Family Practice Vol. 20, No. 6, 670-674
© Oxford University Press 2003, all rights reserved
Article |
Family practitioners' attitudes and knowledge about irritable bowel syndrome
Effect of a trial of physician education
Kaiser Permanente Medical Care Program, Department of Gastroenterology, San Diego, CA and Department of Research and Evaluation, Pasadena, CA, USA
Correspondence to George F Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Center; 4647Zion Avenue, San Diego, CA 92120, USA; Email: George.F.Longstreth{at}kp.org
Received 31 October 2002; Revised 20 May 2003; Accepted 14 July 2003.
Longstreth GF and Burchette RJ. Family practitioners' attitudes and knowledge about irritable bowel syndrome. Effect of a trial of physician education. Family Practice 2003; 20: 670–674.
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Abstract |
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Background. Primary physicians care for most patients with irritable bowel syndrome (IBS), but data on their attitudes and knowledge about the disorder are limited to research in the UK.
Objective. The purpose of the present study was to assess US family practitioners' attitudes and knowledge about IBS and determine the effect of a single education class on these measures.
Methods. In a large health maintenance organization (HMO), a baseline group of family practitioners twice completed a questionnaire on attitudes and knowledge about IBS, 3 months apart. A class group completed it pre-class, immediately post-class and 3 months post-class.
Result. Thirty-five physicians ranked IBS among five chronic, painful syndromes as highest in difficulty satisfying patients, tied with headache for highest in difficulty in practice strategy decision, second in time required, and fourth in diagnostic confidence and satisfaction in caring for patients. IBS and heartburn had widely separated rankings in all five attitudes. The correct answer rate on seven of 13 knowledge questions was <50%, and a majority did not identify the Rome II symptom criteria as typical and lacked other important knowledge. Of the 30 class physicians, the knowledge scores (mean ± SD; maximum possible, 13) of 29 increased from 5.59 ± 1.84 pre-class to 10.21 ± 1.76 immediately post-class (P < 0.0001); 3 months later, the scores were lower (8.93 ± 0.36) than post-class (P < 0.0001), but still higher than pre-class (P < 0.0001). Their attitude rankings were nearly identical pre-class and 3 months later (P > 0.05). In the 19 baseline physicians, IBS attitude rankings and knowledge scores did not change significantly over 3 months (P > 0.05).
Conclusion. These US family practitioners had attitudes about IBS patients and lacked knowledge that could interfere with patient care. A single class improved short-term knowledge but had little effect on attitudes about IBS.
Keywords. Irritable bowel syndrome, physician attitude, physician education, physician knowledge.
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Introduction |
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Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder, and recent research on IBS is important to family practitioners.1,2 Although most studies on IBS have been performed on patients referred to gastroenterologists, primary physicians manage most patients.3 There is substantial support for a diagnosis based mainly on typical symptoms with limited diagnostic testing of patients who are cared for by family practitioners.1,2,4 The economic benefit of a symptom-based diagnosis is underscored by the high health care costs attributable to IBS, including diagnostic test expenses.5 Therefore, there is great potential importance in primary physicians knowing the typical symptoms and usual treatment of IBS. Despite the family practitioners' dominant role in caring for patients with IBS, information on their knowledge about the disorder is limited.6,7 An effective physician–patient interaction is crucial,1 and physician attitudes that could influence this relationship have been investigated only in the UK.6,7
The aims of this study were: (i) to explore US health maintenance organization (HMO) family practitioners' attitudes and knowledge that seem important in managing patients with IBS; and (ii) to determine the immediate and short-term effects of an education programme on these aspects of medical practice.
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Methods |
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Subjects and design
We conducted the study in the Family Practice Department of the San Diego area of the Kaiser Permanente Medical Care Plan, a group-model HMO with >500 000 members. Every adult member has a primary physician. We designed a 2-h education class on IBS that comprised a 1.5 h lecture and a 30 min period for questions and discussion of patient care issues. It broadly covered epidemiology and pathophysiology, but the emphasis was on the clinical features, diagnosis and treatment. The class was supplemented with a concise, written summary of the presentation and relevant publications. The Institutional Review Board approved the study.
