Contraceptive Counseling by General InternalMedicine Faculty and Residents

Rachael R. Dirksen, MD,1 Benjamin Shulman, MS,2 Stephanie B. Teal, MD, MPH,3

and Amy G. Huebschmann, MD4

Abstract

Background: Almost half of US pregnancies are unintended, resulting in many abortions and unwanted ormistimed births. Contraceptive counseling is an effective tool to increase patients’ use of contraception.Methods: Using an online 20-item questionnaire, we evaluated the frequency of contraceptive counselingprovided to reproductive-age women during a prevention-focused visit by University of Colorado internalmedicine resident and faculty providers. We also evaluated factors hypothesized to affect contraceptivecounseling frequency.Results: Although more than 95% of the 146 medicine faculty and resident respondents agreed that contra-ceptive counseling is important, only one-quarter of providers reported providing contraceptive counseling‘‘routinely’’ (defined as ‡ 80% of the time) to reproductive-age women during a prevention-focused visit.Providing contraceptive counseling routinely was strongly associated with taking an abbreviated sexual history‘‘often’’/‘‘routinely’’ (odds ratio [OR] = 11.6 [3.3 to 40.0]) and with high self-efficacy to provide contraceptivecounseling (OR = 6.5 [1.5 to 29.0]). However, fewer than two-thirds of providers reported taking an abbreviatedsexual history ‘‘often’’/‘‘routinely.’’ More than 70% of providers reported inadequate knowledge of contra-ceptive methods as a contraceptive counseling barrier. However, providers’ perceived inadequate knowledgewas not associated with traditional educational exposures, such as lectures and women’s health electives.Conclusions: In prevention-focused visits with reproductive-age women, a minority of internal medicinefaculty and residents reported routine contraceptive counseling. Future efforts to increase contraceptivecounseling among internists should include interventions that increase provider contraceptive counseling self-efficacy and ensure that providers obtain an abbreviated sexual history.

Introduction

Almost half of US pregnancies are unintended, re-sulting in more than one million induced abortions each

year and many unwanted or mistimed births.1,2 Increasing theuse of contraception and decreasing unintended pregnancy isan important public health goal designated in the HealthyPeople 2020 initiatives. Recent evidence demonstrates thatcontraceptive counseling by primary care providers doesincrease patients’ use of contraception at last intercourse.3

Despite our understanding that contraceptive counseling ef-fectively increases patients’ use of contraceptive agents,survey data have shown that fewer than one-quarter of re-

productive-age women report receipt of either contraceptivecounseling or a birth control prescription from a healthcareprovider over a 12-month time period.4 A prior survey spe-cifically evaluating internal medicine residents showed thatresidents infrequently assess the contraceptive needs of theiroutpatients.5 One reason for this is that practical training incontraceptive counseling and family planning is not consis-tently implemented for internists, even though the AmericanBoard of Internal Medicine has designated family planningtraining as a core competency for internal medicine residentssince 1997.6,7 Contraceptive counseling is a vital part of thepatient encounter for primary care providers, but internistsappear particularly less likely to provide contraceptive

1Department of Medicine, Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.2Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado School of Medicine, Aurora,

Colorado.3Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado.4Department of Medicine, Division of General Internal Medicine and Center for Women’s Health Research, University of Colorado

School of Medicine, Aurora, Colorado.

JOURNAL OF WOMEN’S HEALTHVolume 23, Number 8, 2014ª Mary Ann Liebert, Inc.DOI: 10.1089/jwh.2013.4567

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counseling; in part, this may stem from insufficient trainingon the subject.

Other factors previously shown to decrease the frequencyof contraceptive counseling include the medical provider’sperceived lack of knowledge regarding contraceptive meth-ods, the provider’s lack of time to address contraceptionowing to competing medical problems, a lack of routinesexual history taking during clinic visits, provider miscon-ceptions regarding contraception, a low proportion of re-productive-age women in a provider’s practice, and providergender.5,8,9 By understanding better the factors associatedwith the frequency of contraceptive counseling by internalmedicine providers, future interventions may be developed toassist internists in providing comprehensive and safe con-traceptive care to their reproductive-age female patients.

