Wiesenfeld, Harold C. MD, CM*; Dennard-Hall, Keisha MD*; Cook, Robert L. MD, MPH†; Ashton, Michael MD, MPH‡; Zamborsky, Tracy MBA*; Krohn, Marijane A. PhD*
IN THE UNITED STATES, over 18 million new cases of sexually transmitted diseases (STDs) occurred in 2000, with costs of common STDs and their sequelae approaching $10 billion.1,2 Untreated, gonococcal and chlamydial infections in women can lead to pelvic inflammatory disease (PID) and its subsequent adverse impact on reproductive health.3,4 In addition, gonorrhea and chlamydia can enhance the transmission of human immunodeficiency virus (HIV).5,6 Most investigations of STD practice patterns among physicians have focused on screening practices. Screening for Chlamydia trachomatis infections in young women has been shown to offer health benefits, including prevention of PID, lowering the prevalence of chlamydia within a community, and possibly a reduction in risk of HIV transmission.7 Efforts to control the STD epidemic hinge on the provision of quality health care to individuals at risk for STDs. Unfortunately many physicians neither assess patients’ risk for STDs nor counsel patients about safe sex practices, and less than half of physicians currently screen sexually active young women for chlamydia.8–12
Deficits in knowledge regarding the diagnosis and management of STDs may partially explain the inadequacies that currently exist in the provision of care. In a survey of primary care physicians managing patients with PID, one half were unsure of treatment regimens and did not follow Centers for Disease Control and Prevention (CDC) guidelines.13 In addition, a survey of obstetrician-gynecologists found that 37% prescribed outpatient treatment regimens for PID that are not recommended by the CDC.14 There are limited data on physician knowledge regarding the diagnosis and treatment of STDs. The objectives of this study are to provide an assessment of knowledge of the management of STDs among primary care providers, to determine the influence of physician knowledge on practice patterns, and identify demographic variables and practice types associated with physician knowledge.
A random sample of 1600 physicians in Pennsylvania was obtained from the American Medical Association (AMA) master file (KM List, Berlin, NJ). We selected obstetrician/gynecologists, internists, pediatricians, or family physicians/general practitioners and structured the sample to include at least 40% female physicians and included physicians regardless of AMA membership status. The sample size was chosen to provide sufficient power (80%) to detect differences in screening rates between gender and specialties of approximately 15%, given an estimated 50% response rate, as previously described.11
Data were collected via a self-administered, pretested 7-page questionnaire consisting of close-ended questions based on patient scenarios and took approximately 10 to 15 minutes to complete. Questionnaires were mailed in January 1998, and the initial mailing was followed by a postcard reminder and a second mailing for nonrespondents. A third survey questionnaire was sent to those who did not respond within 6 months. Physicians were excluded from the study if they could not be located by mail or telephone despite multiple attempts; if they were retired, on leave, or deceased; if they were no longer residents of Pennsylvania; or if they did not provide routine primary care or gynecologic care to adolescent or young adult women ≤25 years.
The questionnaire gathered information on physician demographic information, practice and knowledge, and physician attitudes and practice behaviors, as previously described.11 First, respondents provided information about their physician specialty, gender, age, race, years in practice, and number of hours spent working in outpatient settings. Information was also collected on practice characteristics and patient demographics such as race, insurance status, and geographic location. Physicians’ STD knowledge, diagnostic testing, and treatment practices were assessed in the context of clinical scenarios related to the prevention and treatment of STDs in both asymptomatic and symptomatic women. Eight questions were designed to evaluate practitioner knowledge regarding the basics elements of diagnosing and treating patients in these clinical scenarios. These scenarios represent common and typical presentations that a clinician caring for reproductive-aged women would routinely encounter in clinical practice. For example, providers were asked what diagnostic tests they would perform when a young woman presents with a complaint of vaginal discharge, a report of an STD exposure, or with evidence of mucopurulent cervicitis on physical examination. Providers were also asked what treatment regimens they would recommend, when applicable. Correct answers were determined based on recommendations outlined in the 1998 CDC STD treatment guidelines.15 The definition of good STD knowledge required a score of 75% of greater. Lower scores were considered to be evidence of inadequate knowledge. Respondents with less than 50% correct answers were considered to have extremely poor STD knowledge.
