Attitudes of Internal Medicine Physicians Toward Type 2 Diabetes.

ABSTRACT

Background. This study was designed to identify differences among internists in their attitudes about diabetes and how those attitudes influence practice behavior.

Methods. A cross-sectional study of 55 internists in an academic medical center was done using the Diabetes Attitude Scale (DAS-3), a valid and reliable measure of attitudes toward diabetes.

Results. Most respondents were white (89%), male (65%), and [greater than or equal to]40 years old (85%). On the need for special training, internists were significantly different from the standardized norm for the DAS-3. Similar differences were observed on the seriousness of type 2 diabetes, the value attached to "tight control," and patient autonomy. Differences by age, sex, and level of training were not significant.

Conclusion. Regardless of age, sex, or level of training, internal medicine physicians have negative attitudes toward type 2 diabetes that require future educational interventions.

IN THE United States, approximately 15.7 million people have diabetes, representing 5.9% of the population. Type 2 diabetes is a chronic, debilitating illness with significant morbidity and mortality and accounts for 90% to 95% of all cases of diabetes in the United States. (1) Most of the complications of diabetes can be delayed or prevented by "tight glucose control." (2-6)

Routine care for patients with type 2 diabetes is provided mainly by primary care physicians such as internists and family physicians. (7) However, data from several studies indicate that the quality of diabetes care in primary care settings is less than optimal. (8,9) Suggested reasons include deficiencies in physician knowledge, lack of belief in the value of aggressive treatment of diabetes, and problems with patient compliance, including the lack of fostering patient autonomy. (10) Other suggested factors include the complicated nature of diabetes care and the substantial time requirements of high-quality diabetes care. (11,12)

Negative attitudes toward diabetes among primary care physicians is thought to be a more significant barrier to improving outcomes than a deficit in diabetes-specific knowledge. (13,14) Data suggest that negative beliefs and attitudes impede guideline adherence (15,16) and aggressive treatment of type 2 diabetes. (14,17) To identify the attitudes of internal medicine physicians toward type 2 diabetes and the differences between attending physicians and physicians-in-training, a survey of internal medicine physicians was conducted in an academic medical center.

MATERIALS AND METHODS

The survey was conducted among general internal medicine residents and attending physicians in an academic medical center. The sample consisted of 55 internal medicine physicians who responded to a Web-based survey of physicians' attitudes towards diabetes.

Instrument

The DAS-3, developed by the Michigan Diabetes Research Training Center, is a measure of diabetes-related attitudes. The DAS-3 is composed of 33 items and 5 subscales. It is designed to capture the perceptions of health care providers on the need for special training, the seriousness of type 2 diabetes, the value of tight control, the psychosocial impact of diabetes, and the need for patient autonomy. The scale was standardized on a large sample of 1,814 physicians, nurses, dietitians, and patients with diabetes. Mean scores for each subscale have been previously established. (18)

Data Collection

Each participant received an e-mail request to participate in the study with an imbedded hyperlink to the survey Web site. The Web-based DAS-3 instrument was designed for completion in 15 minutes, and responses were anonymous. With multiple mailing, we obtained a 65% response rate (55/85). The Institutional Review Board of our institution approved the study.

Statistical Analyses

Mean scores for each of the five subscales of the DAS-3 were calculated. Age, sex, and level of training were used to create physician categories. Mean scores for all physicians were calculated and compared with the standardized mean scores for each subscale with the one-sample t test of mean. Analysis by race/ethnicity of physicians was not done because of the small sample size of nonwhite physicians. Using the two-sample independent t test of means, scores on subscales of the DAS-3 were compared by age, sex, and level of training of physicians. All P values were 2-tailed with [alpha] = .05. Statistical testing was done with SAS software, Version 8.0 (SAS Institute, Cary, NC).

RESULTS

Sample characteristics of the study group are presented in Table 1. Most respondents were white (89%) and male (65%). Resident physicians constituted 67% of the sample, most physicians (85%) were [less than or equal to]40 years old, and the mean age was 34 years (33.5 [+ or -] 9.1).

Attitude Subscales

Table 2 shows descriptive statistics for the five DAS subscales for the study sample. Internal medicine physicians differed significantly from the standardized mean on four attitude subscales. Internal medicine physicians scored significantly lower than the standardized mean for need for special training in teaching, counseling, and behavior change techniques (4.46 vs 4.60, P = .03). On the seriousness of type 2 diabetes subscale, internal medicine physicians scored significantly lower than the standardized mean (4.09 vs 4.40, P < .0001). Internal medicine physicians also scored significantly lower on value attached to tight glucose control in diabetes care (4.01 vs 4.30, P < .0001) and value attached to patient autonomy regarding daily self-care of their diabetes (3.91 vs 4.10, P= .0008).

