This qualitative study found that participating PCPs feel responsible for providing their patients with information about the possibility of medication-induced birth defects. However, PCPs acknowledge that their current practices generally fall short of their own standards for ideal care. PCPs identified five key challenges in helping their patients safely use teratogenic medications and suggested several opportunities for improving counseling about teratogenic medications in primary care settings. Of note, while PCPs do not hesitate to refer patients to specialists if they have complex disease, few were aware of the option of referring their patients to a teratology information specialist. Efforts to inform primary care providers of referral options, including the toll-free information service (1-866-626-6847) operated by the Organization of Teratology Information Specialists may be of benefit. Other targets for intervention identified by PCPs included several that can be implemented in most clinical settings. These include the development of patient information handouts and systems to routinely assess patients’ plans for pregnancy. As half of US pregnancies are unplanned (Finer et al, 2006
), and many PCPs expressed a hesitancy to raise this issue with their patients, the development of such systems may be of particular importance. While more resource intensive, PCPs also felt that clinical decision support built in to electronic medical records holds great promise as a way to help PCPs identify medications that pose teratogenic risks and patients in need of counseling. While use of EMRs has been increasing rapidly it will likely be some time before decision support will be available to aid in provision of teratogenic risk counseling in most primary care settings. In 2005, data from the National Ambulatory Medical Care Survey (NAMCS) indicated that one-quarter of office-based physicians were using some form of electronic medical record (EMR) systems (National Center for Health Statistics, 2008). However, only 9% of these physicians had a “complete EMR system”, with computerized prescription, orders for tests, reporting of test results, and physician notes.
Clinicians also suggested the development of a comprehensive online reference as a way to enhance clinicians’ ability to provide meaningful information on medications’ teratogenic risks. However, developing and maintaining such a web-based database will require a significant amount of funds and attention to ensure that it remains free from bias resulting from pharmaceutical sponsorship. Finally, PCPs felt reimbursement for time spent providing teratogenic risk counseling is needed to support clinicians in the provision of this important aspect of care. Other studies have noted that lack of reimbursement limits provision of primary prevention services (Burack, 1989
A major strength of this study is the open-ended structure of the interview guide, which allowed us to explore clinicians’ perceptions of their role in providing information about teratogenic medications, barriers to the provision of this information and suggestions for ways to improve the provision of this information. There was diversity in terms of focus group participants’ practice settings (general internal medicine, family medicine, university student health service, adolescent medicine setting) as well as training (e.g. medicine, nursing, pharmacy). Of note, statements made by older PCPs were similar to those made by younger PCPs, who were residents currently training in primary care.
A limitation of the study was that it was a convenience sample drawn from a single region. Despite efforts to recruit a socio-demographically diverse sample, most participants were female and white, which may limit generalizability to PCP’s who are male or from different ethnic or racial backgrounds. We suspect that our sample was mostly female because the majority of individuals currently training in primary care are women (Brotherton et al, 2005
), and nursing has long been a predominantly female profession. There is the possibility that social desirability bias may also play a role in our findings. In addition, the qualitative focus of this work does not yield estimates of the prevalence of specific responses, but rather reports on the range of answers that were elicited.
In summary, PCPs perceive themselves as playing an important role in providing their patients information on risk of medication-induced birth defects. Understanding the challenges clinicians face in providing information on teratogenic risks as well as their suggestions for ways to improve provision of such information may help to ensure that women of reproductive age receive appropriate counseling about risks of medication-induced birth defects.