ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE
Physicians' perception of personal risk of HIV infection and AIDS through occupational exposure Kathryn M. Taylor, PhD; Joan M. Eakin, PhD; Harvey A. Skinner, PhD; Merrijoy Kelner, PhD; Marla Shapiro, MD Physicians' response to acquired immune deficiency syndrome (AIDS) is poorly understood and often attributed to fear of human immunodeficiency virus (HIV) infection through occupational exposure. We surveyed 268 physicians from three geographic regions in North America with different specialties and responsibilities for HIV-positive patients. An important difference was found between the published risk and the physicians' perceived risk of infection after a single occupational exposure. Almost half of the respondents stated that they feared contracting AIDS more than other diseases. The physicians who perceived themselves to be at high physical risk were more likely than the others to report that AIDS had changed the way they interact with their patients (r = 0.26, p < 0.001). No relation was found between the perception of physical risk and the number of HIV-infected patients (r = -0.07, p 0.15). However, the perception of social risk showed a small inverse correlation (r = -0.15, p < 0.02), in which the physicians with more HIV-infected patients reported less concern about negative social consequences. The physicians who perceived themselves to be at high personal risk were more likely than the others to report that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing (r = -0.16, p < 0.01 for physical risk; r = -0.29, p < 0.001 for social risk). Multiple regression analyses indicated that physicians' perception of physical risk was not related to age or sex but was modestly related to income source. The perception of social risk was related to sex and income source. Physicians' perception of personal risk is a crucial, yet often unacknowledged, component of the fight against AIDS. Our findings suggest that lack of attention to this issue is seriously compromising initiatives designed to facilitate physician participation in AIDS care.
On comprend assez mal la reaction des medecins devant le syndrome d'immunodeficience acquise (SIDA); on croit souvent pouvoir l'attribuer a la crainte du risque professionnel de contracter le virus immunodeficitaire humain (VIH). Nous avons interroge 268 medecins de trois regions de l'Amerique du Nord exercant diverses specialites et variant quant a la mesure dans laquelle ils ont a traiter des sujets seropositifs. Nous avons trouve une grande difference entre le risque reel du fait d'un contact professionnel isole et celui percu par les medecins. Pres de la moitie d'entre eux ont dit craindre de contracter le SIDA plus que toute autre maladie. Le medecin est d'autant plus porte a affirmer que le SIDA a change son comportement envers ses From the Physician Behaviour Research Unit, Department of Behavioural Science, Faculty ofMedicine, University of Toronto Dr. Taylor was supported by a research scholar award from the Department of National Health and
Welfare.
Reprint requests to: Dr. Kathryn M. Taylor, Physician Behaviour Research Unit, Department of Behavioural Science, Faculty of Medicine, McMurrich Building, University of Toronto, 12 Queen's Park Cres. W, Toronto, Ont. M5S IA8 CAN MED ASSOC J 1990; 143 (6)
493
clients qu'il se croit soumis a un risque physique important (r = 0,26, p < 0,001), mais son estimation de ce risque n'a aucun rapport avec le nombre reel de ses clients seropositifs (r = - 0,07, p = 0,15). Quant a la crainte d'un risque social, elle est en faible correlation negative avec ce nombre (r = - 0,15, p < 0,02). Le medecin est d'autant plus porte a donner raison au chirurgien qui reclame le droit de refuser de traiter un malade ne voulant pas se preter a la recherche des anticorps anti-VIH qu'il se croit lui-meme soumis a un risque eleve (r = -0,16 et p < 0,01 pour le risque physique, r = -0,29 et p < 0,001 pour le risque social). L'analyse des regressions multiples montre que si le risque physique percu par les medecins n'est en rapport ni avec l'age ni avec le sexe du medecin, il varie dans une certaine mesure avec sa source de revenu. Quant au risque social apprehende, il est en rapport avec le sexe et la source de revenu. La maniere dont le medecin considere ces risques personnels joue un r6le central mais souvent inavoue dans la lutte contre le SIDA. Nos trouvailles nous portent a croire que le fait de passer cette question sous silence compromet gravement les efforts qu'on deploie afin d'assurer la participation des medecins au soin des sidatiques.
A cquired immune deficiency syndrome (AIDS) has created immense challenges for the prac-
tice of medicine.1-3 Although physicians have been confronted with many professional dilemmas the fundamental nature of their response to AIDS is not well understood. For example, the reluctance of physicians to take an active role in AIDS treatment and prevention has often been attributed to a fear of human immunodeficiency virus (HIV) infection and AIDS through occupational exposure.45 Many reports,6 9 however, have stated that this fear is largely irrational and is inconsistent with documented evidence of seroconversion rates among health care workers after accidental exposure. To understand better this powerful and apparently "unfounded" reaction by physicians we studied their perception of personal risk.
Methods A self-administered questionnaire was developed that contained 18 demographic, 60 binaryoption and 8 open-ended questions on physicians' attitudes and current behaviour toward HIV infection and AIDS. The questionnaire was designed on the basis of previously described critical concepts underlying physicians' response to AIDS.'0 In July 1988 the questionnaire was mailed to 674 physicians in three geographic settings that varied with respect to the incidence of AIDS: northwestern Ohio, which is a rural area with a relatively low reported incidence (4.5 per 100 000 population; US Centers for Disease Control, Atlanta: personal communication, 1989); Ontario, which has a relatively moderate reported incidence (1 1.1 per 100 000; Federal Centre for AIDS, Ottawa: personal communication, 1989); and a large teaching hospital in Chicago, which has a high reported incidence (14.1 per 100 000; US Centers for Disease Control:
personal communication, 1989). The physicians were randomly selected from published professional listings. Equal numbers of 494
CAN MED ASSOC J 1990; 143 (6)
physicians were chosen from medical, surgical and general practice specialties. This strategy was used because we expected that exposure to HIV-infected patients would affect physicians' responses and that exposure would vary by incidence, geographic setting and specialty. After a single mailing 268 questionnaires (40%) were returned. Eight were received after data entry had been completed, so that 260 were included in the data analysis. This response rate is a conservative estimate, since about 10% of the physicians could not be reached for various reasons (e.g., incorrect address, moved or retired). Also, to ensure candid responses complete anonymity was guaranteed, which necessitated the omission of geographic identifiers. Although this anonymity precluded a second mailing to increase the response rate, the rate fell within the acceptable limits for studies of heterogeneous groups of physicians on controversial issues. 11,12 A variety of relevant characteristics, such as age, medical specialty and exposure to HIV-infected and AIDS patients, were represented (Table 1); the overall nonresponse rate by item was less than 5%. However, since no data were available on the characteristics of the nonresponders the findings should be generalized with caution. The quantitative data were analysed with the use of the SPSS-X statistical software package.'3 The degree of covariation among specific variables was examined with the use of the product-moment correlation coefficient. Stepwise multiple regression analyses were used to evaluate the extent to which the demographic characteristics, specialty or setting and exposure to seropositive patients were correlated with the physical risk index (PRI) and the social risk index (SRI). The PRI was derived from an empiric analysis of 15 items concerning various aspects of physicians' perception that they could acquire HIV infection and AIDS through occupational exposure. Item responses were correlated with the overall index score, and a subset of "good", discriminating items was
selected if the item-index correlation was at least 0.20.14 From the initial pool of 15 items, 7 were retained. The internal consistency reliability estimate for the PRI was 0.64, an acceptable level given the number of items.'4 The SRI was derived in a similar fashion. We analysed seven items concerning the potential of negative social consequences of activities related to HIV infection and AIDS. Six of the items met the criterion of an item-index correlation of at least 0.20. The internal consistency reliability estimate was 0.60. A score was calculated for each index by summing the responses for the seven items on the PRI and the six items on the SRI.