The purpose of this study was to identify the frequency ofcontraceptive counseling provided to reproductive-age wo-men during a prevention-focused visit by University ofColorado internal medicine residents and affiliated outpatientinternist faculty. Also, we sought to identify modifiablefactors that may predict a greater frequency of contraceptivecounseling behavior. We hypothesized that the followingfactors would be associated with a higher frequency of con-traceptive counseling: a higher percentage of reproductive-age women in one’s outpatient practice, a high frequency ofabbreviated sexual history taking, high provider self-efficacyfor contraceptive counseling, high perceived knowledge ofcontraceptive methods, low perceived lack of time, a cultureof origin that does not oppose contraception, no contracep-tion misconception, the presence of plans to pursue an out-patient-based career (residents only), and plans to continueworking in outpatient internal medicine (faculty only). Fi-nally, we assessed the association of provider knowledge ofcontraceptive agents with prior women’s health training inthe form of residency lectures addressing contraceptivecounseling (residents only), continuing medical education(CME) on contraceptive counseling (faculty only), andwomen’s health electives during residency.

Materials and Methods

Study design and participants

We sent an anonymous, 20-item SurveyMonkeyª10 ques-tionnaire by electronic mail to University of Colorado internalmedicine residents and outpatient general internal medicinefaculty in March–April of 2012. Internal medicine clinic sitesincluded two university clinics, three Denver County safety-net clinics, the Veteran’s Affairs Eastern Colorado clinic inDenver, and a private Denver clinic that serves uninsured andunderinsured patients. Exclusion criteria for the study were (1)preliminary residents who complete only a single internshipyear in internal medicine, (2) reporting no reproductive-agewomen in one’s practice, and (3) coinvestigator of the currentstudy. The Colorado Multiple Institutional Review Board ap-proved the study as an exempt protocol. A total of 95 internalmedicine outpatient faculty and 146 internal medicine resi-dents were eligible and invited to participate.

Survey development and measures

With permission of the author, we adapted a previouslypublished survey assessing the frequency and barriers to

contraceptive counseling among internal medicine residents.5

The previously published survey assessed contraceptive coun-seling factors, including sexual history, self-efficacy, outpa-tient medicine career plans, proportion of practice devoted toreproductive-age women, and provider gender. We adaptedthe survey to also assess the prevalence of barriers noted inprior published focus group data and observed by the studyinvestigators (i.e., perceived lack of time, the presence ofcontraception misconceptions, cultural origin that opposescontraception). Separate surveys were created for residents andfaculty, but the only questions that differed between surveysaddressed factors that would vary naturally between studygroups (e.g., postgraduate year for residents, years in clinicalpractice for faculty). The survey was pilot tested by five in-ternal medicine chief residents, who were not participants inthe study, to assess comprehension and responder burden.

The demographics of survey participants were assessedwith regard to age, gender, year in training (residents only),years practicing as attending (faculty only), location of clinic,and plans after residency (residents only) or plans to remainin outpatient internal medicine (faculty only). Study partici-pants were asked to use a four-point Likert scale with verbalanchors to assess how often they address following medicalhistory components during a prevention-focused visit with awoman aged 15–45 years: medications, immunizations, ab-breviated sexual history, contraceptive counseling, seat-beltusage, and preconception counseling (rarely £ 20%, some-times 21–49%, often 50–79%, routinely ‡ 80%). In the sur-vey, we defined abbreviated sexual history taking as askingpatients about such items as ‘‘current sexual activity, numberof partners.’’ We defined contraceptive counseling as bothassessing the ‘‘current contraceptive method’’ and providingcontraceptive counseling ‘‘if needed.’’ Participants also es-timated the proportion of their practice that consisted of re-productive-age women.

