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A survey of physicians knowledge regarding awareness of maternal alcohol use and the diagnosis of FAS.

A survey of physicians knowledge regarding awareness of maternal alcohol use and the diagnosis of... Background: Alcohol is the most widely used drug in the world that is a human teratogen whose use among women of childbearing age has been steadily increasing. It is also probable that Fetal Alcohol Syndrome is under diagnosed by physicians. The objectives of this study were twofold: 1) to evaluate the experience, knowledge and confidence of family physicians with respect to the diagnosis of FAS and 2) to evaluate physicians awareness of maternal drinking patterns. Methods and Participants: A multiple choice anonymous questionnaire was sent to a randomly selected group of family physicians in the Metropolitan Toronto area. Results: There was a 73% (75/103) total response rate; Overall, 6/75 (8%) of family physicians reported that they had actually diagnosed a child with FAS. 17.9% had suspicions but did not make a diagnosis and 12.7% reported making a referral to confirm the diagnosis. Physician rated confidence in the ability to diagnosis FAS was low, with 49% feeling they had very little confidence. 75% reported counselling pregnant women and 60.8% reported counselling childbearing women in general on the use of alcohol. When asked what screening test they used to detect the use of alcohol, 75% described frequency/quantity. Not a single respondent identified using the current accepted screening method for alcohol use (TWEAK) which is recommended by The Centre for Addiction and Mental Health. Conclusions: Family physicians do not feel confident about diagnosing FAS. None of the physicians were aware of the current screening methods to accurately gage alcohol use in pregnant and childbearing women should not exceed 2 standard drinks on any given day and Background The Centre for Addiction and Mental Health(CAMH) in no more than 9 drinks per week. Of these drinkers, it is es- Toronto reports that approximately 80% of Canadian timated that 2% drink greater than 15 drinks per week and women currently consume alcohol, up from 67% in 1986. 4% engage in binge drinking of 5 or more drinks per oc- Guidelines from CAMH specify that low risk drinking casion. [1]. Consequently, it is conceivable that a signifi- Page 1 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 cant number women who are problem drinkers and are of feel comfortable diagnosing FAS and expressed a need for child bearing age, will become pregnant and may give more education [10]. birth to a child with FAS. This generalised lack of information, differences in opin- There are no Canadian statistics on pregnant women ion and inability to diagnosis FAS may reflect the docu- drinkers, however it has been documented in the litera- mented severe inadequacies in medical training regarding ture from the U.S, that women do drink during pregnancy, alcohol use and abuse and more specifically FAS. A with one study reporting that 37% of pregnant teenagers MEDLINE search did not reveal any other Canadian sur- and 24% of pregnant adults reported binge drinking in veys of this type in the literature. As one of our goals at The their 1st trimester [2]. A more recent study documented Motherisk Program alcohol helpline, is to educate physi- that more than 20% of pregnant women drink alcohol cians on how to diagnose FAS, our study was aimed at [3]. identifying the gaps in knowledge that need to be ad- dressed. Many studies have been undertaken to estimate the occur- rence of FAS', with the current accepted incidence of 4.3 Methods and Participants per 100 live births of women who are 'heavy drinkers' [4]. An anonymous self administered questionnaire was sent Even though heavy drinking does not automatically re- to 103 randomly selected family physicians whose names sult in the birth of a affected child, it is generally recog- were listed in the current Canadian Medical Directory. nized that pregnant women should err on the side of They were randomised by selecting every fourth family safety and not consume any alcoholic beverages during physician in the Directory. Initial contact was by a tele- pregnancy [5]. Fortunately, most women do heed this ad- phone call to the physician's receptionist which was sub- vice, but for the ones that do not, there can be serious sequently followed by a fax. A second call and fax was medical, emotional and economic complications in- repeated in two weeks if there had not been a response. volved with a diagnosis of FAS [6]. The questionnaire was two pages long consisting of mul- tiple choice questions. There were twelve questions that The Motherisk Program at the Hospital for Sick Children were divided into three sections 1) demographics 2) abil- is a counseling service for pregnant women and their ity to identify factors related to problem drinking in preg- health professionals concerning exposures such as drugs, nant or childbearing women, by asking them what tools chemicals, radiation and infectious diseases etc. A sepa- they use for assessment of alcohol use eg. maternal report- rate toll free telephone