The score of internal medicine physicians did not differ from the standardized mean on attitude toward the psychosocial impact of diabetes on the lives of people with the disease (4.13 vs 4.20, P = .19).

Differences by Age, Sex, and Level of Training

Table 3 gives a comparison of mean subscale scores on the DAS-3 by age, sex, and level of physician training. No differences were observed on each of the five subscales of the DAS-3 between male and female physicians. Similarly, attending physicians did not differ from resident physicians on any of the subscales of the DAS-3. When younger physicians were compared with older physicians, there were no significant differences on subscale scores except in the need for special training. Older physicians were more to appreciate the need for health care professionals who care for patients with diabetes to have special training in teaching, counseling, and behavior change techniques than younger physicians (4.80 vs 4.40, P=.02)

DISCUSSION

Internal medicine physicians appeared to have certain negative attitudes toward diabetes. These negative attitudes were consistent across age, sex, and level of training of physicians. However, older physicians were more likely to appreciate the need for special training in teaching, counseling, and behavior change techniques for health care professionals who care for patients with diabetes.

According to the results of this study, there is a need for a change in the attitudes of internal medicine physicians toward diabetes. Of particular importance is the need for physicians to acknowledge patient autonomy in diabetes self-management. Consistent with the principles of chronic disease management, decision-making in diabetes care is likely to be more effective when patients are in partnership with their physicians. In addition, negative attitudes toward patient autonomy can impede patient-physician collaboration, which is particularly essential in the management of type 2 diabetes.

Type 2 diabetes is a serious disease, and tight glucose control reduces morbidity and mortality associated with diabetes. Consequently, the negative attitudes toward the seriousness of type 2 diabetes and the low value attached to tight glucose control by internal medicine physicians in this study are important findings. Such negative attitudes may affect implementation of current American Diabetes Association guidelines for diabetes management and outcomes for diabetic patients.

The fact that physicians in training and attending physicians shared similar negative attitudes suggests that such attitudes may develop early in the careers of internal medicine physicians. In addition, it raises questions on when and how these attitudes develop and whether such negative attitudes are directed toward other chronic diseases in primary care settings.

The major implication of this study is that greater attention on physician attitudes is needed, particularly in the case of diabetes, where physician attitudes have been shown to affect practice behavior. In addition, educational interventions at the residency level may be beneficial to promote the right attitudes toward the management of chronic diseases such as diabetes. As in all studies with sample sizes such as ours, replication of the study is necessary to validate our findings.

CONCLUSION

Internal medicine physicians appear to have certain negative attitudes toward diabetes that are consistent across age, sex, and level of training and that seem to develop early in the careers of internal medicine physicians.

References

(1.) Diabetes Statistics, NIH Publication No. 99-3892. March 1999. Available online from http://www.niddk.nih.gov/health/diabetes/pubs/ dmstats/dmstats.htm

(2.) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329:977-986

(3.) UK Prospective Diabetes Study (UKPDS) Group: Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). [Published erratum appears in Lancet 1998; 352:1557]. Lancet 1998; 352:854-865

(4.) UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). [Published erratum appears in Lancet 1999; 354:602] Lancet 1998; 352:837-853

(5.) UK Prospective Diabetes Study (UKPDS) Group: Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. BMJ 1998; 317:720-726

(6.) UK Prospective Diabetes Study (UKPDS) Group: Tight blood pressure control and risk of macrovascular and micro-vascular complications in type 2 diabetes: UKPDS 38. [Published erratum appears in BMJ 1999; 318:29] BMJ 1998; 317:703-713

(7.) Harris MI: Medical care for patients with diabetes, epidemiologic aspects. Ann Intern Med 1996; 124:117-122

(8.) Ho M, Marger M, Beart J, et al: Is the quality of diabetes care better in a diabetes clinic or in a general medicine clinic? Diabetes Care 1997; 20:472-475

(9.) Glasgow RE, Boles SM, Calder D, et al: Diabetes care practices in primary care: results from two samples and three measurement sets. Diabetes Educ 1999; 25:755-763

(10.) Lawler FH, Viviani N: Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines. J Fam Pract 1997; 44:369-373

(11.) Larme AC, Pugh JA: Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care 1998; 21:1391-1396

(12.) Helseth LD, Susman JL, Crabtree BF, et al: Primary care physicians' perceptions of diabetes management. a balancing act. J Fam Pract 1999; 48:37-42

(13.) Weinberger M, Cohen SJ, Mazzuca SA: The role of physicians' knowledge and attitudes in effective diabetes management. Sac Sci Med 1984; 19:965-969

(14.) Anderson RM, Donnelly MB, Davis WK: Controversial beliefs about diabetes and its care. Diabetes Care 1992; 15:859-863

(15.) Kenny SJ, Smith PJ, Goldschmid MG, et al: Survey of physician practice behaviors related to diabetes mellitus in the U.S. physician adherence to consensus recommendations. Diabetes Care 1993; 16:1507-1510

(16.) National Institutes of Health: Metabolic Control Matters: Nationwide Translation of the Diabetes Control and Complications Trial: Analysis and Recommendations. Bethesda, Md, National Institutes of Health, 1994 (NIH Publication No. 94-3773)

(17.) Anderson RM, Donnelly MB, Dedrick RF, et al: The attitudes of nurses, dietitians, and physicians toward diabetes. Diabetes Educ 1991; 17:261-268

(18.) Anderson RM, Fitzgerald JT, Funnell MM, et al: The third version of the Diabetes Attitude Scale. Diabetes Care 1998; 21:1403-1407

TABLE 1.

