Attitudes of medical interns towards the practice of primary health care.

BACKGROUND: Training in different specialties should prepare young physicians to assume responsibilities in primary care. Training for the acquisition of the proper attitude for health care, should be given in the course of the training in different specialties.
OBJECTIVE: To assess the attitudes of medical interns who have undergone rotation in the Department of Family and Community Medicine of a large university hospital, towards the provision of primary care.
METHODS: A cross-sectional study incorporating a structured questionnaire was carried out on a sample of 106 interns; and 20 consultants were selected as a reference group.
RESULTS: All medical interns almost unanimously endorsed continuous, coordinated, accessible and comprehensive care. In contrast, consultants less often supported the provision of such care for their own patients.
CONCLUSIONS: Unless consultants change their attitudes towards the attributes of primary care, the quality of patient care as well as physician training would suffer.

INTRODUCTION

The official implementation of the concept of Primary Health Care (PHC) in Saudi Arabia,1 involved the development and promotion of existing health centers and the forging of links with hospitals as secondary health care facilities. For many years, many questions have been raised throughout the world about the impact that training in different specialties might have on the quality, cost and distribution of medical care.2 One of these questions is related to how well the training in different specialties prepares young physicians to assume the responsibilities involved in primary care delivery.23 In order to acquire the correct attitude for the delivery of primary health care, training in different specialties should include the moulding of attitudes.23

The objective of this study is to assess the attitudes of medical interns, who have undergone rotation in the Department of Family and Community Medicine of a large university hospital, on the provision of primary care and compare these attitudes with those of a reference group of consultants in different specialties.

MATERIAL AND METHODS

A cross-sectional study was carried out on a sample of interns graduated from King Faisal University, at Dammam, Saudi Arabia. The total number of interns involved was 106, 70 (66.0%) of whom were males and 36 (34.0%) females. This represented the number of interns doing their rotation in Family and Community Medicine, within a period of one year, from 1994-95. During a one-month rotation, the intern is required to attend family medicine clinics under the close supervision of consultants and senior residents in the Department of Family and Community Medicine. During this period, the intern is trained to be competent in providing comprehensive and humane care to families in the community he or she is serving, using the problem-solving approach in diagnosis and management. Data was collected by means of a self-administered, structured questionnaire. The questionnaire was adapted from similar studies carried out elsewhere.34 The Institute of Medicine identified the following four attributes of primary care as important: comprehensiveness, coordination, continuity of care, and accessibility.5 Throughout the study, the term ‘primary care’ was avoided because of its tendency to varying interpretations other than the components of health care it is meant to describe. “Primary care” in USA may mean family medicine, general internal medicine or general pediatrics, whereas, in Saudi Arabia it means family medicine only. The questionnaire included items grouped into four sets eliciting information on various aspects of patient care. The first set (two questions) was about continuity of care. The second set (four questions) was on comprehensiveness of care. The third and fourth sets (two and four questions respectively) dealt with the coordination of patient care, and physicians’ accessibility to patients. In addition, the age and gender of the interns involved were recorded. The same questionnaire was administered to 20 consultants in the teaching hospital as a reference group. Five consultants were selected randomly from each of the following specialties: Internal Medicine, Surgery, Obstetrics &Gynecology, and Pediatrics.

Data was entered and analyzed using a personal computer, incorporating the Statistical Package for Social Sciences (SPSS PC+) Version 6.0 (6). Chi-squared test (with Yates's correction) was used to test the differences between categorical data. A p-value of 0.05 or less was considered as indicative of statistical significance.

RESULTS

The total number of interns involved in the study was 106, and the consultants was 20. The mean age of the interns was 26.0±1.67 years and males and females constituted 66.0% and 34.0%, respectively. The mean age of consultants was 48.6 ± 7.7 years, and they comprised 18 (90%) males and 2 (10%) females.

On the question of attitudes towards the continuity of care, the responses of the interns and consultants were as follows: Almost all interns and the majority of consultants (90.0%) agreed that patients should always be managed by the same doctor. If a patient called in for advice without a scheduled appointment, 73.6% of the interns would be ready to see him/her, whereas 50.0% of the consultants (p< 0.03) would (Table 1).

