November 18, 2002
Relatively little is known about current STD practices outside of dedicated STD clinics. Although some small regional studies have been conducted, the last national STD survey of physicians was in 1968; it was very limited in scope, containing only 2 questions (number of STD cases that physicians diagnosed and number reported to public health departments). The health care climate has changed markedly since that time, with shifts toward managed care and advances in STD diagnostics and treatment. In addition, dwindling resources have closed or limited the hours of operation of publicly funded clinics in several geographic areas, raising concerns that financial constraints might contribute to an increasing prevalence of treatable STDs.
This report presents results from a national survey of U.S. physicians that assessed screening, case reporting, partner management, and clinical practices for syphilis, gonorrhea, chlamydia, and HIV infection.
Five medical specialties were selected on the basis of evidence that they provide care for 85 percent of STDs diagnosed in the United States. Surveys were mailed to a randomly selected sample of 7,300 physicians from the Physician Master File of the American Medical Association. Included were physicians who reported that they specialized in obstetrics/gynecology, internal medicine, general or family practice, emergency medicine, or pediatrics; spent at least 50 percent of their professional time in direct patient care; and cared for patients ages 13 to 60. The cumulative response rate was 70.2 percent after adjustment for surveys that were undeliverable or returned as ineligible. Completed surveys (n=4,226) were received from all 50 states and the District of Columbia, with approximately equal regional distribution (Northeast, 21 percent; South, 32 percent; Midwest, 25 percent; West, 22 percent). Fewer than 9 percent of the original sample disqualified themselves because they did not see enough STDs in their practice.
The prevalence of STD screening was surprisingly low for men (19-24 percent) and for nonpregnant women (20-35 percent), as was the percentage of physicians who screened pregnant women (30-32 percent). Although the percentage of obstetricians/gynecologists who screened pregnant women was higher, it was still lower than the recommendations in standard practice guidelines, such as the STD Treatment Guidelines or the Guide to Clinical Preventive Services, that all pregnant women should be screened.
Community-based physicians play an important role in case finding and reporting, but these behaviors are less frequent than might be assumed by public health authorities. From 23 percent to 49 percent of physicians lacked awareness of reporting requirements for either clinicians or laboratories. About half of the physicians treated presumptively for gonorrhea (56.7 percent) and chlamydia (54.2 percent), and, surprisingly, almost 40 percent did so for syphilis. This has implications for disease surveillance, as presumptive treatment may not be accompanied by confirmatory diagnostic tests and physicians are relying on their laboratories to report cases. The newer urine-screening diagnostic tests are rarely used by community-based physicians, although these tests are less invasive, more acceptable to patients, allow screening to be conducted in nontraditional settings, and are easier to implement for both men and women.
The results of this survey suggest that there are many missed opportunities to diagnose, treat or prevent STDs in the United States. Few physicians engage in partner notification, and most instruct patients to self-report to the health department or to notify their partners themselves. This reliance on patient notification represents a gap between common practice and the authors' knowledge of its effectiveness. "A better understanding is needed of what patients actually do when they are advised to inform their partners or the health department of their STD infection," the authors wrote.