Do you discriminate against smokers?

Physicians earn failing grades on COPD report card

By Julia Cyboran

Close to 25% of your colleagues discriminate against patients who smoke, according to the provocative Chronic Obstructive Pulmonary Disease (COPD): A National Report Card published by the Canadian Lung Association and the Canadian Thoracic Society (CTS) last month. Respondents across the country admit they tailor treatment and care to their patient's smoking status.

Have you refused treatment because a patient is a smoker? Have you provided treatment that may not have been as thorough because the patient is a smoker? Over 250 physicians from across the country were asked these and other very specific questions about how they treat smokers in their exam rooms. Results vary from province to province, but the results are undeniably revealing: fully 25% of physicians in the Atlantic provinces admitted to discriminating against smokers, while 8% of their colleagues on the opposite coast in BC confessed to the bias.

BLAME GAME
Dr Kenneth Chapman, a respirologist and professor of medicine at the University of Toronto isn't surprised by his colleagues' bias. "They think, 'The patient smokes, so it's their fault'." But that's not a good enough reason to give lesser care. "Heart attack risk increases in smokers, as does the risk of stroke, but we aren't as quick to discriminate against them," he points out. Dr Chapman finds this kind of thinking dangerous. What's next, he wonders, discriminating against diabetics because they're obese?

Dr Paul Hernandez, chair of the guideline implementation team, isn't convinced discrimination against smokers is as prevalent as the report suggests. "I'm surprised by that figure," he says. "If it's true, it's alarming. I think it's important to dig deeper." But, like Dr Chapman, he does understand why some doctors would approach treatment for smokers differently. "I think from an FP's point of view, some treatments are a lot less effective in patients who continue to smoke," he adds, "but I hope that it doesn't mean that those patients aren't getting access to appropriate treatment."

BACK TO THE BOOKS
The primary objective of the national report was to raise awareness of the disease among the public and physicians, but the surprising findings have left doctors with plenty to think about. The majority of provinces received a grade of "D" or lower, with three provinces — New Brunswick, PEI and Newfoundland — actually failing. The dismal grades were doled out mainly because most Canadian provinces aren't offering adequate care to COPD patients. Physicians themselves aren't up to speed on treatment and guidelines, and the public is grossly unaware of the disease.

"I think there are a number of factors that would explain why Canadian physicians aren't up to date," says Dr Chapman. "One is that they've come to view COPD somewhat nihilistically as a disease they can't do much about." He feels doctors aren't likely to be enthusiastic to fight a disease if they don't think there's anything they can do. "I think that FPs haven't caught up with newer therapies," he adds.

That fact is reflected in the report card. It shows that only 26% of physicians consider themselves to be very familiar with the CTS guidelines; another 21% don't even know what treatments are recommended; and only 7% say they follow the treatment processes outlined in the guidelines all of the time. "We need to increase the education that physicians get in their training," says Dr Hernandez. The CTS has already gotten started; after the report was published, they organized a mass mailing campaign to get the message out to FPs. They sent copies of the guidelines and tools to help doctors learn more about treatment protocols and educate their patients about COPD.

Dr Chapman's all for this, but adds that primary care physicians need better training on lung function tests. "FPs are clearly not comfortable using spirometers," he says. "Stethoscopes have tremendous limits," he explains. "They don't find the disease until it's too far advanced." A spirometer is far more effective, he says — it measures the lung's air capacity, is easy to use and yields clear results in about five minutes.

IT'S NOT ALL YOUR FAULT
Doctors can't shoulder all the blame for Canada's COPD ignorance. Other factors that have contributed to the gravity of the situation are also highlighted in the report. For instance, not all provinces offer pulmonary rehabilitation to COPD patients, and of the provinces that do, only 1.2% of the COPD population is currently being served. Funding of COPD medications also varies widely from province to province.

But regardless of the government's shortcomings, both Dr Hernandez and Dr Chapman think that a lot has to do with the public's knowledge of the disease. "In large part this patient group doesn't speak out on their own or advocate for themselves," explains Dr Hernandez. "We have to direct our message more towards the general public to speak out and ask for better care from their doctors." Dr Chapman agrees. "One of the big targets is to create patient awareness and expectations," he says. "When we do create that awareness, patients are going to see their GPs and ask for breathing tests and treatments."

FPs' CRUCIAL ROLE
That's where family doctors come in. "FPs should be the primary caregivers for the COPD population," says Dr Hernandez. "They should be involved in educating the patient at every level and raising expectations of the kinds of treatments patients can count on. FPs are key members of the healthcare team." Most importantly, says Dr Hernandez, FPs need to be on the lookout for COPD in the right patients (see the chart "Who should be screened", left).

Dr Hernandez stresses one final message to primary care physicians: COPD is treatable. With the right treatment these patients can enjoy a good quality of life.