six physicians because repetition was found in the data. Lincoln and Guba posit that member checks are the most crucial technique for establishing credibility.31 Member checks were conducted by contacting participants after interpretive summaries were developed for verification. Every component in the model was driven by the data and participants mentioned them in their transcripts, although we may have not asked specific questions about each component. Conceptual models are theories resulting from grounded theory analysis. They are inductive and grounded in data rather than developed deductively or based on the existing literature on the topic.28–30
Disaster preparedness is defined as a state of readiness to respond to a disaster.4,32 Emergency preparedness requires physician awareness regarding the possibility of a disaster at any time. After an analysis of participant responses, we created a conceptual model to illustrate the salient components of physician preparedness. The conceptual model (Fig. 1) illustrates the components affecting the preparedness of a physician in the context of bioterrorism.
The conceptual model proposes three contextual components: setting, personal, and professional preparedness elements. Although the emergent event may represent a natural disaster or a human-induced event, in our study, a bioterrorism event was chosen. It is important to note that each contextual factor may have a tangible impact on another contextual setting.
The first circular component represents the setting, represented by a rural geographic area. The next circular component represents the personal context of a physician. This component includes factors such as age, training, and career stage. The final circular component represents physician professional preparedness.
In formulating the conceptual model based on an analysis of the participant data, we defined physician professional preparedness as factors that physicians perceive, anticipate, and experience as being important during and following an emergency. A physician’s professional preparedness is influenced by four interrelated elements: cognitive, clinical, expectation, and simulation preparedness. Fig. 2 shows a time continuum reflecting these four elements at the time of the study data collection (2004), the implementation of the American Board of Disaster Medicine in 2006 and the postboard formation after 2006.
Cognitive and Clinical Preparedness
Cognitive preparedness encompasses the physician’s scientific knowledge and analytical reasoning acumen. Clinical preparedness involves a physician being alert and sensitive to patient symptoms along with the corresponding overt and covert medical signs if such an event has occurred. Clinical preparedness incorporates cognitive preparedness coupled with the corresponding confidence to identify bioterrorism agents from more pedestrian, ubiquitous infectious diseases such as influenza. Thus, clinical preparedness involves a physician being able to discern between a clinical sign or patient symptoms of a verifiable infectious condition related to a bioterrorism agent such as anthrax from other, more common infectious ailments that may present in a similar fashion.
Each physician expressed the anticipated surge in the number of patients presenting to the facility after an event. The participants explained that this surge would consist of two patient categories: an exacerbation of preexisting disorders and previously undiagnosed patients presenting with perceived and/or possibly new disorders (eg, physical, mental, psychosomatic). Clinicians explained that the number of “people that think they are infected would dramatically increase” and “there would be an “exacerbation of most people’s anxieties.” Similarly, it was also stated, “PTSD [posttraumatic stress disorder], anxiety, and substance abuse would probably flare more.” Not only would there be an increase in patients who exhibit physiological symptoms of stress but there also would be an increase in patients with psychosomatic symptoms. One physician explained that there would be a plethora of patients presenting with “all the symptoms—real or thought up.” This physician stated that there would be an increase in patients who truly need care and among patients who are worried about their own perceived morbidity and mortality and therefore perceive that they need medical attention. Furthermore, he explained, “if you look at anthrax, you get a fever, cough, or symptoms common to other illnesses.” Physicians believed that with many of the respiratory bioterrorism-induced illnesses, the early symptoms mimic the symptoms of influenza and thus it may be difficult to differentiate the etiology of illnesses.
There was consensus among the physicians that preexisting conditions would be exacerbated and many new illnesses would arise. For instance, an exacerbation of respiratory symptoms would occur if agricultural products were infected. Alternatively, a gastrointestinal condition may occur because of a salmonella infection. Each participant expressed medical treatments would be highly dependent upon the precipitating event and the diagnosis.
Expectation and Simulation Preparedness
With expectation preparedness, a physician must anticipate the possibility of an event and be prepared for the aftermath, which may be manifested by a patient’s altered health condition. Accordingly, expectation preparedness involves physicians not only anticipating but also accepting the reality that an attack may occur.
Simulation preparedness involves the actual training pertinent to emergencies such as drills/exercises depicting possible scenarios. The objective of simulation training is to assist with preparedness by offering pragmatic, hypothetical experiences. There were contrasting views among physicians regarding simulation preparedness. Respondents unanimously stated that there were many opportunities, yet only three physicians participated.
Physicians placed a greater emphasis on bioterrorism education and training after the events of September 11, 2001. When discussing the importance of training, one doctor stated, “I think that it is. There is certainly a place for it. It was lower in the list before 9/11. It is the world in which we live in. I think we all recognize that. Do we see anthrax every day? No, but it does come up. Is it something we have studied? No, but we are all aware of it.” Every physician noted opportunities to learn about bioterrorism agents. For example, one stated, “Yes, we have had opportunities. Have we taken advantage of those opportunities? No. The last time we did something was 2 years ago.” Another doctor explained the importance of bioterrorism preparedness, “relative to other things, the importance is a five. Some people would ask why not a ten? Bioterrorism acts can happen, but there are the everyday realities of dealing with people’s [other] problems.”