We elicited demographic data and assessed physician attitudes and knowledge with a self-administered questionnaire (‘test’). To develop the attitude section, we interviewed family practitioners, who were not subsequently study participants, concerning aspects of greatest importance to them in caring for patients with chronic, painful disorders. Based on these discussions, we developed five attitude questions. These items each asked the physicians to rank five chronic, painful syndromes (arthralgia, back pain, headache, heartburn and IBS) on a scale from 1 (maximum) to 5 (minimum), using each number only once. The questions were: (i) how confident are you in diagnosing your patients? (ii) how difficult is it to satisfy your patients? (iii) how much time is required to care for your patients? (iv) how much personal satisfaction do you get from caring for your patients? and (v) how difficult is it to decide on practice strategy (test ordering, interaction style with patients, drug prescribing, specialist referral, etc.)? We also composed a knowledge section of 13 questions, each with five answer choices, which covered important topics in the programme. One question requested identification of a group of symptoms typical of IBS, not the symptom criteria's name, and only one of five choices fulfilled one of the three commonly used sets of symptom criteria (Rome II). Physicians were not asked to identify the most useful criteria in practice, as this matter is controversial.2 The answers to the questions were not stated explicitly in the class, i.e. the presentation included information needed to answer them, but we did not ‘teach to the test’. We used the same knowledge questions in each test, but changed the question order on the test immediately after the class.
We selected the physicians based on their office locations, such that they could conveniently attend the class and meet to complete the questionnaires. A baseline group of 20 physicians completed both the attitude and knowledge sections of the questionnaire (first baseline test), and 19 of them completed these sections again 3 months later (second baseline test) without having attended the class to measure attitude and knowledge change in the absence of intervention. A 30 physician class group comprised 14 baseline group physicians (six could not attend) and 16 additional physicians, one of whom arrived too late to complete the pre-test. Therefore, 29 of the 30 class physicians completed both sections of the questionnaire immediately before the class (pre-test), and all 30 class physicians completed a questionnaire containing only the knowledge section immediately after the class (post-test). All 30 physicians also completed both the attitude and knowledge sections again 3 months later (follow-up post-test). We obtained demographic, attitude and knowledge data from 35 physicians using results from the 20 baseline physicians' first test and the pre-test from the 15 additional class physicians who completed it. Before the study, all participants were told that the purpose was to provide education and assess its effect on physician knowledge; investigation of attitudes was not discussed.
Statistical analysis
Statistical analysis included describing the dichotomous data as proportions and continuous data as the mean ± SD. We compared demographic variables from baseline and class groups with chi-square tests for discrete data and t-tests (or Mann–Whitney tests for data not approximately normally distributed) for continuous variables.
For all statistical analyses on the ranking questions beyond descriptive summaries, we reversed the rank responses of the negatively phrased questions (difficulty satisfying patients, time required and difficulty with practice strategy), so that similar responses had similar magnitude meaning across questions. Then, we calculated the mean rank for each painful syndrome across all five questions. We ordered the physicians' attitudes on the five syndromes according to their mean rank values. Ties were assigned the mean of ranks involved. We computed and ranked the differences between pairs of data from two tests on each physician and compared these differences with the Wilcoxon signed rank test. We then computed a generalized kappa statistic of agreement for each syndrome.
Data were analyzed using SAS version 8.2 software (SAS Institute, Cary, NC). The level of significance was P < 0.05. Power was estimated using nQuery Advisor software (Statistical Solutions, Boston, MA).
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Results |
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Of the 36 physicians, 24 (66.7%) were male; their age was 43.0 ± 8.3 years. The time since medical school graduation was 16.1 ± 8.6 years. The 20 baseline physicians and the 16 class physicians who had not served in the baseline group were similar in sex, age and years since medical school graduation (P > 0.05).
The descriptive summary of the baseline attitude rankings from the 35 physicians who completed the first baseline test or a class pre-test is displayed in Table 1. IBS ranked highest in difficulty in satisfying patients, tied with headache for the highest in difficulty of practice strategy decision, ranked second in time required, and fourth in both physician diagnostic confidence and personal satisfaction in caring for patients. In contrast, heartburn ranked first in diagnostic confidence and personal satisfaction and fifth in difficulty in satisfying patients, time required and difficulty of practice strategy decision.