infection and AIDS through occupational exposure, adequacy of protection and clinical care issues (Table 2). The distribution of PRI scores is shown in Fig. 1. The physicians' perception of physical risk varied considerably. The distribution of scores conformed fairly closely to a normal curve; this indicates that the physicians' perception of physical risk was a continuous variable that varied from 0 to 8.14
Perception ofsocial risk The six items constituting the SRI included Table 2: Physicians' responses to items constituting the perceived physical risk index*
Results
No. (and %) of physicians
Item
Perception ofphysical risk
Believe that physicians are at
The seven items constituting the PRI included physicians' perception of risk of acquiring HIV Table 1: Characteristics of 260 physicians participating in survey of perception of personal risk of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) through occupational exposure Characteristic Sex (n = 259) Male Female Age, yr (n = 256) 21-30 31-40 41-50 51-60 > 61
Specialty (n = 255) Medicine Family or general practice Surgery Public health Academic appointment (n = 255) None Assistant professor Lecturer Associate professor Professor Practice type (n = 253) Private
Hospital-based Other Institutional affiliation (n = 252) Teaching hospital Community hospital Other Source of income (n = 252) Primarily fee-for-service Primarily salary
No. (and %) of physicians
203 (78) 56 (22) 18 (7) 103(40) 66 (26) 42 (16) 27 (11)
greater risk than others of acquiring HIV infection and AIDS Would protect themselves first before offering emergency care to patients Believe that fear of contagion interferes with relationship with HIV-positive and AIDS patients Would be concerned about sharing facilities with AIDS clinic Believe that physicians fear AIDS more than they fear other diseases Believe that routine use of gloves does not offer adequate protection Are greatly concerned about the risk of transmitting HIV to own
family
184 (72) 169 (67) 157 (62) 128 (50) 121 (49)
87 (35) 82 (32)
'Each item except the second one is given a score of 1 if answered affirmatively and 0 otherwise; the second item is given a score of 2 if answered affirmatively, 1 if answered that there is no change in fear and 0 if answered that there is less fear. The index score is the sum of the scores for all seven items and can vary from 0 to 8.
121 (47) 72 (28)
51(20)
20
11 (4)
108 (42) 69 (27) 29 (11) 29 (11) 20 (8) 123 (49) 111 (44) 19 (8) 148 (59) 87 (35) 17 (7) 157 (62) 95 (38)
15 10 .ii._ 1 0 0
ar
5
0
1
6 5 Physical risk index score 2
3
4
7
8
Fig. 1: Physicians' perception of physical risk of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) through occupational exposure, by physical risk index scores. CAN MED ASSOC J 1990; 143 (6)
physicians' perception of stigma associated with treating HIV-infected and AIDS patients, personal emotional responses to HIV infection and AIDS and attempts to manage concerns about HIV infection and AIDS (Table 3). The distribution of SRI scores is shown in Fig. 2. Again, the scores varied considerably. The physicians saw themselves as being more at low or moderate social risk for AIDS than at high social risk. The PRI and SRI scores were moderately correlated (r = 0.49, p < 0.001); this suggests that although there was a common dimension underlying both indices (25% shared variance) the physicians' perceptions of personal risk were different at the empiric level. This finding supports our conceptualization that the perception of personal risk includes both physical and social facets.
HIV-infected and AIDS patients (r = - 0.07, p = 0.15) (Table 4). Among the physicians who had no such patients the modal response was high, as compared with low for those with one to four patients and moderate for those with five or more. In contrast, the SRI scores showed a small negative correlation with the number of patients with HIV infection or AIDS (r = -0.15, p < 0.02) (Table 5). The modal response was moderate for the physicians with no or one to four such patients, as compared with low for those with five or more.
Relation of risk perception to medical practices Because it was expected that the risk perception might be associated with certain medical practices'5 the physicians were asked whether they had changed
Relation of risk perception to exposure 25
It was expected that the risk perception might 20 reflect actual exposure to patients at high risk or to (A those with HIV infection or AIDS. The physicians were placed in three groups according to how many 15of their patients had HIV infection or AIDS: none, CS one to four, and five or more. Within each group the 0 -C 15 distribution of physicians was depicted according to their perception of physical risk as low (score of 0 to 3), moderate (4 to 5) or high (6 to 8) and their 0 0 1 2 3 4 5 6 perception of social risk as low (0 to 1), moderate (2 Social risk index score to 3) or high (4 to 6). Overall there was no linear correlation between the perception of physical risk and the number of Fig. 2: Physicians' perception of social risk of HIV infection
c=1
Table 3: Physicians responses tc tems (:Oflristituting the perceived social risk index: No (and O-) .,f physicians
Item
Would react differently to diagnosis of HIV infection a,nd AIDS than to diagnosis K ft'
Moderate High 1
' 2 (48)!
96
(39i
impute own sexual orientatior Concerned about stigma from
97 (38'
having many HIV-infected ano AIDS patients in practice Would limit number of referrals oa HIV-infected and AIDS patients
84 33,
'Each Iten is given
A) score
ct
496
I r
O
Total
(and /O) of physicians 1-4
51 (341 37 (24) 64 (42)
152
no.
Perceived level of risk
a,swere., affirrmatLveiy a,mCd 0
CAN MED ASSOC J 1990: 143 (6)
no.
5
17 (40) 13 (30) 13 (30)
10 (28) 16 (46) 9 (26!