Additional survey questions addressed potential factorshypothesized to affect contraceptive counseling based on priorstudies.5,8 These factors included a low prevalence (defined astwo categories of < 10% and < 20%) of reproductive-agewomen in their primary care practice, taking an abbreviatedsexual history ‘‘rarely’’ or ‘‘sometimes’’ (defined as < 50% ofprevention-focused visits with reproductive-age women), in-adequate time to provide contraceptive counseling (defined asan answer of ‘‘strongly agree’’ or ‘‘somewhat agree’’ to thestatement ‘‘I would provide contraceptive counseling to mypatients more often if I had more time during an annualexam’’) and inadequate knowledge to provide contraceptivecounseling (defined as an answer of ‘‘strongly agree’’ or‘‘somewhat agree’’ to the statement ‘‘I would provide con-traceptive counseling to my patients more often if I had moreknowledge regarding contraceptive methods’’).

Other factors hypothesized to affect contraceptive coun-seling frequency included the presence of religious or ethnicculture of origin that opposed contraception, lack of perceivedimportance of contraceptive counseling (defined as an answerof ‘‘somewhat disagree’’ or ‘‘strongly disagree’’ to the state-ment ‘‘It is important for me to know how to discuss differentforms of contraception, including their effectiveness and po-tential adverse effects’’), low self-efficacy (defined as ananswer of ‘‘strongly disagree’’ or ‘‘somewhat disagree’’ to thestatement ‘‘I feel confident assessing my patients’ currentcontraceptive methods and discussing effective alternate

708 DIRKSEN ET AL.

methods when necessary’’), plans to pursue a nonoutpatientposition (residents only) or plans to stop working in outpatientinternal medicine within the next 5 years (faculty only), andcontraception misconception presence (defined as an answer of‘‘strongly disagree’’ or ‘‘somewhat disagree’’ to the statement‘‘I would generally prescribe contraception to a woman who isinterested in contraception, but has not had cervical cancerscreening within the last 3 years’’). At the time of survey cre-ation, the longest appropriate interval between cervical cancerscreening tests was 3 years, based on US Preventive ServicesTask Force (USPSTF) recommendations. Requiring cervicalcancer screening prior to contraception prescription is a knownand documented barrier to obtaining contraception counseling.

The survey was administered in March and April of 2012,and new USPSTF recommendations for potential longer in-tervals (5 years) were released in March 2012. As such, ourresults potentially underestimate the proportion of partici-pants who would withhold contraception if cervical cancerscreening were not up-to-date. Finally, participants answeredquestions regarding prior women’s health educational ex-posures, either through residency lectures on contraceptivecounseling (residents only) or continuing medical educationon contraceptive counseling (faculty only), or a women’shealth elective during their training (all participants).

Statistical analysis

Descriptive statistics of the study outcomes were reviewedto assess for statistical outliers. All study analyses wereperformed using SAS 9.2 (SAS Institute, Cary, NC). Theprimary outcome of self-reported frequency of contraceptivecounseling among faculty and residents was analyzed using achi-square test for association between the reported fre-quency and faculty/resident status.

The relationship between the presence of barriers or fa-cilitators and frequency of contraceptive counseling wasanalyzed using univariate logistic regression models to de-termine the odds ratio (OR) of providing contraceptivecounseling routinely, as compared to often, sometimes, orrarely ( ‡ 80% vs. < 80%) given the presence or absence ofeach factor. Each barrier was analyzed in a separate logisticmodel. We also tested for association between contraceptivecounseling and preconception counseling with Fisher’s exacttest. Finally, chi-square tests were used to test for associationsbetween three educational exposures (lectures, CME, andwomen’s health electives) and reporting adequate knowledgeto provide contraceptive counseling.

We attempted to develop a multivariate model to deter-mine the strength of association of the more significant bar-riers with contraceptive counseling within the same statisticalmodel. However, the frequency of abbreviated sexual historytaking and high self-efficacy was sufficiently collinear withthe frequency of contraceptive counseling that we could notbuild an appropriate multivariate model incorporating thekey contraceptive counseling predictors.

