Abstract
This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients' family history. Physicians were less likely (P < .05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions.
Keywords: physician satisfaction, substance abuse, resident physicians, faculty physicians, attitudes, screening
Substance abuse is prevalent in clinical practice and costs American society over $246 billion each year.1,2 On the basis of the existence of valid screening tools and the efficacy of prevention for alcohol problems, professional organizations recommend identification and brief intervention.3–6 Despite the enormity of the problem and a broad call for action, physicians fail to recognize substance abuse, leading to missed opportunities for treatment and referral.2,7 This failure has been attributed in part to physician characteristics: negative attitudes toward substance-abusing patients, low levels of confidence in their clinical skills, limited perceived responsibility for the care of substance problems, and perceptions that treatment has limited efficacy.4,8–12
Little attention has been focused on the role that physician satisfaction may play. Low professional satisfaction may decrease physicians' intrinsic motivation to identify and treat patients with addictions.13 Therefore, we surveyed resident and faculty physicians regarding professional satisfaction when caring for patients with addictions. We sought both to describe the level of satisfaction and to examine how perceived responsibility for caring for addictions, confidence in clinical skills, attitudes toward patients with addictions, and interpersonal experience with addictions were related to professional satisfaction.
METHODS
Eligible subjects were hospital-based categorical and primary care internal medicine resident physicians and faculty at 3 outpatient primary care practices on 2 campuses in 1 residency program (including a Veterans Affairs clinic). The Institutional Review Board at Boston University Medical Center approved the study.
Staff researchers distributed and collected the confidential survey in person. Some items were derived from prior physician surveys.9,14,15 The 83-question survey addressed the following areas using 5 Likert-type response options for each question: substance abuse–related practices, physician perceived responsibility and confidence in clinical skills related to addictions care, attitudes toward substance-abusing patients, and professional satisfaction when caring for patients with substance abuse and other medical disorders. The survey also queried whether physicians knew people (other than patients) with substance abuse.
Principal components analysis and internal consistency reliability assessments were performed for items assessing physician practices, perceived responsibility, attitudes, confidence, and professional satisfaction (Cronbach's α ranging from 0.56 to 0.97, for derived scales). All items and scales were scored from 1 to 5 with 5 representing the most favorable response.
We employed χ2 and Fisher's exact tests for categorical variables and t tests and analysis of variance for continuous variables to compare resident and faculty responses. More specific level of training analyses used the Mantel-Haenszel χ2 test for trend (only significant results are reported). Duncan's multiple range test was used to determine significant (P < .05) differences between subgroups of trainees. We then developed 5 multivariable logistic regression models, each adjusting for level of training, gender, and race to assess the relationship between perceived responsibility, attitudes, confidence, and knowing someone with addiction, and the dependent variable, moderate or a great deal of professional satisfaction. McNemar's test was used to compare physician satisfaction and perceived treatability for several diagnoses.
RESULTS
Of 157 physicians surveyed, 144 (92%) completed the survey. Residents (N = 95) were a mean 28.5 years old (SD ±2.7); faculty (N = 49) were 40.3 years old (SD ±7.7). Residents and faculty were 44% and 49% female, 62% and 65% white, 3% and 12% black, 5% and 4% Hispanic, and 23% and 8% Asian, respectively. Faculty physicians graduated from medical school a mean of 14.1 ± SD 8.4 years prior to the survey. One quarter of residents were in their first postgraduate year of training (24%), 34% in year 2, 35% in year 3, and 7% in years 4 or 5. Physicians reported that 24% of their patients had alcohol abuse or dependence and 15% had drug abuse or dependence.
