Determinants of counseling in primary care pediatric practice - Physician attitudes about time, money, and health issues

Objectives: To assess pediatrician goals and practice in preventive counsel ing, and to use social learning theory to examine physician attitudes about preventive health issues, time, and reimbursement to explain physician cou nseling behavior. Design: Random sample survey of American Academy of Pediatrics fellows. Participants: A total of 1620 pediatricians were surveyed with a return rat e of 72%. The 556 pediatricians who had finished training and who currently performed child health supervision were included. Methods: Pediatricians were asked about their goals in 6 areas of health su pervision: biomedical issues, development, behavior, family functioning, sa fety education, and supportive interpersonal interaction. They were also as ked about the prevalence of counseling, importance of specific topics, thei r self-efficacy, outcome expectation in these areas, and their concerns abo ut time and reimbursement for preventive counseling. Results: Assurance of physical health and normal development were the most important goals of child health supervision among the pediatricians surveye d. Goals involving behavioral, family, and safety issues were less importan t and less likely to be addressed in practice. Most did not regularly discu ss family stress, substance abuse, gun safety, and television. In these are as, physicians had less confidence they could provide guidance and lower ex pectation that they could prevent problems. Only 17% felt that they receive adequate reimbursement for preventive counseling. Most have adequate time (53%) and receive adequate respect (57%) for their preventive efforts. Phys icians who were more concerned about time for preventive counseling reporte d less overall counseling (r=-0.28, P<.001). Concern about reimbursement wa s not associated with reported counseling. Multiple regression analysis fou nd that the primary predictors of physician counseling were an issue's impo rtance, a physician's perceived self-efficacy, and perceived effectiveness of counseling, while concerns about time and reimbursement were secondary. Conclusions: Physician goals in child health supervision were primarily bio medical, with psychosocial and safety issues of lesser importance. Concern about time for preventive counseling was associated with less reported coun seling. Physician attitudes regarding the importance of a health issue and their confidence and effectiveness in counseling were more predictive of ph ysician practice than their attitudes about time and reimbursement for prev entive care.