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Datawatch

Ready And Willing? Physicians’ Sense Of Preparedness For Bioterrorism

Abstract

 
Little is known about contemporary physicians’ sense of preparedness for bioterrorism, willingness to treat patients despite personal risk, or belief in the professional duty to treat during epidemics. In a recent national survey few physicians reported that they or their practice are "well prepared" for bioterrorism. Still, most respondents reported that they would continue to care for patients in the event of an outbreak of "an unknown but potentially deadly illness," although only a narrow majority reported believing in a professional duty to treat patients in epidemics. Preparing physicians for bioterrorism should entail providing practical knowledge, preventive steps to minimize risk, and reinforcement of the profession’s ethical duty to treat.

In addition to the knowledge required to address bioterrorism, physicians must also be willing to do so. One recent threat (anthrax) required only that physicians participate in the distribution of antibiotics without undertaking significant personal risk. But other scenarios, such as outbreaks of smallpox, viral hemorrhagic fevers, plague, and new diseases such as severe acute respiratory syndrome (SARS), could require physicians to act at some risk to their own health. The medical profession’s responses to infectious outbreaks over several centuries, including at the outset of the HIV epidemic and early in the SARS outbreak, do not suggest a strict professional tradition.⁴ In recent training exercises for bioterrorism, military and public health strategists assumed that a number of physicians might not be willing to treat patients in the face of a potentially deadly, contagious illness.⁵ Other experts, however, have noted that large numbers of physicians volunteered after September 11, which suggests that many physicians take seriously the duty to treat.⁶ Furthermore, ethical standards support the existence of a professional duty to continue caring for patients during epidemics.⁷ To explore physicians’ readiness to address potential acts of bioterrorism, we conducted a mail survey of a national random sample of physicians involved in direct patient care. The survey focused on physicians’ perceived personal and work-place preparedness for bioterrorist attacks and their willingness to take on personal risk while caring for patients.

Survey Methods

Top Survey Methods Editor's Notes NOTES

 
Participants and study protocol. We selected a random sample of 1,000 patient-care physicians from the American Medical Association (AMA) Masterfile of all licensed physicians in the United States. A confidential survey was mailed to each physician in January 2002. Two subsequent waves of surveys were sent to nonrespondents; the final wave included a $2 cash incentive. The Institutional Review Board of the University of Chicago approved the study protocol.

We found an initial association between survey response time and reported willingness to treat. To discern if this association represented response-wave bias or a temporal trend, we selected an additional random sample of 100 physicians to receive a mailed survey in May 2002.⁸

Survey items. The main dependent variable was an item asking whether physicians would be "willing to continue caring for patients in the event of an outbreak of an unknown but potentially deadly illness." The item was intentionally vague as to the nature of the risk undertaken, since this would be the likely initial scenario in a bioterrorist event. To assess the effect of increasingly specific and preventable risks, a second item asked about willingness to treat in the face of the risk of "contracting a deadly illness," and a third specified the deadly illness as smallpox and stipulated that the physician had not been vaccinated. We also asked respondents whether they or their primary site of clinical practice were well prepared to play a role in handling a bioterrorist event. We included independent variables assessing clinical, psychological, and sociodemographic characteristics. The survey was pretested, and content and construct validity were prospectively assessed.

Analysis. We used a Pearson’s chi-square test to examine the bivariate relationship between each independent variable and the dependent variable. Next, we used nominal logistic regression analysis to examine the multivariate relationships. The regression model included independent variables that were of borderline significance (p <.10) on bivariate analysis, that contained sociodemographic information, or in which we had a substantive interest. We excluded three predictor variables (learned a lot about bioterrorism since September 11, duty to care for patients with HIV, and duty to care for patients with Hepatitis C) because of similarity and covariance with other variables in the model.

Survey Results Of the 1,000 physicians in our sample, forty-seven were unreachable by mail, and nineteen were ineligible for inclusion. Of the remaining 934 physicians, 526 (56 percent) returned completed questionnaires. The mean age of the respondents was fifty, 77 percent were men, 7 percent were from New York City or Washington, D.C., and most had been in practice for more than twenty years (Exhibit 1). Compared with respondents, nonrespondents were more often from New York State or Washington, D.C. (11 percent versus 7 percent), and more often foreign-born (59 percent versus 41 percent).

Discussion In this national random-sample physician survey from 2002, only about 20 percent of physicians felt well prepared to play a role in handling a bioterrorist event. Still, in the face of a hypothetical outbreak of an "unknown but potentially deadly illness," 80 percent affirmed a willingness to treat affected patients. Belief in a duty to treat, feeling prepared to play a role in responding to a bioterrorist attack, and being in primary care practice were each independently associated with physicians’ reported willingness to treat patients under conditions of personal risk.

