Using a national survey, we examined final-year residents' perceived preparedness to counsel about preventive and psychosocial issues. Ideally, all final-year residents in the specialties that provide adult primary care should feel well prepared to address these topics, but this was not the case. Less than half of respondents felt well prepared to counsel patients about depression, substance abuse, and domestic violence, and less than two thirds felt well prepared to counsel about tobacco use or diet and exercise. It appears that the next generation of physicians may not be well prepared to address these priority national health promotion issues.
Residents' perceived preparedness to counsel about preventive behaviors and psychosocial issues varied by specialty, even after adjustment for other differences among specialties. As hypothesized, family practice residents felt better prepared than Obstetrics/Gynecology residents to address smoking, depression, and diet and exercise, but the reverse was true for counseling about domestic violence. No differences were seen by specialty in preparedness to counsel about substance abuse. Internal Medicine residents generally felt less prepared than family practice residents, but the differences were statistically significant only for depression and domestic violence counseling.
Our finding that Obstetrics/Gynecology residents felt best prepared to counsel about domestic violence echoes previous studies demonstrating that Obstetrics/Gynecology providers, compared to family practitioners and Internists, report a higher level of domestic violence screening.24,37
So, although ACGME guidelines for family practice and Internal Medicine also require instruction in the recognition and management of domestic violence, our findings suggest that Obstetrics/Gynecology programs place greater emphasis on domestic violence training than the other primary care programs. In addition, it is likely that Obstetrics/Gynecology residents have more opportunity to practice domestic violence counseling because all of their patients are female. The low rates of Internal Medicine and family practice residents' perceived preparedness to address domestic violence indicate a need for residency training in these fields to improve training on this important topic.
Although the ACGME program requirements for the primary care specialties all state that instruction is required in preventive and psychosocial counseling, there needs to be a focus on assessing and evaluating these counseling competencies. Studies have shown that physicians' self-assessment skills tend to overestimate their actual skill level.38
Although residents are more accurate at self-assessment than practicing physicians, residents also report that their activity and skill levels are higher than they actually are. Therefore, it is likely that the residents' self-perceived preparedness ratings in this study are overly favorable and that there is a greater deficit in preparedness than is actually reported.
Overall, residents' perceived preparedness to counsel about preventive and psychosocial issues was associated primarily with medical specialty rather than with the proportion of time a resident spent in ambulatory settings. Counter to our hypothesis, the proportion of residency time spent in an ambulatory setting was only related to perceived preparedness to counsel for depression. Increasing the amount of time spent in ambulatory settings may be necessary but is not sufficient to guarantee residents' preparedness in the areas of smoking, diet and exercise, substance abuse, and domestic violence. The implication is that not only the amount but also the content of the ambulatory training matters.
We believe that the movement toward competency-based assessment, with a focus on evaluating residents on the ACGME Outcome Project's 6 core competencies (patient care, medical knowledge, communication skills, practice-based learning and improvement, professionalism, and systems-based practice),39,40
is needed. Each residency program should evaluate whether or not its instruction in preventive and psychosocial counseling is achieving needed outcomes and also whether residents are being allocated time needed for counseling activities. Many of our findings of residents' perceived preparedness deficits are consistent with the literature on the counseling behaviors of physicians in practice.5,8,12,13,18,21,37,41–43
Variations by specialty are also consistent with the literature on practicing physicians' counseling behaviors.3,24,37,44–47
Within each specialty, the deficits in residents are similar to the deficits in practicing physicians, indicating a need to improve residency training and faculty development.
This study had several limitations. Our results are based on self-reported preparedness, and it is unknown how this subjective assessment relates to performance. However, research on physician behavior change indicates that confidence in one's ability to make a change (e.g., self-efficacy) is related to the likelihood of doing so.5,43,46
In addition, Internal Medicine training is a common pathway for both primary care internists and those who plan to specialize. Many Internal Medicine residency programs have separate tracks for those individuals who plan to go into primary care. Our survey did not differentiate between these tracks. It is possible that residents in primary care Internal Medicine feel more prepared to counsel about preventive and psychosocial issues than their specialty-bound colleagues. Finally, the generalizability of our findings is limited to residents at academic health centers in 1998; these data will be an important basis for comparison with upcoming data from the ACGME evaluation efforts.
In summary, the majority of adult primary care residents do not feel very well prepared to counsel patients about preventive care and psychosocial issues, and extent of preparedness varies by specialty. Identified strengths of family practice and Obstetrics/Gynecology programs may serve as models to direct future residency training in preventive counseling.