Table 1

Attitude of consultants and interns towards continuity of care

On the comprehensiveness of patient care, significantly fewer interns than consultants believed in periodic screening tests for common diseases (21.7% and 45.0%, respectively, p < 0.05). Both groups were similar in their attitudes towards sharing patient care with other specialties when they see those patients in their own clinical sessions (92.5% and 90.9%, respectively). Similarly, interns and consultants had the same attitude towards being comfortable with practising ongoing patient care (66.9% and 65%, respectively). With regard to patients with psychological problems, 80.0% of consultants were of the view that these patients should be referred to the psychiatrist, while 50.0% of interns thought that they could be managed with the help of paramedical staff such as psychologists and social workers (Table 2).

Table 2

Attitudes of consultants and interns towards comprehensiveness of care

On the coordination of care, 91.5% of interns as against 80% of consultants agreed that patients should always be seen by the same physician, but the difference was not statistically significant. On doctors’ attitudes towards their responsibility for the coordination of total hospital ambulatory care, or the management of specific organic problems, or both, 59.4% of interns and only 45.0% of consultants responded that they would carry both responsibilities (p < 0.03) (Table 3).

Table 3

Attitudes of consultants and interns towards coordination of patient care

When asked about patients’ accessibility to physicians for care, significantly more interns than consultants felt that patients could communicate with them between appointments (83.9% and 60%, respectively; p<0.002). Almost three-quarters of the interns (70.8%), in comparison with 60% of consultants, agreed that patients could call them directly between appointments (p<0.0004). Moreover, 30.2% of the interns and 10% of the consultants expressed their agreement that patients could call them at home outside working hours (p<0.0005).

Few interns (15.1%) and consultants (10%) said that they would feel comfortable if patients called them while they were busy with other patients, but the difference was not statistically significant. Interns and consultants who thought that patients on appointment might wait for 30 minutes or less, if doctors were delayed, constituted 87.7% and 70%, respectively; (p<0.005) (Table 4).

Table 4

Attitudes of consultants and interns towards accessibility of patient care

DISCUSSION

The early exposure of medical interns to family practice has many advantages. Training in this specialty results in a wide range of experiences in dealing with patients. However, the most valuable is their orientation on the principles of continuity of care, comprehensiveness, and coordination of care and physicians’ accessibility to patients in need. This study attempted to assess attitudes of a sample of interns who had undergone training rotation in family practice, towards the above-mentioned aspects of care.

In this study, medical interns were generally more in favor of the attributes of primary care. Consultants, on the other hand, were less inclined to provide this type of care for their patients. As a group, consultants were reluctant to provide continuity, coordination, comprehensiveness and accessibility. Medical interns were also more oriented towards the actual delivery of primary care than consultants. These results might simply reflect the impact of the training of the consultants during different residency programs and their lack of involvement in the general practice of medicine. The attitudes of the consultants may have been influenced by their faculty status, since almost all of them were sub-specialists. Sub-specialists are known, to underrate the attributes of primary care, when they assume the values of subspecialty care. This “association” has been observed and extensively studied.7

It appears that following their sub-specialization period, consultants do not wish to treat medical problems outside their specialties. Although, in general, relatively little is known about the persistence of attitudes and values in the face of changing roles.7 Proper orientation of young physicians towards attributes of primary care will help to avoid the stance of consultants.

This study supports results of similar studies, which showed that positive attitudes towards primary care formed by interns during medical school training actually diminish and sometimes eventually disappear altogether when they become consultants and assume new roles.8

If young physicians follow the pattern of the consultants towards primary care practice, a situation may arise in which there may be a conflict between the type of patients they prefer to see, and those they actually see. This is because older patients, and those with chronic illnesses, who are the most likely to receive subspecialty care, value the primary care attributes of coordination, continuity and comprehensiveness very highly.910

The main difference between interns and consultants in this study is that the former had undergone training rotations in family and community medicine. The training is known to instill into the trainees positive attitudes towards the attributes of primary care.11 This can be further improved by restructuring the period of internship more appropriately for the teaching of the primary care attributes and skills.12 Therefore, the inclusion of training in family and community medicine during internship should be mandatory for graduation. However, this will always be influenced by the attitude of hospital consultants with whom interns are attached most of the time.1314

In conclusion, this study proves that the training in family medicine can create a positive attitude towards primary health care. It also shows that unless consultants change their attitude towards the importance of primary care, the quality of patient care as well as physicians’ training will suffer. This is a cause for concern. The College of Medicine should therefore, examine how negative attitudes towards primary care attributes develop, and their impact on patient care, and future residency training.