Results

Study population characteristics

Of 95 outpatient internal medicine faculty members con-tacted, 66 (69.5%) responded; of 146 internal medicine resi-dents contacted, 80 (54.8%) responded. The study population

consisted of resident and faculty respondents (n = 146) whoreported caring for women 15–45 years of age in their out-patient clinic.

The medicine resident respondents were almost 60% male,closely approximating the gender breakdown of the residentsin the internal medicine residency program (59% male). One-third of resident respondents were in their first year of post-graduate training, slightly fewer than one-third were in theirsecond year, and slightly more than one-third were in theirthird year of training (Table 1).

Of the faculty members who were analyzed, 47.0% werefemale, which is slightly lower than the percentage of womenamong the outpatient general internal medicine faculty whoreceived the survey (51% female). Approximately half thefaculty respondents were £ 10 years postresidency (Table 1).

Factors affecting frequencyof contraceptive counseling

Almost one-fifth of residents and one-third of faculty re-ported routine contraceptive counseling at prevention-focusedvisits (Table 2). Across all providers, routine contraceptivecounseling rates of 25% were lower than reported routinemedication-reconciliation rates (90%) and routine immuniza-tion-review rates (60%) but higher than routine preconception-counseling rates (7%) or routine seat-belt counseling rates(4%). Although there was not a significant association betweenstatus as faculty or resident and frequency of contraceptivecounseling as a categorical variable ( p = 0.14, Table 2), facultyhad a greater odds of performing routine contraceptive coun-seling than residents (OR 2.3 [1.1 to 4.9], unadjusted OR with95% confidence interval [CI] (Table 3). Potential factors af-fecting contraceptive counseling for all providers were brokendown into potential barriers and facilitators that may affect thefrequency of contraceptive counseling (Table 2). The majorityof faculty and residents reported that they perceive inadequatetime (75.3%) and inadequate knowledge (74.0%) as reasonsfor not performing contraceptive counseling (Table 2). Morethan 95% of all providers reported that it was important to beable to discuss various forms of contraception, including theireffectiveness and potential adverse effects. More than a third ofrespondents reported taking an abbreviated sexual history only‘‘rarely’’ or ‘‘sometimes’’ during a prevention-focused visit.

Table 1. Study Population Demographics

All respondents Residents Faculty

Returned surveyand met surveycriteria

146 (100.0%) 80 (54.8%) 66 (45.2%)

Female 64 (43.8%) 33 (41.3%) 31 (47.0%)PGY1 N/A 26 (32.5%) N/APGY2 21 (26.3%)PGY3 32 (40.0%)Years

postresidencyN/A N/A

0–5 14 (21.2%)6–10 19 (28.8%)11–15 9 (13.6%)> 15 21 (31.8%)

Missing data for these survey questions: < 5%.N/A, not applicable; PGY, post-graduate year.

CONTRACEPTIVE COUNSELING BY INTERNISTS 709

Factors that were significantly associated with greater oddsof providing contraceptive counseling routinely includedfemale gender providers (vs. male), faculty providers (vs.residents), reported taking of a sexual history routinely oroften (vs. sometimes or rarely), reported high self-efficacy forcontraceptive counseling (vs. low self-efficacy), reportedadequate knowledge regarding contraceptive methods, andreported adequate time (Table 3). Residents with outpatientinternal medicine plans were significantly more likely toprovide routine contraceptive counseling than residents withnonoutpatient plans (38% vs. 9%, p = 0.001); however, theOR could not be estimated reliably, because only five resi-dents with nonoutpatient plans provided routine contracep-tive counseling. The association of perceived importance ofcontraceptive counseling and contraceptive counseling fre-quency could also not be estimated, as none of the partici-pants who rated importance as low provided contraceptivecounseling routinely. Preconception counseling in preventivevisits with women of childbearing age was reported by only7% of all respondents, by 27% of respondents who reportedroutine contraceptive counseling, and by 0% of respondentswho did not report routine contraceptive counseling ( p < 0.0001

for association of routine contraceptive counseling and routinepreconception counseling).

