Whose Fault is Syphilis ? Physicians’ Views on Syphilis Elimination

1. Whose Fault is Syphilis ?Physicians’ Views on Syphilis Elimination Bradley Stoner, MD, PhD Washington University School of Medicine St. Louis, MO

2. Background: Syphilis Elimination • Four years into national syphilis elimination efforts, syphilis rates remain high among at-risk populations

3. Background: Syphilis Epidemiology • From 2001 to 2002: • Total P & S cases increased 12% • Male-to-female ratio increased 67% • Rates in large US cities increased 21% • Case-rates among African-Americans remain  8 X higher than Caucasians • Increasing MSM / HIV connections CDC, STD Surveillance 2002

4. Case in Point: St. Louis, Missouri • One of the original 32 “high morbidity areas” (HMA) for syphilis elimination • Recent epidemiology mirrors the national experience • 2002 case rate is 54% higher than national avg. • Of the last 30 men interviewed • 12 were MSM • 8 were known HIV+ Data: City of St. Louis Dept. of Health

5. Physician Perspectives on Syphilis • Physicians diagnose and treat patients with sexually transmitted diseases • At the “front lines” of syphilis elimination efforts • At the same time, community-based physicians’ voices are generally absent from national dialogue on syphilis elimination

6. Objectives • Understand practicing physicians’ perspectives on syphilis • Knowledge of clinical manifestations • Attitudes and suppositions about patients • Beliefs about why syphilis persists in communities • Perceptions of blame and responsibility

7. Objectives • Understand physician motivations for clinical treatment decisions • Empiric therapy after exposure • Partner referral and treatment • Engage physicians in ongoing public health discourse on syphilis elimination

8. Methods • 21 primary care physicians from St. Louis area (MD or DO) recruited for qualitative interview study • In-depth, semi-structured ethnographic interview covering • clinical / laboratory aspects of syphilis • social / behavioral attributes of patients • attitudes / beliefs about community-level syphilis control and prevention

9. Methods • Participant-observation of clinical care delivery at sites of syphilis diagnosis and treatment • Public health clinics • Emergency departments • Federally qualified health centers

10. Methods • Semi-structured interviews transcribed, coded, analyzed for recurrent themes (Ethnograph v5.0) • Participant observation data organized, transcribed, condensed for anthropological content analysis

11. Results – Respondent Sample Characteristics of physician respondents (N=21) GenderRace/Ethnicity Male 13 Caucasian 12 Female 8 Af. American 4 Asian American 3 Hispanic/Latino 2 Specialty Internal Med 6 Pediatrics 4 Family Med 3 Emergency Med 3 Ob/Gyn 3 Other 2

12. Results – Syphilis Knowledge • Various stages of syphilis well-known • primary, secondary, tertiary • Timing of clinical symptoms not well-understood or widely shared • unclear when 1o or 2o lesions will appear • belief in high likelihood of neurosyphilis • Inconsistent use of laboratory support • serologic tests • lumbar puncture

13. Respondent 003 “My experience is that patients usually progress quite rapidly from primary to secondary to neurosyphilis. I tell them that they’re lucky to have been diagnosed, because we can prevent brain damage by treating them.” Af. American Female, Pediatrics

14. Respondent 018 “I usually refer every patient for a spinal tap. I don’t do them myself, but I send them to a neurologist. They need to have a spinal tap as soon as possible [regardless of stage] to make sure they don’t have neurosyphilis” Asian-American Female, Family Medicine

15. Respondent 006 “I’ll have them come back every month or so for repeat blood tests, you know, the VDRL and the other one. I [want to] make sure they have been cured… If the blood tests are still positive, I give them more penicillin [intramuscular injection]…” Latino Male, Internal Medicine

16. Results –Perspectives on Patients • Physicians’ views of syphilis patients • promiscuous - low moral standards • drug / alcohol co-morbidity • likely to break appointments, slow to pay bills • unlikely to comply with therapy • Physicians’ attitudes toward patients • paternalistic – “doctor knows best ” • punitive – “sure it hurts, but they deserve it ” • realistic resignation – “they’ll be back again ”

17. Respondent 002 “Well, the ‘typical’ syphilis patient is pretty obvious – someone who’s a drug addict, or at least uses drugs a lot, and engages in high-risk sexual behavior. It’s pretty easy to avoid getting syphilis, I would think – just use a condom. These people are so doped out, I would say, they just avoid doing the obvious.” Caucasian Female, Dermatology