χ2 Testing on dichotomous variables was performed to establish odds ratios (ORs) and confidence intervals (CIs). Logistic regression modeling was performed by entering in the model those provider characteristics associated with STD knowledge on univariate analysis. Number of years since medical training was excluded from the model as this variable demonstrated colinearity with physician age. Data were analyzed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL), and Epi-Info 2002 (CDC).
Of the initial mailing to 1600 physicians, we excluded 546 (34%) because they could not be located (n = 102), were retired, on leave, or deceased (n = 147); they had relocated out of state (n = 33); or did not provide primary care to young women (n = 264). The overall response rate among the remaining 1054 eligible physicians was 51% (n = 541). An additional 85 physicians were excluded because they declared they did not provide gynecologic or reproductive health care. The final sample size included 456 subjects (182 obstetrician/gynecologists, 147 family practitioners, 70 internists, 54 pediatricians, 3 other). Compared to nonrespondents, respondents were more likely to be female, obstetrician/gynecologists, less than 40 years of age, and practicing in nonmetropolitan areas.
The mean number of correct answers to the 8 questions was 5.7 (71%). Only 61% of respondents achieved scores of 75% or greater and thereby were considered to possess good knowledge about the management of STDs in women. There were no differences in mean scores among physician specialties; pediatricians achieved a score of 5.6, family practitioners scored 5.6, internists received a score of 5.9 and obstetrician/gynecologists had a mean score of 5.7 (P = NS).
The relationship between physician personal characteristics, professional factors, and questionnaire performance was analyzed (Table 2). Female physicians scored better on the questionnaire than males, with 73% (156/215) of female physicians demonstrating good STD knowledge compared to 51% (122/238) of male physicians (P <0.001; OR: 2.1; 95% CI: 1.4–3.2). Seventy-six percent (111/147) of physicians under 40 years of age demonstrated good STD knowledge compared to 54% (168/309) of older physicians (P <0.001; OR: 2.3; 95% CI: 1.4–3.6). Similarly, questionnaire scores among physicians within 10 years of completion of their medical training were higher than physicians more remote from training (P <0.001; OR: 2.4; 95% CI: 1.5–3.7). Both physician gender and age remained independently associated with knowledge on the proper management of STDs after multivariate analysis.
Of 304 physicians practicing in large metropolitan centers, 197 (65%) demonstrated quality STD knowledge compared to 81/151 (54%) of physicians practicing in small- or medium-sized towns, a relationship that remained significant after controlling for other variables associated with our outcome on univariate analysis. There was a nonsignificant trend towards better STD knowledge among academic physicians and those in the public health sector compared to physicians in private practice (69% vs. 59%, P = 0.09). Volume of female patients between the ages of 15 and 25 did not have any association with physician knowledge. Sixty-three percent (184/291) of physicians reporting seeing more than 10 young female patients each week demonstrated good STD knowledge compared to 57% (90/157) of those doctors seeing 10 or fewer patients each week (P = NS).
We examined the relationship between STD knowledge and quality of STD training in medical school and postgraduate training, as determined by self-report by the physicians responding to the survey. Physicians who judged their STD training in residency as adequate had higher scores than those with self-reported inadequate STD training (OR: 1.8; 95% CI: 1.1–2.8). Adequate STD education in medical school did not influence STD knowledge (OR: 1.2; 95% CI: 0.8–1.8). Physicians were asked to respond to the statement “I am familiar with the CDC’s Sexually Transmitted Disease Prevention and Treatment Guidelines” using a 5-point scale (strongly agree to strongly disagree). Familiarity with the guidelines was strongly and independently associated with quality STD knowledge. Those familiar with these national guidelines were twice as likely to demonstrate adequate STD knowledge compared to those unfamiliar with the guidelines (OR: 2.0; 95% CI: 1.2–3.3).