Preparedness. These findings have several implications for policymakers and medical professionals. First, they support concerns regarding physicians’ preparedness. Frederick Chen and colleagues studied family physicians during a similar time period and also found that only one-quarter felt prepared to respond to a bioterrorist event and that receipt of response training was associated with preparedness.⁹ In this regard, the context of our survey is of critical importance. The survey took place within six months of a nationwide increase in concerns about bioterrorism preparedness, widespread media coverage of the anthrax exposures, and many new programs to prepare physicians to recognize and treat potential bioterrorist agents. Reflecting this context, nearly one in three physicians reported having learned a lot about "physicians’ roles in responding to bioterrorism" since 9/11. Still, only one in five felt prepared to play a role in responding to an attack. Competing priorities and the perceived low likelihood of a local attack may reduce physicians’ preparedness.¹⁰

Chen and colleagues also noted that there are no published validated measures of bioterrorism preparedness and few data on the effectiveness of specific educational programs.¹¹ We found that one’s sense of personal preparedness correlated with having learned a lot about bioterrorism since September 11 (correlation coefficient =0.50). However, given the complexities of learning about potential bioterrorist threats, it might be unrealistic to believe that most physicians will ever become well trained to recognize and treat even the most likely bioterrorist agents. Efforts to provide physicians with instructions for a general early response to medical disasters (such as where to report in an emergency situation) might foster a greater sense of readiness.

Duty to treat. Being prepared to play a role in responding to a bioterrorist attack entails being willing to assume personal risk. Bioterrorism scenarios such as the TOPOFF and Dark Storm exercises held by the government assumed that some time would pass before physicians would know the type and virulence of the pathogen or agent being used.¹² This uncertainty also played out in the recent naturally occurring SARS outbreak, as it did early in the HIV era.¹³

Arguments supporting a professional duty to treat in the face of uncertainty and risk have been based on multiple ethical and pragmatic grounds, including appeals to virtue, beneficence, patients’ rights, the contract between physicians and society, and social utility.¹⁴ Each of these arguments has limitations, and none can provide specific guidance as to the exact degree of risk to be undertaken. Yet, as with other public service professions, including the fire and police forces, risk has traditionally been part of medical care, and there have long been statements in professional codes of ethics supporting the duty to treat.¹⁵

Our survey reinforces this consensus view, but not without reservation. Although 80 percent of physicians reported a willingness to treat patients despite an uncertain level of risk, 20 percent did not, and only a narrow majority (55 percent) agreed that "physicians have an obligation to care for patients in epidemics even if doing so endangers the physician’s health." Importantly, physicians who believe in a professionwide duty to treat have more than fourfold higher odds of reporting a willingness to treat during an outbreak involving an unknown initial level of risk. While the validity of reports about future behavior cannot be ensured, physicians who deny an obligation to treat under conditions of risk are probably less likely to treat patients in a real incident. Therefore, these results suggest that efforts to ensure physicians’ readiness to address bioterrorist events should include a renewed emphasis on this long-standing professional obligation.

Temporal trends. The temporal trends that we observed are noteworthy, although they are limited by the small size of our second cohort. Both preparedness and the sense of professional obligation to treat during epidemics may be declining.¹⁶ Changes in these areas are not unprecedented. Early in the HIV epidemic, physicians hotly debated the duty to treat.¹⁷ Yet we found that 79 percent of physicians today perceive an obligation to care for HIV-infected patients. The reasons for greater consensus today are complex but likely include improved knowledge of HIV transmission, medical societies’ position statements, legal standards, and changing societal values. Similar factors should be considered in encouraging the duty to treat in future epidemics.

Study limitations. This study has several limitations. First, our results may be influenced by a socially desirable response bias. Second, physicians’ reported preparedness is not the only measure of society’s readiness to respond to bioterrorism. However, perceived preparedness is one measure of the efficacy of physicians’ educational programs, and it has been used and correlated with actual competencies in other settings.¹⁸ Third, although we obtained a response rate similar to that of recent rigorously conducted physician mail surveys, nonrespondents differed from respondents on a few demographic variables.¹⁹ However, none of these variables correlated with preparedness or willingness to treat, and there was not a response-wave bias. Finally, the clinical, psychological, and sociodemographic characteristics that we identified explain only a small amount of the overall variation in respondents’ willingness to undertake risk. Further studies are needed to more fully characterize the factors that contribute to physicians’ willingness to treat.

Some commentators have voiced concerns about a disproportionate focus on bioterrorism preparedness relative to other public health problems with arguably greater immediate effects.²⁰ Certainly, trade-offs must be weighed when potential public health investments are being compared. Whether a perceived preparedness for bioterrorism of 20 percent among U.S. physicians is "enough," and where resources devoted to improving this level of preparation might best be spent, are matters for debate.

Preparedness for handling a bioterrorist attack entails more than knowledge; it requires the willingness to put knowledge to work, perhaps at some risk to oneself. The threat of new disease outbreaks, from bioterrorism or natural causes, has provided an opportunity for physicians to rearticulate and reaffirm long-standing ethical principles regarding the duty to treat.

Editor's Notes

Top Survey Methods Editor's Notes NOTES

 
Caleb Alexander is a former Robert Wood Johnson Scholar and is currently an instructor in the Division of General Internal Medicine and associate faculty in the MacLean Center for Medical Ethics at the University of Chicago Hospitals. Matthew Wynia is director of the American Medical Association’s Institute for Ethics in Chicago and a clinical associate in medicine, Division of Infectious Diseases, at the University of Chicago Hospitals.