line is accessible throughout Can- ing, or questionnaires such as the TWEAK (Table 1) and 3) ada, available for callers who wish to discuss alcohol and the ability to diagnose FAS by asking them to identify key substance use only. Health professionals, including a sub- factors in the making of a diagnosis. A pilot phase of the stantial number of physicians call this line asking for in- study indicated that it could be filled out in 5–10 minutes. formation about FAS. Many of them have told us that due to lack of training, they do not feel comfortable in making Results a diagnosis of FAS. Based on these anecdotal reports we Since this was an exploratory survey of physicians knowl- decided to systematically review the knowledge and prac- edge and practices in this field, descriptive statistics in tice in this field in the Metropolitan Area of Toronto. In numbers and percentages are used to present the results. the related literature, a retrospective chart review study demonstrated that physicians were unable to accurately A total of 75/103 (73%) completed questionnaires were diagnose FAS according to the defined criteria. In this returned: As a group 45.6% were male and 54.4% were fe- study, even though physical features consistent with FAS male and had been practicing a mean of 16.1 ± 9.8 year, were documented in the charts of newborn infants there with the length of practice ranging from 1–40 years. was a 100% failure to diagnose FAS even with document- ed alcohol exposure [7]. The first question asked was' Do you think that your own drinking behaviour(or lack of) influences your ability to In another study, physicians reported uncertainty relating diagnose problem drinking' (12%) said it did, (86.5%) to several factual and opinion based statements concern- said it did not with one person answering 'don't know'. ing FAS, including ability to diagnose at birth and whether With regards to counselling women on the use of alcohol, their colleagues were aware of the major criteria to make 74.7% reported having obtained a history of alcohol use a diagnosis [8]. Another study found that physicians do during pregnancy, while 61% reported having counseled not routinely ask their pregnant patients about alcohol women of child bearing age on the use of alcohol in gen- use [9]. In the single Canadian study, carried out in Sas- eral. However, 34% of respondents reported using the katchewen 9 years ago, the physicians surveyed did not CAGE questionnaire (which is considered relatively in- Page 2 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 Table 1: The 'TWEAK' Test Do you drink alcoholic beverages? If so please take our TWEAK test T Tolerance How many drinks does it takes to make you feel high? x (two or more score two points W Worry Have close friends worried or complained abot your drinking in the past year? x (if yes, score one point) E Eye opener Do you sometimes take a drink first thing in the morning? x (If yes, score one point) A Amnesia Has anyone ever told you about things thay you said or did while you were drinking that you could not remember? x (If yes score one point) K Cut down Do you sometimes feel the need to cut down on your drinking? x (If yes, score one point) Scoring:To score the test a seven point scale is used. A total score of three or more points indicatesthe person is likely to be a heavy drinker Table 2: Physicians recommendations to women regarding alcohol use during pregnancy Recommendation % physicians The amount of alcohol considered safe for the fetus is unknown 57.5 No alcohol is recommended throughout pregnancy 65.0 No alcohol is recommended in the first trimester only 5.0 A glass of wine or beer occasionally is not likely to be of concern 53.8 Other (indicates options not listed above) 2.5 Some physicians selected more than one option Table 3: Physicians opinions regarding general knowledge of FAS Statements True % False % Don't know % Criteria = FAS is an in identifiable syndrome 92 5 3 Childhood = easier to identify during childhood 75 12 13 Dx = Making diagnosis can improve treatment 89 2 9 Life long = Dysmorphology is permanent 72 20 8 Overdiagnosis = FAS is overdiagnosed 3 93 4 sensitive in predominantly white populations as is the diagnosed' the respondents agreed that these statements case in Toronto) or relying on self reporting 66% (which were accurate. (Table 3) From a list of FAS associated fea- is often an underestimation). tures, the respondents were asked to select the three most important features to aid in the diagnoses. Only 8% were To elicit the recommendations physicians would most able to correctly identify the three most important fea- likely give to pregnant women regarding the use of alco- tures, with 50% two features, 30% one feature and 7% hol during pregnancy, they were asked to select statements who could not identify any of the features.