STD screening practices were analyzed according to physicians’ STD knowledge. Physicians who reported that they screened sexually active women under the age of 25 for chlamydia all or most of the time, in accordance with widely accepted clinical practice, were 3.9 times more likely to demonstrate good STD knowledge than those physicians who admitted that they screened less than half of the time (P <0.001; 95% CI: 2.3–6.8).
To determine those physician characteristics associated with extremely poor STD knowledge, we reanalyzed the responses stratifying by a more liberal cut-point. Respondents were identified as having extremely poor STD knowledge if they failed to achieve a score of at least 50% correct answers. On univariate analysis, the characteristics associated with very low scores were age greater than 40 (OR: 4.2; 95% CI: 1.2–17.9), small- or medium-town practice (OR: 2.5; 95% CI: 1.1–5.7), perception of STD education in residency as inadequate (OR: 3.5; 95% CI: 1.5–8.2), and lack of familiarity with CDC STD guidelines (OR: 2.8; 95% CI: 1.1–6.7).
Despite the renewed recognition of the important adverse consequences of STDs, including infertility, ectopic pregnancy, and HIV acquisition, this study demonstrates that STD knowledge is suboptimal among a large proportion of physicians responsible for the reproductive health care of at-risk youth. Only 6 in 10 physicians correctly answered 75% of the questions. Questions posed in the questionnaire represented common clinical scenarios pertaining to STD concerns among at-risk youth, including appropriate diagnostic testing for the symptomatic young woman, antibiotic selection for cervical chlamydial and gonococcal infection, and management of the sexual contacts of men diagnosed with STDs. Physicians responsible for providing reproductive health care to young women would be expected to encounter such issues as part of clinical practice. Setting the bar at 75% correct answers was deemed appropriate to consider as minimum criteria for adequate STD knowledge; when the bar was lowered to 50% correct answers, many physician characteristics remained associated with poor STD knowledge at this lower cut-point. These results demonstrate that knowledge about STDs among a large proportion of primary care physicians is poor and may reflect that substantial numbers of women with or at risk for STDs receive suboptimal care.
We have identified several physician characteristics associated with STD knowledge. Female physicians were twice as likely to demonstrate good STD knowledge compared to male doctors. The influence of physician gender on health care delivery has been demonstrated in other studies. Women under the care of female physicians are more likely to undergo screening with Papanicolaou smears and mammography than those cared for by male physicians.16–18 We previously reported that female physicians were more than twice as likely to screen sexually active teenage women for chlamydia than male physicians.11 St. Lawrence et al.19 demonstrated that female physicians were more attuned to diagnosing STDs, treating sexual partners, and providing risk-reduction counseling. Why female physicians are more likely to deliver effective STD care remains unknown. Female physicians may be more comfortable discussing sexual health issues with their female patients than male physicians. Our earlier work has shown that female physicians had more favorable attitudes regarding STDs, and such attitudes were associated with greater compliance with screening for C trachomatis.11,20
Younger physicians also had better STD knowledge than older physicians. This strong and independent association conflicts with a prior report of better compliance with CDC guidelines for the treatment of PID among physicians with more years since completing residency.13 STD training may be emphasized to a greater degree in medical training over the recent years, possibly due to the evolving knowledge about the adverse impact of STDs, and in particular the close relationship between STDs and HIV transmission. STD education in residency training, if adequate, is associated with better STD knowledge in our survey, yet no such relationship was observed with STD education in medical school. Findings from a recent study of medical students demonstrated that a curriculum for sexually transmitted diseases increased knowledge as measured by responses to STD-related items on the National Board of Medical Examiners examination.21 These results imply that ongoing educational efforts is required to maintain effective knowledge in the management of STDs. Adequate STD training in residency was reported more frequently than in medical school, likely reflecting more enhanced education in fields devoted to primary health care of women compared to the more broad medical coverage in medical school curricula. These findings highlight the urgent need for continuing medical education for STD training to all physicians, particularly those more remote from medical training.