The authors gratefully acknowledge Jean-Luc Benoit and Jeanne Uehling for administrative assistance, Sam Huber for research on the historical foundation of the duty to treat, and Ashwini Sehgal and Steven Miles for helpful comments on earlier drafts. This work was supported by funding from the Institute for Ethics at the American Medical Association (AMA) and by the Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program. The funders had no role in the collection, analysis, interpretation, or reporting of the data. The views expressed in this paper are those of the authors and do not represent the funders’ policies.

NOTES

Top Survey Methods Editor's Notes NOTES

 

1. A.S.Khan, S. Morse, and S. Lillibridge, "Public-Health Preparedness for Biological Terrorism in the USA," Lancet (30 September 2000): 1179–1182; andJ.F.Waeckerle, "Domestic Preparedness for Events Involving Weapons of Mass Destruction," Journal of the American Medical Association (12 January 2000): 252–254.
2. J.L.Gerbeding, J.M. Hughes, and J.P. Koplan, "Bioterrorism Preparedness and Response: Clinicians and Public Health Agencies as Essential Partners," Journal of the American Medical Association (20 February 2002): 898–900.
3. H.C.Lane and A.S. Fauci, "Bioterrorism on the Home Front: A New Challenge for American Medicine,"Journal of the American Medical Association (28 November 2001): 2595–2597.
4. See, for example, A.Zuger and S.H. Miles, "Physicians, AIDS, and Occupational Risk: Historic Traditions and Ethical Obligations," Journal of the American Medical Association (9 October 1987): 1924–1928; and L.K.Altman, "Asian Medics Stay Home, Imperiling Respirator Patients," New York Times (21 March 2003).
5. ANSER Institute for Homeland Security, "Dark Winter," www.homelandsecurity.org/darkwinter/index.cfm (19 June 2003); and T.V.Inglesby, R. Grossman, and T. O’Toole, "A Plague on Your City: Observations from TOPOFF," Clinical Infectious Diseases (1 February 2001): 436–445.
6. G.J.Annas, "Bioterrorism, Public Health, and Civil Liberties," New England Journal of Medicine (25 April 2002): 1337–1342.
7. D.M.Fox, "The Politics of Physicians’ Responsibility in Epidemics: A Note on History," Hastings Center Report (April/May 1988): 5–9; American Medical Association, "Declaration of Professional Responsibility," 6 March 2003, www.ama-assn.org/ama/pub/category/7491.html (19 June 2003); and American College of Physicians, "Ethics Manual," 4th ed., 1998, www.acponline.org/ethics/ethicman.htm (19 June 2003).
8. We assumed that approximately twenty-five physicians of this second cohort would respond, providing a 95 percent probability of detecting a true difference of 20 percent or greater with respect to willingness to treat among early-wave responders in the first and second cohorts (power =.80).
9. F.M.Chen et al., "On the Front Lines: Family Physicians’ Preparedness for Bioterrorism," Journal of Family Practice (September 2002): 745–750.
10. J.G.Bartlett, "Mobilizing Professional Communities," Public Health Reports (Supplement 2, 2001): 40–44.
11. Chen et al., "On the Front Lines."
12. ANSER Institute, "Dark Winter"; and Inglesby et al., "A Plague on Your City."
13. Altman, "Asian Medics Stay Home."
14. R.Bayer, "AIDS and the Duty to Treat: Risk, Responsibility, and Health Care Workers," Bulletin of the New York Academy of Medicine (July/Aug 1988): 498–505.
15. AMA, "Declaration of Professional Responsibility"; and ACP, "Ethics Manual."
16. These trends mirror the substantial decrease in physicians’ use of online bioterrorism training programs throughout 2002, and they should be followed closely. M. Croasdale, "Doctor Interest in Bioterrorism Is Wearing Off," American Medical News (24 June 2002): 9–10.
17. See, for example, E.J.Emanuel, "Do Physicians Have an Obligation to Treat Patients with AIDS?" New England Journal of Medicine 318, no. 25 (1988): 1686–1690[Web of Science][Medline]; and Hastings Center Report, April/May 1998 special issue, which was devoted entirely to this debate.
18. See, for example, D.Blumenthal et al., "Preparedness for Clinical Practice: Reports of Graduating Residents at Academic Health Centers," Journal of the American Medical Association (5 September 2001): 1027–1034; and G.C.Wickstrom et al., "Confidence of Graduating Internal Medicine Residents to Perform Ambulatory Procedures," Journal of General Internal Medicine (June 2000): 361–365.
19. D.A.Asch, M.K. Jedrziewski, and N.A. Christakis, "Response Rates to Mail Surveys Published in Medical Journals," Journal of Clinical Epidemiology (October 1997): 1129–1136.
20. E.Fee and T.M. Brown, "Preemptive Biopreparedness: Can We Learn Anything from History?" American Journal of Public Health (May 2001): 721–726; and V.W.Sidel, H.W. Cohen, and R.M. Gould, "Good Intentions and the Road to Bioterrorism Preparedness," American Journal of Public Health (May 2001): 716–718.

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