A prior women’s health elective was also significantlyassociated, with a 2.5 times greater odds of providing con-traceptive counseling routinely (Table 3). However, therewas not a significant association between provider belief ofhaving inadequate knowledge and educational exposures inthe form of women’s health electives, lectures, or CME incontraceptive counseling (Table 4).

The majority of resident and faculty providers felt that theywould provide contraceptive counseling more often if theyhad more knowledge regarding contraceptive methods. Ofresident participants, 70.0% agreed that they would havepreferred more training in contraceptive methods and coun-seling as part of their internal medicine residency. Of facultyparticipants, 72.7% agreed that they would like more CMEregarding contraceptive methods and counseling.

Discussion

Although we asked University of Colorado internal medi-cine providers about their frequency of provide contraceptive

Table 2. Frequency of Contraceptive Counseling and Assessment

of Potential Factors Affecting Counseling

All respondents Medicine residents Outpatient GIM facultyn (%) n (%) n (%) p-value

Frequency of contraceptive counselingRoutinely ( ‡ 80%) 37 (25.3%) 15 (18.8%) 22 (33.3%) 0.1430Often (50%–79%) 48 (32.9%) 27 (33.8%) 21 (31.8%)Sometimes (21%–49%) 43 (29.5%) 28 (35.0%) 15 (22.7%)Rarely ( £ 20%) 14 (9.6%) 9 (11.3%) 5 (7.6%)

Potential barriersPerceived inadequate time 110 (75.3%) 68 (85.0%) 42 (63.6%) 0.0029Perceived inadequate knowledge 108 (74.0%) 66 (82.5%) 42 (63.6%) 0.0097< 20% of practice are women 15–45

years of age102 (69.9%) 57 (71.3%) 45 (68.2%) 0.6876

< 10% of practice are women 15–45years of age

42 (28.8%) 20 (25.0%) 22 (33.3%) 0.2683

Obtain sexual history < 50% 56 (38.4%) 29 (36.3%) 27 (40.9%) 0.5645Presence of contraception

misconception46 (31.5%) 25 (31.3%) 21 (31.8%) 0.9414

Low self-efficacy 31 (21.2%) 21 (26.3%) 10 (15.2%) 0.1027Presence of religious or ethnic culture

of origin that opposes at least oneform of contraception

15 (10.3%) 12 (15.0%) 3 (4.6%) 0.0641

Plans as nonoutpatient (hospitalist,subspecialty, other) (residents only)

N/A 56 (70.0%) N/A N/A

Plan to stop working in outpatient inthe next 5 years (faculty only)

N/A N/A 2 (3.0%) N/A

Low perceived importance 5 (3.4%) 3 (3.8%) 2 (3.0%) 1.000a

Potential facilitatorsPrior women’s health elective (faculty

and residents)34 (23.3%) 10 (12.5%) 24 (36.4%) 0.0010

Contraceptive-related CME in the past5 years (faculty)

N/A N/A 21 (31.8%) N/A

Prior contraceptive counseling lecture(residents only)

N/A 63 (78.8%) N/A N/A

aFisher’s exact test used to calculate this p-value, owing to small cell sizes; all other p-values calculated with chi-square test forassociation.

CME, continuing medical education; GIM, general internal medicine.

710 DIRKSEN ET AL.

counseling in a fairly ideal circumstance—a prevention-focused visit for a woman of reproductive age—only 33.3% offaculty and 18.8% of residents reported providing contracep-tive counseling routinely ( ‡ 80% of the time). In contrast to thelow rates of counseling observed, more than 95% of respon-dents agreed that contraceptive counseling is important. Thesefindings suggest that overcoming barriers to contraceptivecounseling is important to increase contraceptive counselingfrequency among internal medicine providers. High self-effi-cacy for contraceptive counseling and taking an abbreviatedsexual history routinely were strongly associated with routinecontraceptive counseling in our study population, suggestingthat these are likely facilitators of contraceptive counseling forinternists. We also observed other modifiable barriers to rou-tine contraceptive counseling, including inadequate providerknowledge for contraceptive counseling and the misconcep-tion that cervical cancer screening must be up-to-date to pre-scribe contraception.