(Table 4) which they felt were appropriate for counseling. (Table 2) The respondents were next asked to select what are the To assess physicians knowledge regarding FAS facts in three most important factors in determining the Quality general, they were asked to give their opinion on the accu- of Life (QOL) for a child diagnosed with FAS from a list racy of five statements they were asked to evaluate. As a which included early diagnoses as the most important fac- group, with the exception of the statement 'FAS is over- Page 3 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 Table 4: Identification of FAS diagnostic criteria Most of the respondents felt that they did not feel com- fortable, nor did they feel their colleagues were competent FAS Features % physicians in diagnosing FAS and felt that there should be more edu- cation in medical schools. Even the individuals who stat- ed they did feel competent, were in the most part not able Growth retardation 39.2 CNS neurodevelopmental abnormalities 58.2 to identify all of the diagnostic criteria or name the most Facial dysmorphology 77.2 important factors in determining the optimal quality of Behavioural problems 41.8 life for these children. This last observation is troubling as Cardiac malformations 2.5 early identification of FAS (before the age of 6 years old) Mental retardation 13.9 is considered the single most important factor that deter- Confirmed maternal alcohol exposure 67.1 mines self sufficiency as an adult for those affected [13]. This study was carried out by a 'HIC'(Determinants of The physicians were asked to rate the three most important features of FAS actual three most important features in bold Health in the Community) student from The University of Toronto Medical School. After completing the project, she felt that it would be important that medical students re- ceive more training on the subject to enable to them to tor. Only 53% identified the latter as being the most im- make a difference in helping to deal with this preventable portant factor. condition once they become practicing physicians. At the present time there is little education devoted to this sub- The next question dealt with the physician's perceived ject aside from one or two classes and she and her fellow competency at diagnosing FAS, with 81% of the family students feel there are a great many myths and mispercep- physicians feeling that their training was inadequate. tions regarding FAS. When asked if physicians in general possess the skills and knowledge to diagnose FAS, more than 70% felt that they There are a number of limitations to this study, the main did not. Lastly, 8% of the respondents did feel comforta- one the relatively small number of physicians surveyed. ble with their ability to diagnose FAS, despite the fact they The number of physicians who did not respond to the sur- were unable to identify the three most important diagnos- vey is always a inherent bias, as it is quite possible non re- tic criteria and QOL factors determining the optimal out- sponders may be less knowledgeable about FAS and come for the child. therefore not interested in filling out a questionnaire. However, a 73% response rate is quite high for a random- Discussion ly sent survey to physicians, so this may not be a strong This is the first survey of its kind carried out in the Metro- factor. Lastly, this survey was carried out in Toronto and politan Toronto area where there is a high density of phy- caution is required before extrapolating these findings to sicians serving a heterogeneous population. This survey the rest of Canada. It would be useful to survey physicians confirmed some of the findings of other similar surveys in other areas of Canada, especially where there is a high [7–10] in other geographical areas and we were also able incidence of FAS. to report on several new findings. In summary, physicians feel they need more education The number of physicians (86.5%) who felt that their about FAS as they are not confident about being able to own drinking behaviour (or lack of) did not influence make a diagnosis. They are more comfortable than in the their diagnosis of a drinking problem was an interesting past about asking women about their alcohol use, howev- finding, as it has been documented that this is an impor- er they need further education about screening methods tant factor [11]. This lack of understanding of their own to ensure an accurate record to allow them to become behaviour could be of concern when asking a pregnant alerted to a women who is pregnant or of childbearing age woman about her alcohol use resulting in an over or un- who has a drinking problem. Medical schools should be derestimation of use. Most physicians did counsel their encouraged to include more education in this field in their pregnant patients and women of childbearing age about curriculums and practicing physicians should be encour- alcohol use. However, recommendations were rather in- aged to attend CME's on the subject. At Motherisk we are consistent and they were not up to date on the current ac- developing methods using video conferences to assist cepted screening methods. It was suprising that not a physicians with diagnosis from anywhere in the country. single respondent reported using the TWEAK, which is currently considered the most accurate screening method FAS exerts a heavy toll on society both financially and [12]. emotionally. However, it is one hundred percent prevent- able, so it is imperative that physicians receive compre- Page 4 