43
35
Table 5: Physicians perception of social risk by nurrber of HIV-infected and AIDS patients
76 (31 ; ~eC
by social risk
No. of patients;
Low
Believe that caring for HlV--intecte and AIDS patients is tor emotionally draining to, bi; satisfying More concerned about homosexual patients since discovery of AIDS Believe that having many HIVinfected and AIDS patients may
exposure,
Table 4: Physicians perception of physical risk bs number of HIV-infected and AIDS patients
Perceived level of risk
diseases
otherwise. The ndex score is tlhw f..ld (-at varv frn.r
and AIDS through occupational index scores.
Low Moderate High
No. of patients; (and 0'o) of physicians
0
1-4
.5
42 (29) 63 (43) 41 (28)
13 (32) I17 (41) 11 (27)
19 (51) 12 (32) 6 (16)
41
37
¾-nic
Total
146
graphics and setting variables. First, the PRI was used as the criterion, and various background variables were entered as predictors in three stages: (a) demographic characteristics, (b) specialty or setting variables and (c) exposure to HIV-positive and AIDS patients. This stepwise analysis allowed determination of whether the inclusion of a new block of predictors at each stage added a significant increment to the multiple correlation.'3 The results in Table 6 suggest that the physicians' perception of physical risk was not related to their age or sex. However, a modest relation (multiple r = 0.33, p = 0.06) was apparent when specialty and practice setting variables were included. The change in the multiple correlation from step 1 (multiple r = 0.09) to step 2 (multiple r = 0.33) was statistically significant (p < 0.05). The physicians who perceived themselves to be at high physical risk were more likely than the others to have a fee-for-service income source, to work in a clinical setting and to hold no academic appointment. Neither of the expoRelation of risk perception to background sure variables in Table 6 was related to the physiand practice setting cians' perception of physical risk. In the second multiple regression analysis the Two separate multiple regression analyses were conducted to examine the extent to which the PRI relations between demographic and practice variaand the SRI were correlated with physician demo- bles were examined, with the SRI as the criterion
the way they interact with their patients since the discovery of AIDS. Their answers correlated with the PRI and the SRI. Fig. 3 shows that the physicians who perceived themselves to be at high physical risk were more likely than the others to answer Yes (r = 0.26, p < 0.001). A smaller linear trend was evident with respect to social risk (r = 0.19, p < 0.002). The physicians were also asked whether they believed that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing (Fig. 4). The correlation with the perception of physical risk was -0.16 (p < 0.01), as compared with -0.29 (p < 0.001) for the perception of social risk. More of the physicians who perceived themselves to be at high physical risk than of the others felt that the surgeons had such a right. The physicians who perceived themselves to be at moderate or high social risk also felt this way.
Physical risk 60 60_
50
-
=
40
-
.a
30
-
20
-
Physical risk
~~~Physical risk
50 40
0
10.0 ,
-
20 10
_
10
0
0
Low
I Low Moderate High Perceived level of risk
Social risk
50
40
30
Moderate High Perceived level of risk
Social risk
50 40-
-
C
30
0
CL20-
20-
0
0
10
_
or
10
0
0
Low Moderate High Perceived level of risk
Fig. 3: Proportion of physicians who have reportedly changed the way they interact with their patients since the discovery of AIDS, by type and level of perceived risk.
Low
Moderate High Perceived level of risk
Fig. 4: Proportion of physicians who felt that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing, by type and level of perceived risk. CAN MED ASSOC J 1990; 143 (6)
497
(Table 7). The male physicians were more likely than their female counterparts to perceive themselves as being at a high social risk. Income source was a significant predictor with regard to setting variables. For example, physicians with a fee-for-service income source were more likely than those on salary to see themselves as being at a high social risk. Neither of the exposure variables was related to the SRI.
Discussion
Actual versus perceived risk The US Centers for Disease Control has assessed the risk of HIV infection and AIDS among physicians after a single accidental exposure to HIV at work to be 0.5% or less.'6 '7 This figure is lower than the published risk of contracting most other infectious diseases after a single exposure. For example, the risk for hepatitis B is 10% to 20%.18.19 However, almost half of the respondents stated that their fear of contracting AIDS was greater than their fear of contracting other diseases. A review of the open-ended data revealed that when asked to identify their main concerns with regard to AIDS many of the physicians cited risk to their own safety. This suggests a difference between published and perceived risk, which may help to explain the apparent discrepancy between the published risk of HIV infection and AIDS and physicians' behaviour such
as refusal to treat seropositive patients. Since physicians' behaviour is probably linked more to perceived risk than to actual risk some physicians may believe that refusing to treat is appropriate. Some studies have attributed physicians' perception (or misperception) of the risk of HIV infection simply to a lack of knowledge of the rate of seroconversion after accidental occupational exposure. However, responses to the open-ended questions in our study suggested that physicians' assessment may also include their perception of the degree of avoidability, acceptability and credibility of the risk. For example, many of the physicians reported that they could control their practice to avoid patients with high-risk behaviours, were reluctant to accept any risk associated with a universally fatal outcome and found it difficult to trust AIDS statistics that were continually being revised and sometimes
conflicting.
Perception ofphysical risk It was expected that those physicians who cared for the fewest number of HIV-infected and AIDS patients would believe themselves to be at the lowest physical risk.820 However, many who reported having no such patients perceived themselves to be at high risk. A perception of high risk may have encouraged physicians to screen such patients from their practice. Alternatively, physicians with no HIV-infected or AIDS patients may have had in-
Table 6: Relation of physical risk to physicians background and practice setting Predictors
Step 1: Demographics Age, yr Sex (O female, 1 male Step 2: Specialty/setting Surgery (O No. 1 Yes) Family practice (0 No 1 Yes)
Standar dized
'j
ai1 I) i..
498
CAN MED ASSOC J 1990; 143 (6)
U-i
r7 06
Income source
ostsk)
Probabil tI
33 I
.: I
0.04
0.19
U.
0.06
0.95
C'.(..
0.04
0 97
i.03)
0.32
0.-75
-.