Our finding that 18.8% of internal medicine residents rou-tinely provide contraceptive counseling was consistent with aprior study that reported 17% of internal medicine residentsroutinely provide contraceptive counseling.5 Similar to ourfindings, Lohr et al. also found a strong association betweenroutine sexual history taking and routinely providing contra-ceptive counseling (OR 6.1, 95% CI 2.38–15.49).5 Lack oftime was noted as a barrier to contraceptive counseling in bothour study and two other qualitative focus group studies.8,11

Akers et al. also found that providers felt that they had inad-equate knowledge regarding contraceptive methods.8

Our study is the first, to our knowledge, to look at theassociation of contraceptive counseling by faculty vs. resi-dent status. Our finding that only one-third of outpatient in-ternist faculty provide routine contraceptive counselingsuggests that medicine faculty are not consistently modelingcontraceptive counseling behavior for residents.

More than 95% of faculty and resident internal medicinerespondents reported that contraceptive counseling is

Table 3. Association of Hypothesized Factors with

the Provision of Routine Contraceptive Counseling

ORaLower

CIUpper

CI p-value

Study population characteristicsFemale vs. male 4.3 1.9 9.8 0.0004Faculty vs. resident 2.3 1.1 4.9 0.0337

Absence of potential barriersPerceived adequate time

vs. inadequate time3.1 1.3 7.2 0.0090

Perceived adequateknowledge vs.inadequate knowledge

3.9 1.7 8.9 0.0015

‡ 20% of practicedevoted to women vs.< 20%

2.4 1.1 5.4 0.0271

‡ 10% of practicedevoted to women vs.< 10%

1.0 0.4 2.2 0.8937

Routinely/often takesexual history vs. not

11.6 3.3 40.0 0.0001

Misconception absentvs. present

1.5 0.6 3.3 0.3802

Self-efficacy (high vs. low) 6.5 1.5 29.0 0.0135Religious or ethnic

culture that opposescontraception absentvs. present

1.0 0.3 3.3 0.9823

Plans to work inoutpatient setting(residents only) vs.nonoutpatient setting

N/Ab N/A

Plans to continueworking in outpatientsetting for at least thenext 5 years (facultyonly) vs. not

N/Ac N/A

Perceived importance(dichotomize highvs. low)

N/Ad N/A

Potential facilitatorsPrior women’s health

elective (faculty andresidents) yes vs. no

2.5 1.1 5.8 0.0276

Contraceptive-relatedCME in the past 5years (faculty only)yes vs. no

1.6 0.5 4.6 0.4248

Prior contraceptivecounseling lectures(residents only) yesvs. no

N/Ae N/A

aOR of providing contraceptive counseling routinely, as com-pared to often, sometimes, or never ( ‡ 80% vs. < 80%).

bOR estimate not reliable: £ 5 residents with nonoutpatient plansreported routine counseling ( ‡ 80% of preventive visits).

cOR not estimable: Only two faculty were not planning to continuepractice in an outpatient setting.

dOR not estimable: 0 providers who do not perceive contraceptivecounseling as important (out of 4) reported routine counseling ( ‡ 80%of preventive visits).

eOR estimate not reliable: < 5 participants with no prior contra-ceptive counseling lectures provided routine counseling ( ‡ 80% ofpreventive visits).

CI, confidence interval; OR, odds ratio.

Table 4. Association Between Educational

Exposures and Reporting Inadequate Knowledge

About Contraceptive Counseling

Inadequateknowledge

Total n n (%) p-valuea

Residents who hadcontraceptive counselinglectures

63 53 (84.1%) 0.78

Residents who did nothave contraceptivecounseling lectures

16 13 (81.3%)

Faculty who had CMEregarding contraception

21 12 (57.1%) 0.26

Faculty who did not haveCME regardingcontraception

42 30 (71.4%)

Women’s health electivecompleted

34 26 (76.5%) 0.95

Women’s health electivenot completed

108 82 (75.9%)

aChi-square test for association between educational exposure andreporting inadequate knowledge.