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 hensive education in this field, not only to help prevent babies born with this syndrome, but also in early detec- tion which can lead to interventions that can improve the quality of life of affected children. Competing interests None declared Acknowledgements References 1. Cornelius MD, Geua D: Research Foundation Web Site 2000 [http Ad- diction //www.arf.org] 2. Cornelius MD, Richardson GA, Day NL, Taylor PM: A comparison of prenatal drinking in two recent samples of adolescents and adults. J Stud Alcohol 1994, 55:412-9 3. Stratton , et al: Alcohol consumption among pregnant and childbearing women. CDC 1997 4. Abel EL: An update of the incidence of FAS: FAS is not an equal oportunity birth defect Neurotoxicol Teratol 1995, 17:437- 5. Abel EL, Kruger M: What really causes FAS? Teratology 1999, 59:4-6 6. Nulman I, Gladstone J, O'Hayon B, Koren G: The effects of alcohol on the fetal brain-the central nervous system tragedy. Hand- book of Developmental Neurotoxicology 1998567-586 7. Little BB, Snell MN, Rosenfeld CR, Gilstrap 3rd LC, Gant NF: Failure to recognize fetal alcohol syndrome in newborn. Am J Dis Child 1990, 144:1142-46 8. Abel EL, Kruger M: What do physicians know and say about fe- tal alcohol syndrome: a survey of obstetricians, pediatricians and family physicians. Alcohol Clin Exp Res. 1998, 22:1951-4 9. Donovan CL: Factors predisposing, enabling and reinforcing screening of patients for preventing fetal alcohol syndrome: a survey of New Jersey physicians. J Drug Edu 1991, 21:35-42 10. Nanson JL, Bolaria R, Snyder Morse B, Weiner LR: Physician awareness of fetal alcohol syndrome: a survey of pediatri- cians and general practitioners. CMAJ 1995, 152:1071-1076 11. Brewster JM, Single EW, Ashley MJ, Chow YC, Skinner HA, Rankin JG: Preventing alcohol problems: a survey of Canadian med- ical schools. CMAJ. 1990, 143:39-45 12. Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML: Alcohol screening questionnaires in women. a critical review. JAMA 1998, 280:166-171 13. Streissguth AP, Barr HM, Kogan J, Bookstein FL: Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome and fetal alcohol effects. Final report. Abstract: Fetal alcohol syndrome conference, Washington DC 1996 Publish with BioMed Central and every scientist can read your work free of charge "BioMedcentral will be the most significant development for disseminating the results of biomedical research in our lifetime." 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A survey of physicians knowledge regarding awareness of maternal alcohol use and the diagnosis of FAS.

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Publisher
Springer Journals
Copyright
Copyright © 2002 by Nevin et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
eISSN
1471-2296
DOI
10.1186/1471-2296-3-2
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Abstract

Background: Alcohol is the most widely used drug in the world that is a human teratogen whose use among women of childbearing age has been steadily increasing. It is also probable that Fetal Alcohol Syndrome is under diagnosed by physicians. The objectives of this study were twofold: 1) to evaluate the experience, knowledge and confidence of family physicians with respect to the diagnosis of FAS and 2) to evaluate physicians awareness of maternal drinking patterns. Methods and Participants: A multiple choice anonymous questionnaire was sent to a randomly selected group of family physicians in the Metropolitan Toronto area. Results: There was a 73% (75/103) total response rate; Overall, 6/75 (8%) of family physicians reported that they had actually diagnosed a child with FAS. 17.9% had suspicions but did not make a diagnosis and 12.7% reported making a referral to confirm the diagnosis. Physician rated confidence in the ability to diagnosis FAS was low, with 49% feeling they had very little confidence. 75% reported counselling pregnant women and 60.8% reported counselling childbearing women in general on the use of alcohol. When asked what screening test they used to detect the use of alcohol, 75% described frequency/quantity. Not a single respondent identified using the current accepted screening method for alcohol use (TWEAK) which is recommended by The Centre for Addiction and Mental Health. Conclusions: Family physicians do not feel confident about diagnosing FAS. None of the physicians were aware of the current screening methods to accurately gage alcohol use in pregnant and childbearing women should not exceed 2 standard drinks on any given day and Background The Centre for Addiction and Mental Health(CAMH) in no more than 9 drinks per week. Of these drinkers, it is es- Toronto reports that approximately 80% of Canadian timated that 2% drink greater than 15 drinks per week and women currently consume alcohol, up from 67% in 1986. 