Multip!e /ap vaiue ."i0,09
') .S
Academic appointme,n(O No. 1 Yes) Clinical setting (O privam1 hospital-based)
(O fee-for-service. 1 salary) Patient setting (O private, 1 clinic) Research activities (O none '1 some) Step 3: Exposure No of HIV-positive patients (O none 1 one to four. 2 five or more) Patients at risk of AIDS (O no risk. 1 some
T ratioJ
tion. However, working in relative isolation from creased anxiety because they might have been less tion. However, working in relative isolation from likely than other physicians to use universal precau- colleagues may increase their feeling of vulnerability. tions. Perception of risk may thus be both a determinant and an outcome of medical practice. Perception ofsocial risk The data also suggest that perception of risk is related to behaviour. For example, the physicians The perceptions of social risk varied, and most who perceived themselves to be at high physical risk of the physicians had low or moderate SRI scores. were more likely than the others to believe that The male physicians were more likely than their surgeons have the right to refuse patients who do not female counterparts to perceive social risks. The wish to undergo HIV antibody testing. They were physicians with the largest number of HIV-infected also more likely than the others to state that they had and AIDS patients believed themselves to be at the changed their interaction with all of their patients, lowest social risk. This finding may indicate that regardless of actual risk. direct experience with such patients dispels physiSince behaviour has been widely reported to cians' perceptions of social risk. On the other hand, vary by specialty21,22 it was expected that surgeons physicians who do not perceive a social risk may be would be more likely than family practitioners to more likely than other physicians to develop an perceive themselves to be at high risk. However, AIDS practice. specialty and practice setting afforded only a modest relation to perception of physical risk. This finding Implications questions the assumption that specialty alone is a strong predictor of physicians' response to AIDS. Physicians' perception of personal risk is a Further research is needed to examine more specific crucial, yet often unacknowledged, component of the groupings of specialties. fight against AIDS. Our findings suggest that lack of Other factors emerged as significant differentia- attention to this issue is seriously compromising tors of physicians. The respondents who saw them- initiatives designed to facilitate physician participaselves to be at high physical risk were more likely tion in AIDS care. Professional education, for examthan the others to have a fee-for-service income ple, is considered to be key in modifying physicians' source, to work in a clinical setting and to have no reluctance to perform AIDS-related tasks.23 Many academic appointment. Such physicians may choose educational programs for physicians, however, are to work in solo practice, where they have more implicitly predicated on the belief that mispercepcontrol over the composition of their patient popula- tion of personal risk is due to lack of information. It Table 7: Relation of social risk to physicians' background and practice setting Predictors Step 1: Demographics Age, yr Sex(Ofemale, 1 male) Step 2: Specialty/setting Surgery (0 No, 1 Yes) Family practice (0 No, 1 Yes) Academic appointment (0 No, 1 Yes) Clinical setting (0 private, 1 hospital-based) Income source
Standardizedj3
T ratio
Probability
0.19
0.24 2.28
0.81 0.02
-0.08 -0.04
-0.89 - 0.41
0.41 0.69
- 0.12
-1.16
0.25
0.06
0.37
0.71
-0.23
-1.93
0.06
-0.09
-0.70
0.49
0.09
0.77
0.44
-0.09
-1.05
0.30
0.10
1.14
0.26
0.02
Multiple r
p value
0.18
0.10
0.34
0.05
0.36
0.06
(0 fee-for-service, 1 salary) Patient setting (O private, 1 clinic) Research activities (0 none, 1 some) Step 3: Exposure No. of HIV-positive patients (0 none, 1 one to four, 2 five or more) Patients at risk of AIDS (0 no risk, 1 some risk)
CAN MED ASSOC J 1990; 143 (6)
499
is often presumed that providing up-to-date information regarding the low incidence of seroconversion after accidental occupational exposure will reduce physicians' anxiety and foster behaviour more consistent with the published risk.24 Despite extensive AIDS training programs, however, there has been little evidence that physicians' attitudes or behaviour have changed.25-27 Since behaviour may be related to a perception of risk that is based on more than simply a lack of knowledge, the fundamental premises of these programs must be re-examined. In addition, since physicians with no HIVinfected or AIDS patients may see themselves to be at high risk the challenge will to be to create educational programs relevant to all physicians, regardless of specialty. This may encourage a more equal distribution of the current and predicted AIDS workload. Failure to consider physicians' perception of personal risk will impede the efforts of those struggling to devise solutions to critical problems and threaten compliance with promising recommendations.
Conclusions Our findings suggest that eliciting, examining and addressing physicians' perception of physical and social risks is critical in modifying physicians' response to AIDS. Such an undertaking will be highly challenging for a profession that prizes deductive, objective and consistent reasoning. However, addressing physicians' perception of personal risk may have serious and unanticipated consequences. What are the implications of formally acknowledging their fear? Can physicians effectively educate and reassure patients without suppressing their own anxieties? Will patients' confidence in their physicians and AIDS information be undermined if physicians publicly declare their apprehensions? Will the admission of fear threaten physicians' claim to professional status in society? Addressing these complex questions may be one of the greatest challenges facing the medical profession in the 1 990s. We thank Drs. Roland T. Skeel, Division of Hematology and Oncology, Medical College of Ohio, Toledo, Roger Hand, chief of general and internal medicine, University of Illinois College of Medicine, Chicago, and Kingsley Watts, Department of Family and Community Medicine, University of Toronto. We also thank Katherine Galarneau for her assistance in conducting the study. This study was funded by grant 6606-1845-AIDS from the Department of National Health and Welfare and by the Federal Centre for AIDS.
References 1. Emmanuel EJ: Do physicians have an obligation to treat 500
CAN MED ASSOC J 1990; 143 (6)