CONTRACEPTIVE COUNSELING BY INTERNISTS 711

important, but only 73.7% of residents and 84.8% of facultyreport high self-efficacy, showing a gap between perceivedimportance and confidence to deliver counseling. In addition,82.5% of residents and 63.6% of faculty reported inadequatecontraceptive knowledge, and improved knowledge is relatedto improved self-efficacy for most behaviors.12

Because the frequency of taking an abbreviated sexualhistory was strongly associated with contraceptive counselingfrequency, an important area to evaluate is simultaneouslytraining internal medicine providers to increase their self-efficacy for performing abbreviated sexual histories and de-livering contraceptive counseling. This is particularly relevantbecause prior studies have shown that internal medicine pro-viders are not routinely taking a sexual history as part of pre-vention-focused visits13 and are less likely to take a sexualhistory than pediatricians or obstetricians and gynecologists.14

In taking abbreviated sexual histories, we can identify patientsin need of contraceptive counseling or preconception coun-seling. In doing so, women may avoid unintended pregnancies,or women who are ambivalent or intend to become pregnantcan make necessary plans, such as starting prenatal vitaminsand stopping any teratogenic medications.

Our findings should also be considered in the context ofrecent healthcare policy changes. The Affordable Care Actmandated that women’s preventive health visits must be of-fered to all health plan enrollees without individual copaymentand should include the following contraception-related mea-sures for reproductive-age women: preconception counseling,contraceptive counseling, and counseling regarding all FDA-approved contraception methods.15 Adherence to this mandatewould allow internist and other primary care providers to ap-propriately identify patients at risk for unintended pregnancyand to discuss appropriate short-term and long-term contra-ceptive methods. If these Affordable Care Act mandatestranslate into a quality reporting system that requires primarycare providers to report on how well they are meeting qualityreporting measures, such as contraceptive counseling for pre-ventive women’s health visits, it would incentivize internistsand other primary care providers to provide and documentpreconception and contraceptive counseling. However, at thetime of this publication, there were not yet any MedicarePhysician Quality Reporting System (PQRS) measures withregard to preconception or contraceptive counseling.

We found a strikingly low rate of preconception counselingin preventive visits with women of reproductive age: Only 7%of providers reported routinely performing preconceptioncounseling. Women of reproductive age seen by internists maybe more likely to be on teratogenic medications or have healthconditions that could be worsened by pregnancy.16 The In-stitute of Medicine rejected listing preconception counselingas a separately reimbursable service through the AffordableCare Act, contending that it was already an integral part of thewell-woman visit. Among our respondents, preconceptioncounseling was not routinely included in preventive visits forwomen of reproductive age, suggesting a need for futurestudies to address the provider, practice, and policy-levelfactors related to this important omission.

Increasing self-efficacy for contraceptive counseling ap-pears to be another likely method to increase contraceptivecounseling among internists. One way to improve residentself-efficacy in both abbreviated sexual history taking andcontraceptive counseling is through faculty guidance and

experience. However, only one-third of faculty reported de-livering contraceptive counseling routinely in this study, soresidents need other sources of guidance as well. Residentsmay get some exposure to contraceptive counseling throughlectures and women’s health electives, but we did not find asignificant association between these educational exposuresand contraceptive counseling knowledge, although a wom-en’s health elective was significantly associated with greaterfrequency of routine contraceptive counseling provision. Inour study population, women’s health electives were requiredfor participants of the primary care track; specific women’shealth training may be one reason that residents with outpa-tient plans outperformed residents with nonoutpatient planswith regard to routine contraceptive counseling provision.