4% engage in binge drinking of 5 or more drinks per oc- Guidelines from CAMH specify that low risk drinking casion. [1]. Consequently, it is conceivable that a signifi- Page 1 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 cant number women who are problem drinkers and are of feel comfortable diagnosing FAS and expressed a need for child bearing age, will become pregnant and may give more education [10]. birth to a child with FAS. This generalised lack of information, differences in opin- There are no Canadian statistics on pregnant women ion and inability to diagnosis FAS may reflect the docu- drinkers, however it has been documented in the litera- mented severe inadequacies in medical training regarding ture from the U.S, that women do drink during pregnancy, alcohol use and abuse and more specifically FAS. A with one study reporting that 37% of pregnant teenagers MEDLINE search did not reveal any other Canadian sur- and 24% of pregnant adults reported binge drinking in veys of this type in the literature. As one of our goals at The their 1st trimester [2]. A more recent study documented Motherisk Program alcohol helpline, is to educate physi- that more than 20% of pregnant women drink alcohol cians on how to diagnose FAS, our study was aimed at [3]. identifying the gaps in knowledge that need to be ad- dressed. Many studies have been undertaken to estimate the occur- rence of FAS', with the current accepted incidence of 4.3 Methods and Participants per 100 live births of women who are 'heavy drinkers' [4]. An anonymous self administered questionnaire was sent Even though heavy drinking does not automatically re- to 103 randomly selected family physicians whose names sult in the birth of a affected child, it is generally recog- were listed in the current Canadian Medical Directory. nized that pregnant women should err on the side of They were randomised by selecting every fourth family safety and not consume any alcoholic beverages during physician in the Directory. Initial contact was by a tele- pregnancy [5]. Fortunately, most women do heed this ad- phone call to the physician's receptionist which was sub- vice, but for the ones that do not, there can be serious sequently followed by a fax. A second call and fax was medical, emotional and economic complications in- repeated in two weeks if there had not been a response. volved with a diagnosis of FAS [6]. The questionnaire was two pages long consisting of mul- tiple choice questions. There were twelve questions that The Motherisk Program at the Hospital for Sick Children were divided into three sections 1) demographics 2) abil- is a counseling service for pregnant women and their ity to identify factors related to problem drinking in preg- health professionals concerning exposures such as drugs, nant or childbearing women, by asking them what tools chemicals, radiation and infectious diseases etc. A sepa- they use for assessment of alcohol use eg. maternal report- rate toll free telephone line is accessible throughout Can- ing, or questionnaires such as the TWEAK (Table 1) and 3) ada, available for callers who wish to discuss alcohol and the ability to diagnose FAS by asking them to identify key substance use only. Health professionals, including a sub- factors in the making of a diagnosis. A pilot phase of the stantial number of physicians call this line asking for in- study indicated that it could be filled out in 5–10 minutes. formation about FAS. Many of them have told us that due to lack of training, they do not feel comfortable in making Results a diagnosis of FAS. Based on these anecdotal reports we Since this was an exploratory survey of physicians knowl- decided to systematically review the knowledge and prac- edge and practices in this field, descriptive statistics in tice in this field in the Metropolitan Area of Toronto. In numbers and percentages are used to present the results. the related literature, a retrospective chart review study demonstrated that physicians were unable to accurately A total of 75/103 (73%) completed questionnaires were diagnose FAS according to the defined criteria. In this returned: As a group 45.6% were male and 54.4% were fe- study, even though physical features consistent with FAS male and had been practicing a mean of 16.1 ± 9.8 year, were documented in the charts of newborn infants there with the length of practice ranging from 1–40 years. was a 100% failure to diagnose FAS even with document- ed alcohol exposure [7]. The first question asked was' Do you think that your own drinking behaviour(or lack of) influences your ability to In another study, physicians reported uncertainty relating diagnose problem drinking' (12%) said it did, (86.5%) to several factual and opinion based statements concern- said it did not with one person answering 'don't know'. ing FAS, including ability to diagnose at birth and whether With regards to counselling women on the use of alcohol, their colleagues were aware of the major criteria to make 74.7% reported having obtained a history of alcohol use a diagnosis [8]. Another study found that physicians do during pregnancy, while 61% reported having counseled not routinely ask their pregnant patients about alcohol women of child bearing age on the use of alcohol in gen- use [9]. In the single Canadian study, carried out in Sas- eral. However, 34% of respondents reported using the katchewen 9 years ago, the physicians surveyed did not CAGE questionnaire (which is considered relatively in- Page 2 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 Table 