patients with AIDS? N EngI J Med 1988; 318: 1686-1690 2. Zuger A, Miles S: AIDS and occupational risk: historic traditions and ethical obligations. JAMA 1987; 258: 19241928 3. Steinbrook R, Lo B, Tripack J et al: Ethical dilemmas in caring for patients with the acquired immunodeficiency syndrome. Ann Intern Med 1985; 103: 787-790 4. Gerbert B, Maguire B, Badner V et al: Why fear persists: health care professionals and AIDS. JAMA 1988; 260: 34813483 5. Wertz DC, Sorenson JR, Liebling L et al: Caring for persons with AIDS: knowledge and attitudes of 1,047 health care workers attending AIDS Action Committee Educational Programs. J Primary Prev 1983; 8: 109-124 6. Dan BB: Patients without physicians: the new risk of AIDS [E]. JAMA 1987; 258: 1940 7. Cotton D: The impact of AIDS on the medical care system. JAMA 1988; 260: 519-523 8. Link RN, Feingold AR, Charap MH et al: Concerns of medical and pediatric house officers about acquiring AIDS from their patients. Am J Public Health 1988; 78: 455-459 9. Richardson JL, Lochner T, McGuigan K et al: Physician attitudes and experience regarding the care of patients with acquired immunodeficiency syndrome (AIDS) and related disorders (ARC). Med Care 1987; 25: 675-685 10. Taylor KM, Shapiro M, Skinner HA et al: Understanding physicians' response to AIDS. Can Med Assoc J 1989; 140: 597-602 11. Dillman DA: Mail and Telephone Surveys: the Total Design Method, Wiley, New York, 1978: 12-28 12. Lin N: The Foundations of Social Research, McGraw, New York, 1976: 25-32 13. Statistical Package for the Social Sciences, User's Guide, 3rd ed, SPSS Inc., Chicago, 1988: 3-14 14. Nunnally JC: Psychometric Theory, McGraw, New York, 1978: 10-20 15. Mayer K: The clinical challenges of AIDS and HIV infection. Law Med Health Care 1986; 14: 281-288 16. Recommendations for prevention of HIV transmission in health care settings. MMWR 1987; 36 (suppl 2S): 3S- 18S 17. Update: acquired immunodeficiency syndrome and human immunodeficiency virus infection among health care workers. MMWR 1988; 37: 229-239 18. Denes AE, Smith JL, Maynard JE: Hepatitis B infection in physicians: result of a nationwide seroepidemiologic survey. JAMA 1978; 239: 210-212 19. Moss A, Osmond D, Bacchetti P et al: Risk of seroconversion for acquired immunodeficiency syndrome (AIDS) in San Francisco health workers. J Occup Med 1986; 28: 821-824 20. Paine SL, Briggs D: Knowledge and attitudes of Victorian medical practitioners in relation to the acquired immunodeficiency syndrome. Med JAust 1988; 148: 221-225 21. Ponsford G: AIDS in the OR: a surgeon's view. Can Med Assoc J 1987; 137: 1036-1039 22. Sim AJ: Surgeons and HIV [C]. Br Med J 1988; 296: 80 23. Wertz DC, Sorenson JR, Liebling L et al: Knowledge and attitudes of AIDS health care providers before and after educational programs. Public Health Rep 1987; 102: 248-254 24. Shultz JM, MacDonald KL, Heckert KA et al: The Minnesota AIDS Survey: a statewide survey of physician knowledge and clinical practice regarding AIDS. Minn Med 1988; 71: 277283 25. Whalen JP: Participation of medical students in the care of patients with AIDS. JMed Educ 1987; 62: 53-54 26. Imperato PJ, Feldman JG, Nayeri K et al: Medical students' attitudes towards caring for patients with AIDS in a high incidence area. N Y State J Med 1988; 88: 223-227 27. Lewis CE, Freeman HE, Caplan SH et al: The impact of a program to enhance the competencies of primary care physicians in caring for patients with AIDS. J Gen Intern Med 1986; 1: 287-294
Physicians' perception of personal risk of HIV infection and AIDS through occupational exposure Kathryn M. Taylor, PhD; Joan M. Eakin, PhD; Harvey A. Skinner, PhD; Merrijoy Kelner, PhD; Marla Shapiro, MD Physicians' response to acquired immune deficiency syndrome (AIDS) is poorly understood and often attributed to fear of human immunodeficiency virus (HIV) infection through occupational exposure. We surveyed 268 physicians from three geographic regions in North America with different specialties and responsibilities for HIV-positive patients. An important difference was found between the published risk and the physicians' perceived risk of infection after a single occupational exposure. Almost half of the respondents stated that they feared contracting AIDS more than other diseases. The physicians who perceived themselves to be at high physical risk were more likely than the others to report that AIDS had changed the way they interact with their patients (r = 0.26, p < 0.001). No relation was found between the perception of physical risk and the number of HIV-infected patients (r = -0.07, p 0.15). However, the perception of social risk showed a small inverse correlation (r = -0.15, p < 0.02), in which the physicians with more HIV-infected patients reported less concern about negative social consequences. The physicians who perceived themselves to be at high personal risk were more likely than the others to report that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing (r = -0.16, p < 0.01 for physical risk; r = -0.29, p < 0.001 for social risk). Multiple regression analyses indicated that physicians' perception of physical risk was not related to age or sex but was modestly related to income source. The perception of social risk was related to sex and income source. Physicians' perception of personal risk is a crucial, yet often unacknowledged, component of the fight against AIDS. Our findings suggest that lack of attention to this issue is seriously compromising initiatives designed to facilitate physician participation in AIDS care.
On comprend assez mal la reaction des medecins devant le syndrome d'immunodeficience acquise (SIDA); on croit souvent pouvoir l'attribuer a la crainte du risque professionnel de contracter le virus immunodeficitaire humain (VIH). Nous avons interroge 268 medecins de trois regions de l'Amerique du Nord exercant diverses specialites et variant quant a la mesure dans laquelle ils ont a traiter des sujets seropositifs. Nous avons trouve une grande difference entre le risque reel du fait d'un contact professionnel isole et celui percu par les medecins. Pres de la moitie d'entre eux ont dit craindre de contracter le SIDA plus que toute autre maladie. Le medecin est d'autant plus porte a affirmer que le SIDA a change son comportement envers ses From the Physician Behaviour Research Unit, Department of Behavioural Science, Faculty ofMedicine, University of Toronto Dr. Taylor was supported by a research scholar award from the Department of National Health and
Welfare.
Reprint requests to: Dr. Kathryn M. Taylor, Physician Behaviour Research Unit, Department of Behavioural Science, Faculty of Medicine, McMurrich Building, University of Toronto, 12 Queen's Park Cres. W, Toronto, Ont. M5S IA8 CAN MED ASSOC J 1990; 143 (6)
493
clients qu'il se croit soumis a un risque physique important (r = 0,26, p < 0,001), mais son estimation de ce risque n'a aucun rapport avec le nombre reel de ses clients seropositifs (r = - 0,07, p = 0,15). Quant a la crainte d'un risque social, elle est en faible correlation negative avec ce nombre (r = - 0,15, p < 0,02). Le medecin est d'autant plus porte a donner raison au chirurgien qui reclame le droit de refuser de traiter un malade ne voulant pas se preter a la recherche des anticorps anti-VIH qu'il se croit lui-meme soumis a un risque eleve (r = -0,16 et p < 0,01 pour le risque physique, r = -0,29 et p < 0,001 pour le risque social). L'analyse des regressions multiples montre que si le risque physique percu par les medecins n'est en rapport ni avec l'age ni avec le sexe du medecin, il varie dans une certaine mesure avec sa source de revenu. Quant au risque social apprehende, il est en rapport avec le sexe et la source de revenu. La maniere dont le medecin considere ces risques personnels joue un r6le central mais souvent inavoue dans la lutte contre le SIDA. Nos trouvailles nous portent a croire que le fait de passer cette question sous silence compromet gravement les efforts qu'on deploie afin d'assurer la participation des medecins au soin des sidatiques.
A cquired immune deficiency syndrome (AIDS) has created immense challenges for the prac-
tice of medicine.1-3 Although physicians have been confronted with many professional dilemmas the fundamental nature of their response to AIDS is not well understood. For example, the reluctance of physicians to take an active role in AIDS treatment and prevention has often been attributed to a fear of human immunodeficiency virus (HIV) infection and AIDS through occupational exposure.45 Many reports,6 9 however, have stated that this fear is largely irrational and is inconsistent with documented evidence of seroconversion rates among health care workers after accidental exposure. To understand better this powerful and apparently "unfounded" reaction by physicians we studied their perception of personal risk.