18. Respondent 016 “I’ve seen about eight or ten patients with syphilis in the last year or so – they sort of show up whenever they have a new problem, then disappear before paying their bills…” “Syphilis hits you when you are down on your luck… white, black, gay, straight, that’s what ties them all together.” Caucasian Female, Family Medicine

19. Respondent 014 “You can usually get them to take the first shot [of penicillin], but getting them to come back for numbers two and three is a problem.” “Actually, I don’t mind giving the shots, because it certainly makes them think twice about why they’re here. Maybe that will keep them from getting it again, I don’t know…” Caucasian Female, Internal Medicine

20. Results – Syphilis Persistence • Patient-driven • Failure to heed risk-reduction warnings • not due to knowledge-deficit, but rather patients intentionally put self in harm’s way • Failure to comply with therapy or follow-up • Health department-driven • Failure to follow-up on known cases • Failure to conduct adequate contact elicitation • Failure to follow-up on named partners

21. Respondent 004 “You want to know why St. Louis is the syphilis capital of the nation? I can tell you why. If people didn’t go around having unsafe sex, and then ignoring symptoms and not coming in to get checked out and treated, the problem would go away. It’s that simple.” Af. American Male, Internal Medicine

22. Respondent 020 “I think the health department has a lot of answering to do about this… we’ve known this for a long, long time – you have to treat the sex partners, not just the patients. We do a pretty good job of treating [the patients], but who’s looking out for the partners…?” Asian-American Male, OB/GYN

23. Respondent 011 “The health department never seems to have enough money, or enough trained staff, to do the job effectively. People get infected two, three times before the health department gets around to notifying them [as a contact]…” Caucasian Male, Pediatrics

24. Respondent 015 “So the patient says, ‘I don’t know who my partner was,’ and the health department says, like, ‘Well, OK then.’ I mean, that makes it easier for everybody, doesn’t it? No partners to track down, less work for the investigator… everyone goes home happy.” Caucasian Male, Internal Medicine

25. Results – Blame and Responsibility • Blame the patients • They should know better, but they don’t take measures to protect themselves • Blame the health department • They should act quickly and thoroughly to prevent further transmission from the index case • Blame the health insurance system • Uninsured patients and partners have a difficult time getting seen in the private sector

26. Results – Blame and Responsibility • But don’t blame the doctors • They are selflessly devoted to caring for the sick and needy • They feel caught in the crossfire

27. Respondent 013 “I think physicians, as a group, are really not appreciated for all we do…People see the money and prestige and all, but really it’s much more complicated. We’re putting ourselves out for our patients every day.” Af. American Female, Internal Medicine

28. Respondent 008 “I see every patient who walks in the [emergency department] door. We don’t turn anyone away. What other profession pretty much guarantees you [access to] the provider, regardless of your ability to pay?” Caucasian Male, Emergency Medicine

29. Respondent 021 “The financial pressures are enormous – just running the office, making payments, malpractice insurance…I do it because I love it, but it’s getting harder to say that, because of, well, the financial constraints.” Caucasian Male, Family Medicine

30. Discussion • Qualitative interviews allowed respondents to speak freely on interrelated topics • Valuable information on perceptions and attitudes – difficult to obtain through quantitative methods

31. Discussion • Physicians expressed dissatisfaction with patients and with public health system • Combat metaphors commonly invoked • fightingsyphilis, battlingpatients, strugglingwiththe health department • Physicians feel they are unfairly targeted for missing diagnoses, failing to treat patients, and other clinical mishaps

32. Discussion • Respondents invoked twin recurring themes • failure of personal responsibility on the part of patients • fragile public health apparatus for rapid diagnosis, treatment, and partner notification • No systematic differences in physician responses by gender, race/ethnicity, or practice specialty

33. Limitations • Self-selected sample • not generalizable to all physicians • key informants provide “window on world” of physicians engaged in syphilis treatment • Interpretive bias – ethnographic lens • Thematic content may require validation using larger sample, formal methods • Mid-level providers not included in study

34. Summary • Physicians feel undervalued and under-appreciated in syphilis elimination efforts • Physicians attitudes and perspectives may foster adversarial relationships with patients as well as public health personnel • Including physician voices in syphilis elimination discourse can serve to promote public health goals