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Table 2 shows the physicians' correct answer rates on the knowledge section. Their correct answer rate on seven of the 13 questions was <50%. Only 35% of them knew that the Manning, Rome and Rome II criteria are used for diagnosing IBS.3 Furthermore, only 49% of physicians identified a group of typical IBS symptoms. Also, a minority knew that women with IBS are predisposed to undergo hysterectomy,8 IBS can develop after acute infectious gastroenteritis,9 digital facilitation of defecation may point toward the pathophysiology of constipation,1 dietary and pharmacological fibre therapy often increase bloating1 and loperamide use does not cause dependency.1 A bare majority knew that cognitive–behavioural therapy may be effective for IBS.10 A higher proportion of physicians correctly answered questions on overall pathophysiology,1 IBS-related pain location,11 general management,1 bloating12 and alosetron.1,2
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The 19 baseline group physicians who completed both first and second tests revealed no significant change in rankings for IBS (P > 0.05). They had knowledge scores of 4.95 ± 2.12 initially and, 3 months later, the scores were 5.21 ± 1.99 without class intervention (P > 0.05) out of a maximum score of 13.
We evaluated education-related change in physician attitude and knowledge in the 29 physicians who completed both a pre-test and a 3-month follow-up test. Their pre-test attitudes about IBS patients were identical to all the physicians' baseline rankings, as summarized in Table 1, with two exceptions: they rated IBS second in difficulty in satisfying patients instead of first, and IBS attained solitary first position in difficulty of practice strategy instead of tying with back pain. Their pre-test and follow-up attitude rankings were identical except that IBS moved from fourth to fifth in diagnostic confidence and from second to first in difficulty in satisfying patients. The Wilcoxon signed rank test revealed no significant change in attitude ranks by syndrome with >80% power. The generalized kappa statistic on the re-ranked sums revealed significant agreement between pre-class and follow-up ranks for arthralgia (P = 0.04), back pain (P = 0.04) and IBS (P = 0.003), but not for heartburn (P > 0.05) and headache (P > 0.05), indicating that physicians' attitudes changed the least for the former three syndromes. Their knowledge scores increased from 5.59 ± 1.84 on the pre-test to 10.21 ± 1.76 on the post-test (P < 0.0001). The scores of all 30 class participants decreased from 10.27 ± 1.76 on the post-test to 8.93 ± 0.36 on the follow-up post-test (P < 0.0001), but the follow-up post-test scores still exceeded the pre-test scores (P < 0.0001).
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Discussion |
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Experienced US family practitioners had attitudes about patients with IBS and lack of knowledge about some important aspects of the disorder that could interfere with patient care. These findings differ somewhat from the observations on British GPs' attitudes and knowledge.6,7 An education class had a favourable immediate effect on their knowledge and, despite some knowledge decrement during the following 3 months, a short-term knowledge gain persisted. In contrast, the class had no significant short-term effects on the physicians' attitudes about IBS patients.
Compared with other patients with painful syndromes, the physicians thought it was difficult to decide on practice strategy for IBS patients and to satisfy them. They also attributed a relatively large time requirement to IBS patients, had low diagnostic confidence and experienced a low level of satisfaction in caring for them. We modelled our method of comparing painful syndromes on the survey of British GPs by Thompson et al.6 They obtained physicians' rankings on pelvic pain, headache, backache, muscle aches and IBS on their difficulty in distinguishing functional from organic conditions, difficulty in satisfying patients and in time consumption. We expanded the attitudes assessed and modified the syndromes, including the addition of heartburn. Compared with the British physicians' moderate ratings for diagnostic confidence, difficulty in satisfying IBS patients and time demand, our physicians manifested relatively low diagnostic confidence and reported that IBS patients are the most difficult to satisfy and are relatively time consuming. Various factors could underlie the disparate results, including different physician practice styles regarding their reliance on diagnostic tests and dissimilar patient expectations and overall satisfaction with care. Notably, the physicians assigned IBS and heartburn widely separated rankings on all five attitudes. A plausible explanation is that typical heartburn patients have a more limited symptom profile, less prominent psychosocial factors and a much better response rate to drug therapy than many patients with IBS, making them usually easier to manage.