Methods A self-administered questionnaire was developed that contained 18 demographic, 60 binaryoption and 8 open-ended questions on physicians' attitudes and current behaviour toward HIV infection and AIDS. The questionnaire was designed on the basis of previously described critical concepts underlying physicians' response to AIDS.'0 In July 1988 the questionnaire was mailed to 674 physicians in three geographic settings that varied with respect to the incidence of AIDS: northwestern Ohio, which is a rural area with a relatively low reported incidence (4.5 per 100 000 population; US Centers for Disease Control, Atlanta: personal communication, 1989); Ontario, which has a relatively moderate reported incidence (1 1.1 per 100 000; Federal Centre for AIDS, Ottawa: personal communication, 1989); and a large teaching hospital in Chicago, which has a high reported incidence (14.1 per 100 000; US Centers for Disease Control:
personal communication, 1989). The physicians were randomly selected from published professional listings. Equal numbers of 494
CAN MED ASSOC J 1990; 143 (6)
physicians were chosen from medical, surgical and general practice specialties. This strategy was used because we expected that exposure to HIV-infected patients would affect physicians' responses and that exposure would vary by incidence, geographic setting and specialty. After a single mailing 268 questionnaires (40%) were returned. Eight were received after data entry had been completed, so that 260 were included in the data analysis. This response rate is a conservative estimate, since about 10% of the physicians could not be reached for various reasons (e.g., incorrect address, moved or retired). Also, to ensure candid responses complete anonymity was guaranteed, which necessitated the omission of geographic identifiers. Although this anonymity precluded a second mailing to increase the response rate, the rate fell within the acceptable limits for studies of heterogeneous groups of physicians on controversial issues. 11,12 A variety of relevant characteristics, such as age, medical specialty and exposure to HIV-infected and AIDS patients, were represented (Table 1); the overall nonresponse rate by item was less than 5%. However, since no data were available on the characteristics of the nonresponders the findings should be generalized with caution. The quantitative data were analysed with the use of the SPSS-X statistical software package.'3 The degree of covariation among specific variables was examined with the use of the product-moment correlation coefficient. Stepwise multiple regression analyses were used to evaluate the extent to which the demographic characteristics, specialty or setting and exposure to seropositive patients were correlated with the physical risk index (PRI) and the social risk index (SRI). The PRI was derived from an empiric analysis of 15 items concerning various aspects of physicians' perception that they could acquire HIV infection and AIDS through occupational exposure. Item responses were correlated with the overall index score, and a subset of "good", discriminating items was
selected if the item-index correlation was at least 0.20.14 From the initial pool of 15 items, 7 were retained. The internal consistency reliability estimate for the PRI was 0.64, an acceptable level given the number of items.'4 The SRI was derived in a similar fashion. We analysed seven items concerning the potential of negative social consequences of activities related to HIV infection and AIDS. Six of the items met the criterion of an item-index correlation of at least 0.20. The internal consistency reliability estimate was 0.60. A score was calculated for each index by summing the responses for the seven items on the PRI and the six items on the SRI.
infection and AIDS through occupational exposure, adequacy of protection and clinical care issues (Table 2). The distribution of PRI scores is shown in Fig. 1. The physicians' perception of physical risk varied considerably. The distribution of scores conformed fairly closely to a normal curve; this indicates that the physicians' perception of physical risk was a continuous variable that varied from 0 to 8.14
Perception ofsocial risk The six items constituting the SRI included Table 2: Physicians' responses to items constituting the perceived physical risk index*
Results
No. (and %) of physicians
Item
Perception ofphysical risk
Believe that physicians are at
The seven items constituting the PRI included physicians' perception of risk of acquiring HIV Table 1: Characteristics of 260 physicians participating in survey of perception of personal risk of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) through occupational exposure Characteristic Sex (n = 259) Male Female Age, yr (n = 256) 21-30 31-40 41-50 51-60 > 61
Specialty (n = 255) Medicine Family or general practice Surgery Public health Academic appointment (n = 255) None Assistant professor Lecturer Associate professor Professor Practice type (n = 253) Private
Hospital-based Other Institutional affiliation (n = 252) Teaching hospital Community hospital Other Source of income (n = 252) Primarily fee-for-service Primarily salary
No. (and %) of physicians
203 (78) 56 (22) 18 (7) 103(40) 66 (26) 42 (16) 27 (11)
greater risk than others of acquiring HIV infection and AIDS Would protect themselves first before offering emergency care to patients Believe that fear of contagion interferes with relationship with HIV-positive and AIDS patients Would be concerned about sharing facilities with AIDS clinic Believe that physicians fear AIDS more than they fear other diseases Believe that routine use of gloves does not offer adequate protection Are greatly concerned about the risk of transmitting HIV to own
family
184 (72) 169 (67) 157 (62) 128 (50) 121 (49)
87 (35) 82 (32)
'Each item except the second one is given a score of 1 if answered affirmatively and 0 otherwise; the second item is given a score of 2 if answered affirmatively, 1 if answered that there is no change in fear and 0 if answered that there is less fear. The index score is the sum of the scores for all seven items and can vary from 0 to 8.
121 (47) 72 (28)
51(20)
20
11 (4)
108 (42) 69 (27) 29 (11) 29 (11) 20 (8) 123 (49) 111 (44) 19 (8) 148 (59) 87 (35) 17 (7) 157 (62) 95 (38)
15 10 .ii._ 1 0 0
ar
5
0
1
6 5 Physical risk index score 2
3
4
7
8
Fig. 1: Physicians' perception of physical risk of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) through occupational exposure, by physical risk index scores. CAN MED ASSOC J 1990; 143 (6)
physicians' perception of stigma associated with treating HIV-infected and AIDS patients, personal emotional responses to HIV infection and AIDS and attempts to manage concerns about HIV infection and AIDS (Table 3). The distribution of SRI scores is shown in Fig. 2. Again, the scores varied considerably. The physicians saw themselves as being more at low or moderate social risk for AIDS than at high social risk. The PRI and SRI scores were moderately correlated (r = 0.49, p < 0.001); this suggests that although there was a common dimension underlying both indices (25% shared variance) the physicians' perceptions of personal risk were different at the empiric level. This finding supports our conceptualization that the perception of personal risk includes both physical and social facets.
HIV-infected and AIDS patients (r = - 0.07, p = 0.15) (Table 4). Among the physicians who had no such patients the modal response was high, as compared with low for those with one to four patients and moderate for those with five or more. In contrast, the SRI scores showed a small negative correlation with the number of patients with HIV infection or AIDS (r = -0.15, p < 0.02) (Table 5). The modal response was moderate for the physicians with no or one to four such patients, as compared with low for those with five or more.