Practices
Although almost all physicians reported asking new patients (at least usually) if they drink alcohol (94%) or use illicit drugs (93%), and asked drinking amounts of patients who reported drinking (94%), only 40% reported usually using a formal screening tool for new patients who drink alcohol or asked new patients about a family history of alcoholism (24%). First-year residents were significantly less likely to ask about family history (13% vs 19% for second-year, 24% for third-year residents, and 33% for faculty; test for trend, P = .04). Few (21%) advised a preventive message of safe drinking limits for patients who drink but do not have alcohol problems. Most physicians reported usually counseling patients with alcohol abuse (faculty 90% vs first-year residents 52%, second-year residents 63%, and third-year residents 76%; test for trend P < .001) and drug abuse (faculty 88% vs first-year residents 52%, second-year residents 63%, and third-year residents 73%; test for trend, P < .001) (Table 1). While most physicians (81%) asked patients with alcoholism about changes in drinking practices in follow-up, 50% asked nonalcoholic drinkers and 11% asked non-drinkers about changes.
Table 1.
Resident and Faculty Differences in Substance Abuse–related Practices, Confidence, and Attitudes
| Residents | Faculty | |
|---|---|---|
| Counseling patients with alcohol problems at least usually, % | 67 | 90 |
| Counseling patients with drug problems at least usually, % | 66 | 88 |
| Confidence in assessment and intervention skills, mean | 3.4 | 3.7 |
| Agreement with negative attitudes toward substance-abusing patients, mean | 4.0 | 4.3 |
Scales reported above range from 1 to 5 with 5 being the most favorable response (see text). All comparisons reported in the table are statistically significant.
Perceived Responsibility, Confidence, and Attitudes
Faculty and resident physicians had similar levels of perceived responsibility for addressing substance abuse (mean 4.6 and 4.4, respectively, on a 1-to-5 scale, meaning moderate to very responsible); they also had similar confidence in their screening and change initiation skills (mean scores ranging from 3.4 to 3.7); scores were similar across postgraduate year of training. Faculty had greater confidence than did residents in their assessment and intervention skills (mean 3.7 vs 3.4; P = .01)(Table 1); interns scored significantly lower than did other residents and faculty (mean 2.9; P < .05). Physicians agreed with statements reflecting positive attitudes toward substance abuse treatment and its success, and disagreed with statements of negative attitudes toward substance-abusing patients (mean scores ranging from 4.0 to 4.3, meaning [dis]agreement or strong [dis]agreement). Fewer physicians, however, agreed that alcoholism (84%) and drug addiction (85%) were treatable than agreed that diabetes was treatable (96%) (P = .001 for both comparisons). They reported that their own efforts in treating alcohol and drug problems had succeeded infrequently (19% and 12%, respectively). Faculty were less likely than residents to agree with negative attitudes toward substance-abusing patients (4.3 vs 4.0; P = .01); second- (3.8) and third- (4.0) postgraduate-year residents had lower scores (more agreement with negative attitudes) than first-, fourth-, and fifth-year residents and faculty (4.2 to 4.5; P < .05)(Table 1).
Personal Experience
Most physicians (85% of faculty, 72% of residents) reported knowing someone (other than a patient) with an alcohol or drug problem; 33% reported that this person was family, a close friend or themselves. Physicians reporting this personal experience reported greater confidence in using formal screening tools (73% vs 47%; P = .005) and in counseling patients regarding alcohol use (57% vs 32%; P = .011). Knowing someone with addiction was not significantly related to perceived responsibility, attitudes, professional satisfaction, and practices (data not shown).
Professional Satisfaction
Physicians were more satisfied when caring for patients with hypertension than with depression or substance problems (Table 2). Resident physicians were significantly less likely to experience satisfaction when caring for patients with alcohol problems, drug problems, or depression when compared to caring for patients with hypertension (Table 2). Likewise, faculty reported less satisfaction when caring for patients with alcohol and drug problems than when caring for hypertensive patients. Faculty were more satisfied than were residents when caring for patients with alcohol problems and depression.
Table 2.
Professional Satisfaction of Primary Care Physicians Caring for Patients with Addictions and Other Diagnoses
| % Who Experience “A Great Deal” or a “Moderate” Amount of Satisfaction When Caring for Patients With… | Residents | Faculty |
|---|---|---|
| Alcohol problems* | 32‡ | 49§ |
| Drug problems | 30‡ | 31¶ |
| Depression† | 43‡ | 69 |
| Hypertension | 79 | 76 |
P = .042 for the comparison of resident and faculty physicians. The proportions for first-, second-, third-, fourth-, and fifth-year residents were similar and ranged from 29% to 33%.
