Clinicians and SCD patients alike say that negative clinician attitudes have a major impact on the quality of SCD care. We found evidence to suggest that a brief video-intervention can be used to improve attitudes held by clinicians towards these patients. While multiple interventions to improve the quality of pain management for SCD patients have been tested,9
we identified only one other study which directly attempted to modify clinician attitudes toward these patients. Jamison and Brown found that a multi-modal intervention to improve the care of SCD patients, which included a provider education and sensitivity training component, led to an increase in patient satisfaction.18
However, no direct assessment of the impact of these methods on clinician attitudes was provided.
Our intervention demonstrated its strongest impact on the reduction of negative attitudes. The negative attitudes scale asked clinicians to estimate the percentage of SCD patients who possess negative characteristics such as being drug-seeking upon entrance into the hospital. Multiple studies have shown that clinicians tend to overestimate the prevalence of addiction among SCD patients.8,19,20
Shapiro et al. found that 53% of emergency department physicians, and 23% of hematologists thought that greater than 20% of SCD patients were addicted to analgesics.19
No studies, however, have shown that these patients are any more likely than other patient populations to be addicted, and estimates of the prevalence of addiction among SCD patients range from 0 to 11%.21–24
Nevertheless, SCD patients frequently report that clinicians treat them as if they have addiction issues.12,25–31
Our intervention suggests one potential way to reduce these clinician beliefs.
Our video-intervention reduced the extent to which certain behaviors exhibited by SCD patients were viewed as raising clinician concern that the patient is inappropriately drug-seeking. Elander defines concern-raising behaviors in the context of SCD as observable patient behaviors that clinicians may view as signs that the patient is drug-seeking, but which are equally, if not more, likely to be attributed to inadequacies in the management of the patient’s pain.32,33
In his study, Elander found that concern-raising behaviors were statistically associated with patient attempts to seek relief from their pain, while there was no association between these behaviors and patient behaviors driven by actual substance addiction.33
In our study, clinicians participating in the intervention group demonstrated a lower level of endorsement of behaviors (such as requesting a specific type and dosage of opioids) as a sign that the clinician should be concerned about drug-seeking.
Nevertheless, our intervention demonstrated no impact in reducing the extent to which one set of behaviors (specifically: a patient appearing to change his or her behavior when a clinician walks into the room, having a history of signing out of a hospital against medical advice, or tampering with patient-controlled analgesia devices) were seen as signs that the patient may be drug-seeking. A number of hypotheses might explain this lack of an effect. For one, these behaviors may truly be more indicative of underlying substance abuse issues among patients, and thus clinicians would be correct in viewing these as “red-flags” for patient drug-seeking. It is interesting to note, though, that we have previously reported that adult SCD patients with a history of leaving a hospital against medical advice were more likely to have reported having difficulty in persuading healthcare providers about their pain, while we found no significant statistical association between self-discharge history and having a positive toxicology screen within the prior 5 years.34
Alternatively, these particular “red-flag” behaviors may be perceived by clinicians as more indicative of underlying substance abuse issues among patients. If the significance of these particular behaviors differs in degree from other concern-raising behaviors within the perceptions of clinicians, then specially tailored interventions to address these particular beliefs may be required. Future research should assess to what extent underlying substance abuse issues, difficulties in communicating with clinicians about pain, or other potential causes can explain the incidence of these specific behaviors among SCD patients.
Our intervention had a small effect on increasing the positive attitudes that clinicians held toward SCD patients. Our positive attitudes scale asked clinicians to estimate, among other things, the percentage of SCD patients that they could see themselves being friends with. Previous research by van Ryn found that physicians were more likely to rate white than black patients as someone with whom they could see themselves being friends.2
Other research has found that patients who are not liked by their physicians receive lower quality medical care.35
Additionally, patients who are respected by their physicians perceive higher quality communication in routine medical encounters than patients who are not respected.36
Higher perceived quality of clinician communication with SCD patients has been shown to be associated with the amount of trust in clinicians expressed by this population.37
As the content of our intervention focused on describing the many challenges that adults with SCD can face in seeking treatment for pain, it may not have possessed the content needed to improve clinician feelings of “affiliation” or “liking” toward SCD patients generally. Despite this, the fact that we did observe a small improvement in positive attitudes toward these patients is encouraging.
This study was subject to certain limitations that should be considered when interpreting the results. While our study found statistical differences between the intervention and control groups on 3 of our 4 outcome measures, the clinical significance of these differences is unclear. The majority of the research which has documented clinician attitudes toward patients with SCD has been qualitative in nature. Therefore, it is unclear how quantitative assessments of differences between clinicians in their attitudes toward SCD patients translate into observed differences in the actual quality of care delivered to their patients. Future research should seek to directly estimate this relationship.
As the participants in our intervention group completed the survey immediately after viewing the video-intervention, the duration of the effects observed in this study are unknown. It is possible that periodic “refreshers” are needed to sustain the intervention effect.
The extent to which our findings are generalizable to clinicians working in other treatment settings is unclear. The clinicians participating in our study treat SCD patients in the setting of an academic medical center located in an urban environment. Future research must examine the extent to which the geographic location, environment, healthcare setting, and the institutional culture interact to affect clinician attitudes toward SCD patients as this may have important implications for the content that ought to be included in interventions designed to improve clinician attitudes.
Similarly, as the participants in our study consisted of nurses and internal medicine residents alone, the extent to which our findings are generalizable to other types of clinicians is unknown. It will be important for future efforts in this area to assess the extent to which our intervention may impact the attitudes of attending physicians, emergency department physicians, and emergency department nurses, among others.
We used a randomized post-test only control group design because of its efficiency and the protection it provides against many common threats to internal validity. A limitation of this design is the assumption of the baseline equivalency of the outcome variable between the intervention and control groups.13
However, as our randomization scheme appeared to induce equivalency between our intervention and control groups on every measured demographic characteristic, we have evidence to support the validity of the assumption of baseline equivalency on our outcome measure as well.
Lastly, it is possible that the changes in clinician attitudes observed in this study may be attributable to a social desirability bias. However, the fact that the attitudinal surveys employed in this study were self-administered and anonymous may have minimized any impact this bias had on our findings.38
Despite its limitations, our study suggests that a relatively simple educational intervention can be used to improve clinician attitudes toward patients with SCD. A strength of our intervention was the use of adult patients with the disease describing in their own words the challenges they face in seeking treatment for pain. In our experience, we have found that the only exposure to SCD patients that most clinicians have is when the patient presents during a pain episode, when emotions and frustrations are running high. A higher percentage of clinicians may exhibit less negative attitudes toward this population if they had more opportunities to interact with individuals with the disease outside the immediate patient–clinician dynamic. Clinicians need more opportunities to view individuals with SCD as individuals (not just as patients), and to reflect upon their own reactions to encountering these individuals when they are in pain. Ultimately, we hope that this attitudinal shift will lead to improved quality of care for all patients with the disease.