Relation of risk perception to medical practices Because it was expected that the risk perception might be associated with certain medical practices'5 the physicians were asked whether they had changed
Relation of risk perception to exposure 25
It was expected that the risk perception might 20 reflect actual exposure to patients at high risk or to (A those with HIV infection or AIDS. The physicians were placed in three groups according to how many 15of their patients had HIV infection or AIDS: none, CS one to four, and five or more. Within each group the 0 -C 15 distribution of physicians was depicted according to their perception of physical risk as low (score of 0 to 3), moderate (4 to 5) or high (6 to 8) and their 0 0 1 2 3 4 5 6 perception of social risk as low (0 to 1), moderate (2 Social risk index score to 3) or high (4 to 6). Overall there was no linear correlation between the perception of physical risk and the number of Fig. 2: Physicians' perception of social risk of HIV infection
c=1
Table 3: Physicians responses tc tems (:Oflristituting the perceived social risk index: No (and O-) .,f physicians
Item
Would react differently to diagnosis of HIV infection a,nd AIDS than to diagnosis K ft'
Moderate High 1
' 2 (48)!
96
(39i
impute own sexual orientatior Concerned about stigma from
97 (38'
having many HIV-infected ano AIDS patients in practice Would limit number of referrals oa HIV-infected and AIDS patients
84 33,
'Each Iten is given
A) score
ct
496
I r
O
Total
(and /O) of physicians 1-4
51 (341 37 (24) 64 (42)
152
no.
Perceived level of risk
a,swere., affirrmatLveiy a,mCd 0
CAN MED ASSOC J 1990: 143 (6)
no.
5
17 (40) 13 (30) 13 (30)
10 (28) 16 (46) 9 (26!
43
35
Table 5: Physicians perception of social risk by nurrber of HIV-infected and AIDS patients
76 (31 ; ~eC
by social risk
No. of patients;
Low
Believe that caring for HlV--intecte and AIDS patients is tor emotionally draining to, bi; satisfying More concerned about homosexual patients since discovery of AIDS Believe that having many HIVinfected and AIDS patients may
exposure,
Table 4: Physicians perception of physical risk bs number of HIV-infected and AIDS patients
Perceived level of risk
diseases
otherwise. The ndex score is tlhw f..ld (-at varv frn.r
and AIDS through occupational index scores.
Low Moderate High
No. of patients; (and 0'o) of physicians
0
1-4
.5
42 (29) 63 (43) 41 (28)
13 (32) I17 (41) 11 (27)
19 (51) 12 (32) 6 (16)
41
37
¾-nic
Total
146
graphics and setting variables. First, the PRI was used as the criterion, and various background variables were entered as predictors in three stages: (a) demographic characteristics, (b) specialty or setting variables and (c) exposure to HIV-positive and AIDS patients. This stepwise analysis allowed determination of whether the inclusion of a new block of predictors at each stage added a significant increment to the multiple correlation.'3 The results in Table 6 suggest that the physicians' perception of physical risk was not related to their age or sex. However, a modest relation (multiple r = 0.33, p = 0.06) was apparent when specialty and practice setting variables were included. The change in the multiple correlation from step 1 (multiple r = 0.09) to step 2 (multiple r = 0.33) was statistically significant (p < 0.05). The physicians who perceived themselves to be at high physical risk were more likely than the others to have a fee-for-service income source, to work in a clinical setting and to hold no academic appointment. Neither of the expoRelation of risk perception to background sure variables in Table 6 was related to the physiand practice setting cians' perception of physical risk. In the second multiple regression analysis the Two separate multiple regression analyses were conducted to examine the extent to which the PRI relations between demographic and practice variaand the SRI were correlated with physician demo- bles were examined, with the SRI as the criterion
the way they interact with their patients since the discovery of AIDS. Their answers correlated with the PRI and the SRI. Fig. 3 shows that the physicians who perceived themselves to be at high physical risk were more likely than the others to answer Yes (r = 0.26, p < 0.001). A smaller linear trend was evident with respect to social risk (r = 0.19, p < 0.002). The physicians were also asked whether they believed that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing (Fig. 4). The correlation with the perception of physical risk was -0.16 (p < 0.01), as compared with -0.29 (p < 0.001) for the perception of social risk. More of the physicians who perceived themselves to be at high physical risk than of the others felt that the surgeons had such a right. The physicians who perceived themselves to be at moderate or high social risk also felt this way.
Physical risk 60 60_
50
-
=
40
-
.a
30
-
20
-
Physical risk
~~~Physical risk
50 40
0
10.0 ,
-
20 10
_
10
0
0
Low
I Low Moderate High Perceived level of risk
Social risk
50
40
30
Moderate High Perceived level of risk
Social risk
50 40-
-
C
30
0
CL20-
20-
0
0
10
_
or
10
0
0
Low Moderate High Perceived level of risk
Fig. 3: Proportion of physicians who have reportedly changed the way they interact with their patients since the discovery of AIDS, by type and level of perceived risk.
Low
Moderate High Perceived level of risk
Fig. 4: Proportion of physicians who felt that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing, by type and level of perceived risk. CAN MED ASSOC J 1990; 143 (6)
497
(Table 7). The male physicians were more likely than their female counterparts to perceive themselves as being at a high social risk. Income source was a significant predictor with regard to setting variables. For example, physicians with a fee-for-service income source were more likely than those on salary to see themselves as being at a high social risk. Neither of the exposure variables was related to the SRI.
Discussion
Actual versus perceived risk The US Centers for Disease Control has assessed the risk of HIV infection and AIDS among physicians after a single accidental exposure to HIV at work to be 0.5% or less.'6 '7 This figure is lower than the published risk of contracting most other infectious diseases after a single exposure. For example, the risk for hepatitis B is 10% to 20%.18.19 However, almost half of the respondents stated that their fear of contracting AIDS was greater than their fear of contracting other diseases. A review of the open-ended data revealed that when asked to identify their main concerns with regard to AIDS many of the physicians cited risk to their own safety. This suggests a difference between published and perceived risk, which may help to explain the apparent discrepancy between the published risk of HIV infection and AIDS and physicians' behaviour such
as refusal to treat seropositive patients. Since physicians' behaviour is probably linked more to perceived risk than to actual risk some physicians may believe that refusing to treat is appropriate. Some studies have attributed physicians' perception (or misperception) of the risk of HIV infection simply to a lack of knowledge of the rate of seroconversion after accidental occupational exposure. However, responses to the open-ended questions in our study suggested that physicians' assessment may also include their perception of the degree of avoidability, acceptability and credibility of the risk. For example, many of the physicians reported that they could control their practice to avoid patients with high-risk behaviours, were reluctant to accept any risk associated with a universally fatal outcome and found it difficult to trust AIDS statistics that were continually being revised and sometimes
conflicting.