Confident and economical management of IBS requires familiarity with its typical symptoms, other clinical correlates and principles of therapy. The finding that only 49% of physicians recognized the Rome II criteria as typical of IBS could contribute to their lack of diagnostic confidence and result in unnecessary testing. This matter seems more important than their low recognition of the purpose of the Manning, Rome and Rome II criteria, as it is more useful to recognize the typical IBS symptoms than simply to know the names of typical symptom clusters. Few British GPs had heard of the Manning or Rome criteria, but they diagnosed IBS with few tests.6 Gastroenterologists see some patients who report that their primary physicians had not advised them to use loperamide properly or to reduce fibre intake for bloating, and the lack of knowledge on these issues revealed in the study could explain such occurrences and other types of unsuccessful primary care management. The physicians' unfamiliarity with the clinical correlates of IBS could also interfere with proper care. For example, not realizing the increased hysterectomy rate in IBS patients could lead to mislabelling IBS as ‘chronic pelvic pain’ and possibly lead to unnecessary surgery.8
The lack of a class effect on the physicians' attitudes is disappointing. We hoped that increasing the physicians' knowledge about IBS, especially its diagnosis and treatment, would lead to increased diagnostic confidence, less difficulty in satisfying patients, less time consumption, a greater sense of physician satisfaction and less difficulty in deciding on practice strategy. It appears from this study that increased knowledge alone does not result in such changes. A more intensive programme that addresses the general principles of managing patients with chronic functional disorders might be more effective. For example, an 8 h communication workshop improved physicians' awareness of ‘difficult’ patients and their confidence in dealing with them, and it reduced the proportion of frustrating visits. However, this programme did not improve the physicians' assessment of patient satisfaction.13
The strengths of the study include the experienced nature of the physicians studied; on average, they were near mid-career. Their knowledge gain seems attributable to the class, as a comparison group without exposure to the class did not learn the same material over a 3-month period. The questionnaire items on attitude were broadly designed, and the knowledge items reflected important class content; however, the questionnaire was not validated against another physician attitude survey or actual practice tendencies, and formal evaluation of questionnaire sensitivity to change was not conducted. We are unaware that any such instrument has received such validation. Furthermore, we do not know whether the acquired knowledge improved patient care.
Family practitioners play a far more important role than gastroenterologists in managing IBS. For example, a US community-based study found that only 5% of IBS diagnoses were made by a gastroenterologist, and only 14% of men and 20% of women with IBS visited a gastroenterologist during 13 years of observation.3 Similarly, British GPs referred only 20% of patients with IBS to a gastroenterologist.7 However, preliminary data from two US HMO surveys raise doubts about the accuracy of diagnosis. In one study, many patients who met the Rome symptom criteria did not have a diagnosis of IBS in the administrative database14 and, in the other survey, only 
50% of patients diagnosed by a physician with IBS fulfilled Rome symptom criteria.15
The findings of this study offer a possible explanation for diagnostic inaccuracy and reflect the potential of a single class to increase knowledge. The benefits of the physician–patient interaction are dependent on physician attitudes.16 The particular significance of this relationship in managing patients with IBS underscores the importance of physicians' attitudes about patients. More studies are needed on family practitioners' attitudes about patients with IBS, their knowledge about the syndrome, and methods that improve the physicians' diagnosis and treatment.
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Acknowledgments |
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This study was sponsored by a grant from Glaxo Wellcome Inc.
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References |
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1 Camilleri M, Heading RC, Thompson WG. Consensus report: clinical perspectives, mechanisms, diagnosis and management of irritable bowel syndrome. Aliment Pharmacol Ther 2002; 16: 1407–1430.[CrossRef][Web of Science][Medline]
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12 Serra J, Azpiroz F, Malagelada J-R. Impaired transit and tolerance of intestinal gas in the irritable bowel syndrome. Gut 2001; 48: 14–9.
13 Brown JB, Boles M, Mullooly JP, Levinson W. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Ann Intern Med 1999; 131: 822–829.
14 Knight K, Higuchi K, Wilson A et al. Diagnosis of irritable bowel syndrome in managed care: missed opportunity? Am J Gastroenterol 2001; 96 (Suppl): S272.
15 Levy RL, Whitehead WE, Feld A. Do patients with IBS receive a diagnosis of IBS, abdominal pain, constipation or diarrhea? Am J Gastroenterol 2001; 96 (Suppl): S320.
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