To confirm whether mandating women’s health electiveswould impact routine contraceptive counseling rates wouldrequire assessing changes in contraceptive counseling rates ina randomized controlled trial across institutions or before/after a ‘‘natural experiment’’ of implementing mandatorywomen’s health electives for internal medicine residents in asingle institution. Other interventions to build providers’ self-efficacy to provide contraceptive counseling may includeguided practice exercises, through virtual computer-basedscenarios or in clinical training environments, as guidedpractice is known to build self-efficacy.13,17 Given the lowrates of preconception counseling we observed, future in-terventions to improve contraceptive counseling should alsoaddress preconception counseling. Finally, not all internalmedicine providers need to be experts in contraceptivemanagement, and an important strategy may be to develop an‘‘ask, advise, and refer’’ strategy18 so providers may referpatients to knowledgeable providers within the practice orwithin the women’s health community when needed.19

A strength of this study is the assessment of both faculty andresident internal medicine provider counseling practices. Aweakness of this study is that our respondents were affiliatedwith a single institution, thus reducing the external validity ofour findings. To mitigate this weakness, we surveyed providersfrom seven distinct internal medicine clinics affiliated with ourinstitution, including academic clinics, safety-net clinics, aVeteran’s Affairs clinic, and a nonprofit privately funded clinic.

Another possible weakness is that a social-desirability biascould have led providers to overreport their counseling fre-quency and self-efficacy; if this occurred, our results wouldoverestimate actual contraceptive counseling practices. An-other limitation of this study is that the results are based onprovider self-report, which may be different from actual pro-vider behavior, owing to social-desirability response bias.Thus, a potential future direction would be to assess associa-tions of provider, patient, and system-level predictors of con-traceptive counseling with objective measures of contraceptivecounseling, such as chart review, or direct observation ofclinical encounters via recording device or an observer. Al-though patient-response bias may also be an issue, patientsurveys to assess provider contraceptive counseling behaviorcould be used to avoid provider response bias.

Conclusions

Our key findings are that internists underutilize contracep-tive counseling and that taking an abbreviated sexual historyroutinely and high self-efficacy for providing contraceptive

712 DIRKSEN ET AL.

counseling are likely predictors of contraceptive counseling.We did not find that traditional contraceptive counselingeducational exposures, such as lectures and CME, were sig-nificantly associated with medicine providers’ perceivedknowledge in contraceptive methods. Therefore, we need todesign and test methods to improve self-efficacy for abbrevi-ated sexual history taking and contraceptive counseling amonginternists to determine optimal approaches.

One way this could occur is for women’s health and generalinternal medicine researchers to codevelop and test improvedcontraceptive counseling education methods. In addition todeveloping enhanced contraceptive counseling education, itwill also likely be helpful to develop methods for medicineproviders with lower contraceptive counseling self-efficacy toask, advise, and refer patients for contraceptive counseling towomen’s health colleagues, similar to methods used to im-prove smoking-cessation counseling in primary care set-tings.20 Because many internal medicine providers do notobtain abbreviated sexual histories routinely, it is important forinternal medicine providers and health systems to improvestandard medical history forms to include an abbreviatedsexual history among other women’s health-related questions.

Specifically, we propose that it would be beneficial to en-hance office systems to use unobtrusive methods (e.g., paperforms, online data entry) to inquire about sexual history, con-traceptive method history, and other women’s health-relatedhistory so these data are systematically collected for providersto review efficiently. Overall, we need to develop and testinnovative strategies to increase contraceptive counseling byinternists to ensure that all primary care providers give womenthe necessary tools to manage their reproductive health.

Acknowledgments

Amy G. Huebschmann is supported by NIH/NCATSColorado CTSI Grant Number KL2 TR000156. Contents arethe author’s sole responsibility and do not necessarily rep-resent official National Institutes of Health views.

Contributors were Research Consulting Lab, ColoradoBiostatistics Consortium, University of Colorado, and Col-orado Clinical & Translational Sciences Institute.

Author Disclosure Statement

No competing financial interests exist.

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Address correspondence to:Rachael R. Dirksen, MD

Division of General Internal MedicineUniversity of Iowa Health Care

105 9th StreetCoralville, IA 52241

E-mail: rachael-dirksen@uiowa.edu

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