Perception ofphysical risk It was expected that those physicians who cared for the fewest number of HIV-infected and AIDS patients would believe themselves to be at the lowest physical risk.820 However, many who reported having no such patients perceived themselves to be at high risk. A perception of high risk may have encouraged physicians to screen such patients from their practice. Alternatively, physicians with no HIV-infected or AIDS patients may have had in-
Table 6: Relation of physical risk to physicians background and practice setting Predictors
Step 1: Demographics Age, yr Sex (O female, 1 male Step 2: Specialty/setting Surgery (O No. 1 Yes) Family practice (0 No 1 Yes)
Standar dized
'j
ai1 I) i..
498
CAN MED ASSOC J 1990; 143 (6)
U-i
r7 06
Income source
ostsk)
Probabil tI
33 I
.: I
0.04
0.19
U.
0.06
0.95
C'.(..
0.04
0 97
i.03)
0.32
0.-75
-.
Multip!e /ap vaiue ."i0,09
') .S
Academic appointme,n(O No. 1 Yes) Clinical setting (O privam1 hospital-based)
(O fee-for-service. 1 salary) Patient setting (O private, 1 clinic) Research activities (O none '1 some) Step 3: Exposure No of HIV-positive patients (O none 1 one to four. 2 five or more) Patients at risk of AIDS (O no risk. 1 some
T ratioJ
tion. However, working in relative isolation from creased anxiety because they might have been less tion. However, working in relative isolation from likely than other physicians to use universal precau- colleagues may increase their feeling of vulnerability. tions. Perception of risk may thus be both a determinant and an outcome of medical practice. Perception ofsocial risk The data also suggest that perception of risk is related to behaviour. For example, the physicians The perceptions of social risk varied, and most who perceived themselves to be at high physical risk of the physicians had low or moderate SRI scores. were more likely than the others to believe that The male physicians were more likely than their surgeons have the right to refuse patients who do not female counterparts to perceive social risks. The wish to undergo HIV antibody testing. They were physicians with the largest number of HIV-infected also more likely than the others to state that they had and AIDS patients believed themselves to be at the changed their interaction with all of their patients, lowest social risk. This finding may indicate that regardless of actual risk. direct experience with such patients dispels physiSince behaviour has been widely reported to cians' perceptions of social risk. On the other hand, vary by specialty21,22 it was expected that surgeons physicians who do not perceive a social risk may be would be more likely than family practitioners to more likely than other physicians to develop an perceive themselves to be at high risk. However, AIDS practice. specialty and practice setting afforded only a modest relation to perception of physical risk. This finding Implications questions the assumption that specialty alone is a strong predictor of physicians' response to AIDS. Physicians' perception of personal risk is a Further research is needed to examine more specific crucial, yet often unacknowledged, component of the groupings of specialties. fight against AIDS. Our findings suggest that lack of Other factors emerged as significant differentia- attention to this issue is seriously compromising tors of physicians. The respondents who saw them- initiatives designed to facilitate physician participaselves to be at high physical risk were more likely tion in AIDS care. Professional education, for examthan the others to have a fee-for-service income ple, is considered to be key in modifying physicians' source, to work in a clinical setting and to have no reluctance to perform AIDS-related tasks.23 Many academic appointment. Such physicians may choose educational programs for physicians, however, are to work in solo practice, where they have more implicitly predicated on the belief that mispercepcontrol over the composition of their patient popula- tion of personal risk is due to lack of information. It Table 7: Relation of social risk to physicians' background and practice setting Predictors Step 1: Demographics Age, yr Sex(Ofemale, 1 male) Step 2: Specialty/setting Surgery (0 No, 1 Yes) Family practice (0 No, 1 Yes) Academic appointment (0 No, 1 Yes) Clinical setting (0 private, 1 hospital-based) Income source
Standardizedj3
T ratio
Probability
0.19
0.24 2.28
0.81 0.02
-0.08 -0.04
-0.89 - 0.41
0.41 0.69
- 0.12
-1.16
0.25
0.06
0.37
0.71
-0.23
-1.93
0.06
-0.09
-0.70
0.49
0.09
0.77
0.44
-0.09
-1.05
0.30
0.10
1.14
0.26
0.02
Multiple r
p value
0.18
0.10
0.34
0.05
0.36
0.06
(0 fee-for-service, 1 salary) Patient setting (O private, 1 clinic) Research activities (0 none, 1 some) Step 3: Exposure No. of HIV-positive patients (0 none, 1 one to four, 2 five or more) Patients at risk of AIDS (0 no risk, 1 some risk)
CAN MED ASSOC J 1990; 143 (6)
499
is often presumed that providing up-to-date information regarding the low incidence of seroconversion after accidental occupational exposure will reduce physicians' anxiety and foster behaviour more consistent with the published risk.24 Despite extensive AIDS training programs, however, there has been little evidence that physicians' attitudes or behaviour have changed.25-27 Since behaviour may be related to a perception of risk that is based on more than simply a lack of knowledge, the fundamental premises of these programs must be re-examined. In addition, since physicians with no HIVinfected or AIDS patients may see themselves to be at high risk the challenge will to be to create educational programs relevant to all physicians, regardless of specialty. This may encourage a more equal distribution of the current and predicted AIDS workload. Failure to consider physicians' perception of personal risk will impede the efforts of those struggling to devise solutions to critical problems and threaten compliance with promising recommendations.
Conclusions Our findings suggest that eliciting, examining and addressing physicians' perception of physical and social risks is critical in modifying physicians' response to AIDS. Such an undertaking will be highly challenging for a profession that prizes deductive, objective and consistent reasoning. However, addressing physicians' perception of personal risk may have serious and unanticipated consequences. What are the implications of formally acknowledging their fear? Can physicians effectively educate and reassure patients without suppressing their own anxieties? Will patients' confidence in their physicians and AIDS information be undermined if physicians publicly declare their apprehensions? Will the admission of fear threaten physicians' claim to professional status in society? Addressing these complex questions may be one of the greatest challenges facing the medical profession in the 1 990s. We thank Drs. Roland T. Skeel, Division of Hematology and Oncology, Medical College of Ohio, Toledo, Roger Hand, chief of general and internal medicine, University of Illinois College of Medicine, Chicago, and Kingsley Watts, Department of Family and Community Medicine, University of Toronto. We also thank Katherine Galarneau for her assistance in conducting the study. This study was funded by grant 6606-1845-AIDS from the Department of National Health and Welfare and by the Federal Centre for AIDS.
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