Two respondents offered training sessions explained that they have attended “lots of them.” One articulated, “We have done drills. We had classes here—small group discussions. There is a lot of asking what if, how do we handle such? The first wave of people that we will see will be the mental health people. The people who truly have an exposure to the event will probably remain on the scene.” Another participant stated, “We had a CME [continuing medical education] day with bioterrorism—smallpox and anthrax.” This respondent had attended numerous seminars with simulation training involving mock exercises. In contrast to the other four participants, it appears that these two physicians believed that they were prepared to respond to a bioterrorism event.
The present study introduced a conceptual model developed from participant responses to improve our understanding of rural physician preparedness regarding bioterrorism events. Rural physicians reported varied levels of professional preparedness from the perspective of the model’s derived elements of expectation, simulation, clinical, and cognitive preparedness.
The model adds to the existing literature by postulating holistic preparedness elements and the need to connect physician preparedness with other health personnel and emergency officials to improve information channels and expectation preparedness. The model explains the importance of disaster preparedness and the need to focus on continuing to improve these elements to prepare rural physicians adequately for bioterrorism.
The American Board of Disaster Medicine is an affiliate of the Academy of Disaster Medicine, which comprises physicians with considerable knowledge of disaster management. The board was formed in 2006 for the purpose of education in the discipline of disaster medicine and board certification in this new specialty. The principal objectives are to help train, coordinate, and promote the science of disaster medicine.
Fig. 2 reflects the changes regarding disaster preparedness from the beginning of our study in 2004 through the implementation of the board and beyond. This figure includes a preboard period when the data were collected and the status of the four elements defined in our study. At the time of data collection, there was no formal board and each preparedness element was marginally adequate or deficient, according to our participants. The process concludes with postboard implementation and the evolution of the four elements. Two elements—cognitive and clinical preparedness—presumably will improve with CME and certification opportunities. Expectation preparedness also should increase with enhanced awareness and information, although it may be tempered by the relatively infrequent number of bioterrorism events. Simulation preparedness opportunities have increased significantly.
In our opinion, resources for preparedness should be focused on physicians and other health personnel. Moreover, rural health organizations also should be a central focus. We chose to focus specifically on rural physicians, not to the detriment of other professionals or institutions, but rather because physicians often are the frontline decision makers in health settings. Physicians decipher clinical signs and are responsible for identifying and managing illnesses. For this reason, we believe that physicians affect preparedness on multiple levels within the organization and community. Thus, it is our opinion that targeting frontline decision makers directly should translate to heightened awareness among other health personnel and promote better coordination with emergency management organizations.
In our study, the physicians expressed an expectation of a large increase in patients presenting with illnesses. Physicians realized the need to be cognitively prepared from a scientific/educational perspective and the importance of clinical awareness to discern pertinent signs and patient symptoms. Physicians also recognized the need to have expectation awareness to consider bioterrorism infectious agents as a possible differential among presenting patients. The respondents articulated that the conditions and corresponding treatments would be event dependent.
Physician professional preparedness is, however, partially deficient in a few components. Many participants described their personal expectation of the likelihood of a bioterrorism event occurring as low or not as pertinent a priority as perhaps their expectation preparedness for more conventional illnesses. The majority of clinicians explained that although training opportunities existed, they had not availed themselves of these opportunities. Physicians expressed the inherent difficulties in differentiating early signs and presenting patient symptoms of a common respiratory illness from a possible bioterrorism-induced respiratory illness. Based on participant responses it appears that rural physicians believed that they were less than fully prepared regarding bioterrorism from the perspective of one or more of the elements of the formulated model.
According to the analysis of the respondent data and the formulation of our model, it appears that preparedness initiatives may be effectively achieved if physicians are aware of the possibility of bioterrorism, suspect and recognize an event when it occurs, and institute appropriate medical management. Broader public health aspects of bioterrorism preparedness, including prevention measures, also are important areas for informed action by physicians. Medical education and training curricula should include information on bioterrorism agents. Frontline physicians (ie, those most likely to examine patients affected by a bioterrorism agent) should participate more readily in CME and consider board certification in disaster medicine, given that participation in these programs was previously unavailable or inconsistent in our sample.
Our study had a few limitations. The study does have multisite designs, but the limitation of not having multiple participants at each site. This is primarily because many sites were staffed by only one physician. One way to increase the external validity of a qualitative study is to use several participants from different sites to represent the variation, which may allow the results to be applied to a greater range of similar situations.33 Another possible limitation of this study is a selection problem, which is known as key informant bias.34 This study used key informant interviews to describe preparedness. This is a limitation because when one relies on a small number of informants regarding a significant part of the data, it may not guarantee that the selected informants’ views are representative.35 Another limitation involves the research setting. Florida has a history of hurricanes; thus, the reported physician attitudes about preparedness may not reflect attitudes in states not prone to hurricanes.
This study introduces a conceptual model developed from participants’ responses that can be used to improve our understanding of rural physicians’ bioterrorism preparedness. The conceptual model is valuable because it illustrates some areas of question and future inquiry.
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