Medical training fails to prepare providers to care for patients with chronic hepatitis B infection

Table 1 Distribution of demographic and professional characteristics among respondents n (%)

Characteristic	Value1
Age (yr)
24-27	65 (30)
28-31	68 (32)
32-39	43 (20)
40+	39 (18)
Median
Sex
Male	99 (47)
Female	113 (53)
Racial/ethnic background
White, non-Hispanic	78 (38)
Chinese or Taiwanese	22 (11)
South Asian	21 (10)
Other or unspecified Asian or Pacific Islander	43 (21)
Black or African American	17 (8)
Hispanic or Latino	13 (6)
Other or mixed	14 (7)
Level of training
Incoming intern	63 (29)
Outgoing intern	60 (27)
Senior resident	26 (12)
Attending physician	70 (32)
Specialty
Internal medicine	88 (40)
Family medicine	8 (4)
Pediatrics	42 (19)
Obstetrics and gynecology	10 (5)
General surgery	22 (10)
Emergency medicine	10 (5)
Psychiatry	8 (4)
Other	31 (14)
Practice setting
Academic practice	170 (78)
Private practice	28 (13)
Other or multiple	19 (9)

¹Summed frequencies > 100 are due to spreadsheet rounding. Missing data are excluded.

Table 2 Correct responses to hepatitis B knowledge assessment

	Number	Percent	Percent1
Through which of the following can HBV be transmitted?	89	41%	47%
Which blood test(s) would you order to screen for chronic hepatitis B infection?	52	24%	20%
Which blood test(s) would you order to confirm immunity to hepatitis B after vaccination?	153	70%	73%
Which of the following viral hepatitis infections can be prevented by immunization?	160	73%	77%
According to California law, who is/are required to report new hepatitis B diagnoses?	31	14%	11%
A patient has been told by a previous physician that he is a healthy hepatitis B carrier. What are the appropriate next steps, if any?	28	13%	16%
Which of the following patient groups has the highest prevalence of chronic hepatitis B?	137	63%	64%
Asians > Caucasians, African Americans, and Hispanics/Latinos (CORRECT RESPONSE)	107	49%
Which of the following is most likely to result in chronic infection with hepatitis B?	105	48%	52%
Which of the following conditions can be caused by chronic infection with hepatitis B?	173	79%	83%
What are the symptoms of most patients with chronic hepatitis B?	138	63%	69%
Without proper monitoring, what is the chance of dying from chronic hepatitis B?	35	26%	18%
Is there a cure for chronic hepatitis B?	194	89%	91%
Is there a treatment for chronic hepatitis B?	191	87%	89%
According to the American Association for the Study of Liver Diseases (AASLD) guidelines, which of the following are appropriate screening tests for liver cancer?	68	31%	34%

¹Adjusted for positive control measuring baseline cancer screening knowledge and self-reported counseling practices.

Table 3 Physician self-reported practices n (%)

Question	Value
Do you routinely screen asymptomatic patients for chronic hepatitis B in your practice?
Yes	52 (24)
Would you screen for chronic hepatitis B in an HIV-positive individual?
Yes1	208 (95)
No	3 (1)
Don't know	8 (4)
Would you screen for chronic hepatitis B in a 40-yr-old with a history of hemophilia?
Yes1	167 (76)
No	39 (18)
Don't know	13 (6)
Would you screen for chronic hepatitis B in a healthy 28-yr-old man born in China?
Yes1	156 (71)
No	57 (26)
Don't know	6 (3)
Would you screen for chronic hepatitis B in a Caucasian woman who travels frequently to Central America?
Yes	71 (32)
No1	133 (61)
Don't know	15 (7)
Would you screen for chronic hepatitis B in a cafeteria food server during a pre-employment physical?
Yes	86 (39)
No1	121 (55)
Don't know	12 (5)

¹Indicates correct response.