1: The 'TWEAK' Test Do you drink alcoholic beverages? If so please take our TWEAK test T Tolerance How many drinks does it takes to make you feel high? x (two or more score two points W Worry Have close friends worried or complained abot your drinking in the past year? x (if yes, score one point) E Eye opener Do you sometimes take a drink first thing in the morning? x (If yes, score one point) A Amnesia Has anyone ever told you about things thay you said or did while you were drinking that you could not remember? x (If yes score one point) K Cut down Do you sometimes feel the need to cut down on your drinking? x (If yes, score one point) Scoring:To score the test a seven point scale is used. A total score of three or more points indicatesthe person is likely to be a heavy drinker Table 2: Physicians recommendations to women regarding alcohol use during pregnancy Recommendation % physicians The amount of alcohol considered safe for the fetus is unknown 57.5 No alcohol is recommended throughout pregnancy 65.0 No alcohol is recommended in the first trimester only 5.0 A glass of wine or beer occasionally is not likely to be of concern 53.8 Other (indicates options not listed above) 2.5 Some physicians selected more than one option Table 3: Physicians opinions regarding general knowledge of FAS Statements True % False % Don't know % Criteria = FAS is an in identifiable syndrome 92 5 3 Childhood = easier to identify during childhood 75 12 13 Dx = Making diagnosis can improve treatment 89 2 9 Life long = Dysmorphology is permanent 72 20 8 Overdiagnosis = FAS is overdiagnosed 3 93 4 sensitive in predominantly white populations as is the diagnosed' the respondents agreed that these statements case in Toronto) or relying on self reporting 66% (which were accurate. (Table 3) From a list of FAS associated fea- is often an underestimation). tures, the respondents were asked to select the three most important features to aid in the diagnoses. Only 8% were To elicit the recommendations physicians would most able to correctly identify the three most important fea- likely give to pregnant women regarding the use of alco- tures, with 50% two features, 30% one feature and 7% hol during pregnancy, they were asked to select statements who could not identify any of the features.(Table 4) which they felt were appropriate for counseling. (Table 2) The respondents were next asked to select what are the To assess physicians knowledge regarding FAS facts in three most important factors in determining the Quality general, they were asked to give their opinion on the accu- of Life (QOL) for a child diagnosed with FAS from a list racy of five statements they were asked to evaluate. As a which included early diagnoses as the most important fac- group, with the exception of the statement 'FAS is over- Page 3 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 Table 4: Identification of FAS diagnostic criteria Most of the respondents felt that they did not feel com- fortable, nor did they feel their colleagues were competent FAS Features % physicians in diagnosing FAS and felt that there should be more edu- cation in medical schools. Even the individuals who stat- ed they did feel competent, were in the most part not able Growth retardation 39.2 CNS neurodevelopmental abnormalities 58.2 to identify all of the diagnostic criteria or name the most Facial dysmorphology 77.2 important factors in determining the optimal quality of Behavioural problems 41.8 life for these children. This last observation is troubling as Cardiac malformations 2.5 early identification of FAS (before the age of 6 years old) Mental retardation 13.9 is considered the single most important factor that deter- Confirmed maternal alcohol exposure 67.1 mines self sufficiency as an adult for those affected [13]. This study was carried out by a 'HIC'(Determinants of The physicians were asked to rate the three most important features of FAS actual three most important features in bold Health in the Community) student from The University of Toronto Medical School. After completing the project, she felt that it would be important that medical students re- ceive more training on the subject to enable to them to tor. Only 53% identified the latter as being the most im- make a difference in helping to deal with this preventable portant factor. condition once they become practicing physicians. At the present time there is little education devoted to this sub- The next question dealt with the physician's perceived ject aside from one or two classes and she and her fellow competency at diagnosing FAS, with 81% of the family students feel there are a great many myths and mispercep- physicians feeling that their training was inadequate. tions regarding FAS. When asked if physicians in general possess the skills and knowledge to diagnose FAS, more than 70% felt that they There are a number of limitations to this study, the main did not. Lastly, 8% of the respondents did feel comforta- one the relatively small number of physicians surveyed. ble with their ability to diagnose FAS, despite the fact they The number of physicians who did not respond to the sur- were unable to identify the three most important diagnos- vey