P = .003 for the comparison of resident and faculty physicians. The proportions for first-, second-, third-, fourth- and fifth-year residents were similar and ranged from 38% to 47%.
P = .001 for comparison with proportion of resident physicians reporting the same amount of satisfaction when caring for patients with hypertension. Subgroup comparisons for each postgraduate year of training are all statistically significant at P < .05.
P = .01 for comparison with proportion of faculty physicians reporting the same amount of satisfaction when caring for patients with hypertension.
P = .001 for comparison with proportion of faculty physicians reporting the same amount of satisfaction when caring for patients with hypertension.
In analyses adjusting for level of training (resident or faculty), gender, and race (white vs other), knowing someone with addiction was not related to professional satisfaction caring for patients with substance problems. However, positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI 1.09 to 5.69), and perceived responsibility for addressing alcohol and other drug problems (AOR, 5.59; 95% CI, 2.07 to 15.12) were significantly associated with reporting a moderate or a great deal of professional satisfaction when caring for patients with substance problems.
DISCUSSION
Physicians, residents more so than faculty, were significantly less satisfied when caring for patients with alcohol and drug problems than when caring for patients with a traditional medical disorder, hypertension. These physicians perceived that care for patients with addictions was their responsibility, they were confident in their skills to address problems, and held positive attitudes, even though they felt their efforts had been successful in fewer than a fifth of patients. Residents had less favorable attitudes than faculty. Most knew someone with addiction, although this experience was not associated with practices or satisfaction.
Both resident and faculty physicians reported favorable basic practices. Since a bias toward reporting more favorable practices is not unexpected, it is notable that they reported not using formal screening tools known to be more effective than nonstandardized approaches,16 asking about family history (necessary to identify at-risk drinkers), doing appropriate follow-up assessment necessary to identify remission and relapse,5 or giving safe-drinking advice.
Our differential findings for faculty and residents suggest that experience and/or training impact satisfaction caring for patients with alcohol and drug problems. Favorable perceptions (confidence in skills, attitudes toward patients, and perceived responsibility) were related to professional satisfaction; these findings suggest targets for training. These favorable perceptions and professional satisfaction are likely necessary for successful care of patients with substance problems, as suggested by a prior study in which more-satisfied physicians diagnosed more patients with alcohol problems.17 A possible framework for these findings is that perceptions relate to satisfaction that in turn might impact physician motivation13 and empathy, a key element in such care.18
The main limitation of this study is the sample, one residency program. However, the sample allowed comparisons between resident physicians and their teachers, and a high response rate was achieved. It is likely that the results can be generalized to other large, diverse internal medicine residency training programs. An additional limitation is our inability to infer the direction of associations from the data. To assist in understanding the findings, we rely on published theoretical frameworks.9,10,13,18 We speculate that physician education might address attitudes, confidence, and perceived responsibility, which in turn would impact satisfaction and actual practice.19 In the past decade, national consortia have recommended that the performance of residents in managing substance abuse be improved20 using faculty development and the establishment of specific requirements for residencies and specialty board examinations. The data reported herein support this call to improve addictions education.
Systems barriers to identifying and managing patients with alcohol and drug problems will also need to be addressed to improve professional satisfaction and encourage best practices, such as the routine and repeated use of standardized and validated screening tools, and appropriate prevention, intervention and follow-up of substance problems in primary care settings.
Acknowledgments
We thank the faculty and resident physicians at Boston University School of Medicine for completing the surveys, and staff researchers M. Alexandra Ordoñez and Noelia Kvaternik for survey distribution and manuscript preparation.
Dr. Saitz received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar (Grant No. 031489) for this work. He and Dr. Samet were also supported in this work by the Center for Substance Abuse Prevention (Faculty Development Grant T26-SP08355). Drs. Samet, Saitz, and Sullivan, and Mr. Winter and Ms. Lloyd-Travaglini receive support from the National Institute on Alcohol Abuse and Alcoholism (R01-AA10870). Dr. Friedmann was supported by a Mentored Clinical Scientist Career Development Award (K08-DA 00320).
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