Table 4 Distribution of responses to questions about confidence in hepatitis B knowledge n (%)

Question	Response	Value
I am confident that I know who should be screened for chronic hepatitis B
	Strongly disagree	11 (5)
	Disagree	60 (27)
	Neutral	78 (36)
	Agree	59 (27)
	Strongly agree	8 (4)
	Did not reply	3 (1)
I am confident that I know who should be vaccinated for chronic hepatitis B
	Strongly disagree	7 (3)
	Disagree	23 (11)
	Neutral	52 (24)
	Agree	104 (47)
	Strongly agree	31 (14)
	Did not reply	3 (1)
I am confident that I know when a patient with chronic hepatitis B should be referred to a specialist
	Strongly disagree	5 (2)
	Disagree	57 (26)
	Neutral	72 (33)
	Agree	67 (31)
	Strongly agree	16 (7)
	Did not reply	2 (1)
	Very poorly	8 (4)
	Not well	65 (30)
	Neutral	101 (46)
	Fairly well	41 (19)
	Very well	2 (1)
	Did not reply	2 (1)

Table 5 Associations of training level and other characteristics with correct (compared with incorrect) responses to questions about hepatitis B knowledge and clinical practice

Question	Characteristic	Relative risk1	(95%CI)	P value
Which blood test(s) would you order to screen for chronic hepatitis B infection?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	1.2	(0.5-3.1)
	Senior resident	2.1	(0.7-6.1)
	Attending	2.0	(0.7-5.7)
Do you routinely screen asymptomatic patients for chronic hepatitis B in your practice? (yes vs no)
	Incoming intern	1.0	(Reference)
	Outgoing intern	1.1	(0.4-3.1)
	Senior resident	1.5	(0.5-5.2)
	Attending	1.5	(0.4-5.3)
According to California law, who is/are required to report new hepatitis B diagnoses?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	0.7	(0.3-2.1)
	Senior resident	0.2	(0.02-1.6)
	Attending	0.6	(0.1-2.4)
A patient has been told by a previous physician that he is a healthy hepatitis B carrier. What are the appropriate next steps, if any?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	1.8	(0.5-6.7)
	Senior resident	1.4	(0.2-8.7)
	Attending	0.9	(0.1-7.8)
	Not confident in knowledge about referral for chronic hepatitis B3	1.0	(Reference)
	Confident in knowledge about referral for chronic hepatitis B3	6.0	(2.4-15.0)	0.0001
What is the relative prevalence of chronic hepatitis B in Caucasians, African Americans, Asians, and Hispanics/Latinos?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	0.8	(0.4-1.7)
	Senior resident	1.8	(0.7-4.6)
	Attending	1.2	(0.5-2.9)
Which of the following is most likely to result in chronic infection with hepatitis B?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	2.0	(1.0-4.2)
	Senior resident	3.3	(1.2-9.0)
	Attending	1.9	(0.7-5.0)	0.080
Without proper monitoring, what is the chance of dying from chronic hepatitis B?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	0.8	(0.3-1.9)
	Senior resident	0.3	(0.1-1.5)
	Attending	0.6	(0.2-2.3)
According to the American Association for the Study of Liver Diseases guidelines, which of the following are appropriate screening tests for liver cancer?2
	Incoming intern	1.0	(Reference)
	Outgoing intern	3.6	(1.5-8.7)
	Senior resident	5.6	(1.9-16.4)
	Attending	4.8	(1.6-14.9)	0.005
	Age (5-yr increase)	0.7	(0.5-0.9)	0.005

¹All estimates adjusted for age (continuous years);

²Questions included in calculation of total hepatitis B knowledge score;

³"Confident": respondent "strongly agrees" or "agrees" that he or she is confident about knowledge; "not confident": respondent "disagrees," "strongly disagrees," or is neutral.

Table 6 Differences in total hepatitis B knowledge scores by cohort

Cohort	Difference in score1	(95%CI)	P value
Total hepatitis b knowledge score
Incoming intern	0.0	(Reference)
Outgoing intern	0.1	(-0.9-1.2)
Senior resident2	1.7	(0.4-3.0)	0.010
Attending Physician	0.9	(-0.4-2.2)
Age (5-yr increase)2	-0.4	[-0.6-(-0.1)]	0.003
Responded incorrectly to other cancer screening questions and smoking cessation practices	0.0	(Reference)
Responded correctly to other cancer screening questions and smoking cessation practices2	1.0	(0.2-1.8)	0.010
Age (5-yr increase)	-0.4	[-0.6-(-0.1)]	0.003
Hepatitis b screening knowledge score
Incoming intern	0.0	(Reference)
Outgoing intern	-0.2	(-0.6-0.3)
Senior resident	0.5	(-0.1-1.5)
Attending	0.3	(-0.3-1.0)
Hepatitis b vaccination knowledge score
Incoming intern	0.0	(Reference)
Outgoing intern	0.1	(-0.8-1.2)
Senior resident	0.1	(0.2-2.8)
Attending	0.1	(-0.4-2.2)

¹All estimates adjusted for age (continuous years);

²The P value < 0.05.