is always a inherent bias, as it is quite possible non re- tic criteria and QOL factors determining the optimal out- sponders may be less knowledgeable about FAS and come for the child. therefore not interested in filling out a questionnaire. However, a 73% response rate is quite high for a random- Discussion ly sent survey to physicians, so this may not be a strong This is the first survey of its kind carried out in the Metro- factor. Lastly, this survey was carried out in Toronto and politan Toronto area where there is a high density of phy- caution is required before extrapolating these findings to sicians serving a heterogeneous population. This survey the rest of Canada. It would be useful to survey physicians confirmed some of the findings of other similar surveys in other areas of Canada, especially where there is a high [7–10] in other geographical areas and we were also able incidence of FAS. to report on several new findings. In summary, physicians feel they need more education The number of physicians (86.5%) who felt that their about FAS as they are not confident about being able to own drinking behaviour (or lack of) did not influence make a diagnosis. They are more comfortable than in the their diagnosis of a drinking problem was an interesting past about asking women about their alcohol use, howev- finding, as it has been documented that this is an impor- er they need further education about screening methods tant factor [11]. This lack of understanding of their own to ensure an accurate record to allow them to become behaviour could be of concern when asking a pregnant alerted to a women who is pregnant or of childbearing age woman about her alcohol use resulting in an over or un- who has a drinking problem. Medical schools should be derestimation of use. Most physicians did counsel their encouraged to include more education in this field in their pregnant patients and women of childbearing age about curriculums and practicing physicians should be encour- alcohol use. However, recommendations were rather in- aged to attend CME's on the subject. At Motherisk we are consistent and they were not up to date on the current ac- developing methods using video conferences to assist cepted screening methods. It was suprising that not a physicians with diagnosis from anywhere in the country. single respondent reported using the TWEAK, which is currently considered the most accurate screening method FAS exerts a heavy toll on society both financially and [12]. emotionally. However, it is one hundred percent prevent- able, so it is imperative that physicians receive compre- Page 4 of 5 (page number not for citation purposes) BMC Family Practice 2002, 3 http://www.biomedcentral.com/1471-2296/3/2 hensive education in this field, not only to help prevent babies born with this syndrome, but also in early detec- tion which can lead to interventions that can improve the quality of life of affected children. Competing interests None declared Acknowledgements References 1. Cornelius MD, Geua D: Research Foundation Web Site 2000 [http Ad- diction //www.arf.org] 2. Cornelius MD, Richardson GA, Day NL, Taylor PM: A comparison of prenatal drinking in two recent samples of adolescents and adults. J Stud Alcohol 1994, 55:412-9 3. Stratton , et al: Alcohol consumption among pregnant and childbearing women. CDC 1997 4. Abel EL: An update of the incidence of FAS: FAS is not an equal oportunity birth defect Neurotoxicol Teratol 1995, 17:437- 5. Abel EL, Kruger M: What really causes FAS? Teratology 1999, 59:4-6 6. Nulman I, Gladstone J, O'Hayon B, Koren G: The effects of alcohol on the fetal brain-the central nervous system tragedy. Hand- book of Developmental Neurotoxicology 1998567-586 7. Little BB, Snell MN, Rosenfeld CR, Gilstrap 3rd LC, Gant NF: Failure to recognize fetal alcohol syndrome in newborn. Am J Dis Child 1990, 144:1142-46 8. Abel EL, Kruger M: What do physicians know and say about fe- tal alcohol syndrome: a survey of obstetricians, pediatricians and family physicians. Alcohol Clin Exp Res. 1998, 22:1951-4 9. Donovan CL: Factors predisposing, enabling and reinforcing screening of patients for preventing fetal alcohol syndrome: a survey of New Jersey physicians. J Drug Edu 1991, 21:35-42 10. Nanson JL, Bolaria R, Snyder Morse B, Weiner LR: Physician awareness of fetal alcohol syndrome: a survey of pediatri- cians and general practitioners. CMAJ 1995, 152:1071-1076 11. Brewster JM, Single EW, Ashley MJ, Chow YC, Skinner HA, Rankin JG: Preventing alcohol problems: a survey of Canadian med- ical schools. CMAJ. 1990, 143:39-45 12. Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML: Alcohol screening questionnaires in women. a critical review. JAMA 1998, 280:166-171 13. Streissguth AP, Barr HM, Kogan J, Bookstein FL: Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome and fetal alcohol effects. Final report. Abstract: Fetal alcohol syndrome conference, Washington DC 1996 Publish with BioMed Central and every scientist can read your work free of charge "BioMedcentral will be the most significant development for disseminating the results of biomedical research in our lifetime." 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