Sample Demographics (n = 55)

                                  No. (%)

Age groups (yr)
  [less than or equal to]40       47 (85)
  >40                              8 (15)
  Mean age (yr) [+ or -] SD  33.5 [+ or -] 9.1

Sex
  Male                            36 (65)
  Female                          19 (35)

Ethnicity
  White                           49 (89)
  Nonwhite                         6 (11)

Level of training
  Attending                       18 (33)
  Resident                        37 (67)
TABLE 2.

Comparison of Sample Subscale Men Scores and Standardized Mean Scores

                                       Sample           Standardized
Subscales                        (mean [+ or -] SD)  (mean [+ or -] SD)

Need for special training        4.46 [+ or -] 0.45  4.60 [+ or -] 0.40
Seriousness of type 2 diabetes   4.09 [+ or -] 0.28  4.40 [+ or -] 0.53
Value of tight control           4.01 [+ or -] 0.22  4.30 [+ or -] 0.47
Psychosocial impact of diabetes  4.13 [+ or -] 0.40  4.20 [+ or -] 0.50
Need for patient autonomy        3.91 [+ or -] 0.40  4.10 [+ or -] 0.53


Subscales                        P Value

Need for special training         .03
Seriousness of type 2 diabetes   <.0001
Value of tight control           <.0001
Psychosocial impact of diabetes   .19
Need for patient autonomy         .0008
TABLE 3.

Comparison of Mean Subscale Scores by Sex, Level of Training, and Age

Categories                              Male               Female

Need for special training        4.53 [+ or -] 0.40  4.33 [+ or -] 0.50
Seriousness of type 2 diabetes   4.12 [+ or -] 0.28  4.05 [+ or -] 0.27
Value of tight control           3.96 [+ or -] 0.28  4.04 [+ or -] 0.19
Psychosocial impact of diabetes  4.18 [+ or -] 0.47  4.10 [+ or -] 0.37
Need for patient autonomy        3.86 [+ or -] 0.50  3.93 [+ or -] 0.35

Categories                       P Value      Attending

Need for special training          .10    4.62 [+ or -] 0.34
Seriousness of type 2 diabetes     .36    4.17 [+ or -] 0.24
Value of tight control             .25    4.04 [+ or -] 0.24
Psychosocial impact of diabetes    .52    4.18 [+ or -] 0.37
Need for patient autonomy          .50    3.84 [+ or -] 0.51

Categories                            Resident       P Value

Need for special training        4.38 [+ or -] 0.47    .06
Seriousness of type 2 diabetes   4.25 [+ or -] 0.29    .14
Value of tight control           3.99 [+ or -] 0.21    .50
Psychosocial impact of diabetes  4.10 [+ or -] 0.42    .46
Need for patient autonomy        3.94 [+ or -] 0.35    .40

Categories                       Age ([less than or equal to]40)

Need for special training              4.40 [+ or -] 0.45
Seriousness of type 2 diabetes         4.09 [+ or -] 0.27
Value of tight control                 4.00 [+ or -] 0.22
Psychosocial impact of diabetes        4.12 [+ or -] 0.40
Need for patient autonomy              3.90 [+ or -] 0.38

Categories                           Age (>40)       P Value

Need for special training        4.80 [+ or -] 0.18    .02 (*)
Seriousness of type 2 diabetes   4.13 [+ or -] 0.35    .73
Value of tight control           4.07 [+ or -] 0.22    .41
Psychosocial impact of diabetes  4.17 [+ or -] 0.45    .77
Need for patient autonomy        3.94 [+ or -] 0.56    .82

(*)P<.05= Significance.

RELATED ARTICLE: KEY POINTS

* Persons with diabetes in the United States experience significant morbidity and mortality from the disease.

* Results from the United Kingdom Progressive Diabetes Study indicate the "tight" glucose control is effective at reducing complications and deaths from type 2 diabetes.

* Internists in a southern medical school were surveyed about their attitudes toward type 2 diabetes

* Internists were less likely to believe that type 2 diabetes was serious, value "tight" control, value patient autonomy, and believe in the necessity for special training on counseling and behavior modification techniques.

* Attitudes were similar regardless of age, sex, or level of training