Familiarity with the CDC’s STD treatment guidelines was independently associated with STD knowledge. Sixty-four percent of physicians familiar with the STD treatment guidelines demonstrated good STD knowledge, compared to less than one half of those physicians unfamiliar with the guidelines. These guidelines are readily available free of charge [by mail or downloaded online at http://www.cdc.gov/std/treatment; accessed December 22, 2004]. However, nearly 20% of physicians who provide health care to at-risk populations are unfamiliar with the STD treatment guidelines. To our knowledge, these data are the first to demonstrate that familiarity with STD treatment guidelines is associated with STD knowledge. In a survey of primary care physicians in California, those unfamiliar with CDC guidelines for the treatment of women with PID answered management questions nearly as well as those physicians familiar with the guidelines.13 It was therefore postulated that the CDC guidelines might have limited effect on physician practice patterns. To the contrary, our results indicate that familiarity with the CDC’s STD treatment guidelines are associated with better STD knowledge, which then may translate into quality STD care. Increasing the proportion of physicians who are familiar with the CDC’s STD treatment guidelines as part of continued education efforts may enhance the quality of STD care delivered. We believe that the CDC’s STD treatment guidelines are an invaluable tool for physicians caring for patients with or at risk for STDs and that novel and improved efforts to distribute these guidelines and encourage their use may be an effective strategy to improve the management of individuals with or at risk for STDs.
Providers in metropolitan centers fared better than those in small communities. We hypothesize that because the burden of STDs is in urban centers, physicians practicing in these areas are more likely to encounter STDs and would therefore be more knowledgeable in STD-related issues. The prevalence of chlamydia in smaller nonurban communities is substantial, indicating that the STD epidemic extends beyond large metropolitan centers.22 The rate of reported chlamydial infections in some rural communities exceeds that of urban centers.23 It is therefore critical that physicians practicing in more rural communities possess adequate STD knowledge to better serve their at-risk populations.
The strengths of this study lie in its large sample size, and the survey response rate of 51% is considered reasonable for a physician survey. We believe that the questionnaire was fair and tests basic knowledge that every provider of routine gynecologic care would be expected to use in the management of women with or at risk for STDs. The bar for adequate knowledge was set at a score of at least 75% correct answers. Only 61% of respondents were able to achieve this goal, despite the fact that all respondents had identified themselves as providers of routine gynecologic care to young women. Because the questionnaire was self-administered and the physicians were free to consult reference materials, the results obtained might, in fact, overestimate the degree of STD knowledge. In addition, those possessing poor knowledge may have been less likely to return the questionnaire secondary to fear of poor performance. As such, actual STD knowledge among physicians may be lower than the results measured from this study.
We recognize that the limitations of the study are due primarily to its survey format. All provided responses are self-reported and may not correlate with actual practice. Other studies have attempted to address this issue by incorporating mock patient visits into the study design. Given the large sample size of this effort and the vast number of practices that were included, using mock patient visits would be very costly. However, we believe that the results reflect quality of STD care delivered by these physicians because those physicians who followed national guidelines for chlamydia screening were nearly 4 times more likely to demonstrate adequate STD knowledge than those physicians who fail to screen at-risk women. The response rate of 51% is reasonable for a physician survey; the rate is lower than that obtained by St. Lawrence et al.19 but similar to or greater than the response rates of other physician surveys.12–14 Another limitation is that the correct answers were based on the 1998 CDC STD treatment guidelines; however, we believe that the results of this survey are valid today as the reference answers in this survey are also consistent with the 2002 STD guidelines.24 There is no information to suggest that STD knowledge among primary care providers has improved since this survey was undertaken. Another limitation is that this study did not address the STD care at other venues such as emergency departments and other urgent care settings. Finally, we understand that this study is reflective of findings of Pennsylvania physicians and may not necessarily be indicative of knowledge patterns among physicians in other regions.
In summary, knowledge on the management of STDs by providers charged with the care of individuals at risk for STDs is too often poor. We have identified several physician characteristics associated with proper knowledge on the management of STDs in women. Efforts should focus on enhancing STD education as part of continuing education programs. As part of these efforts, consideration should be given to widely disseminate the CDC’s STD treatment guidelines to all providers providing care to those at risk for STDs.
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