Wah-Yun Low¹, Chirk-Jenn Ng², Ngiap-Chuan Tan³, Wan-Yuen Choo¹, Hui-Meng Tan⁴

The issue of erectile dysfunction (ED) provides a paradoxical situation to both the patients and physicians. A study of healthcare needs in the general population had indicated that only a small proportion of patients wanting professional help for sexual problems actually received it [1]. Many doctors preferred to initiate discussion on sexual issues related to their medical condition [2]. For those who sought treatment, there was a delay of about one year between the onset and presentation of the complaint by ED patients to the GPs. Although physicians are the most frequently consulted professionals for sexual problems, it has been suggested that they are often ill prepared to handle these problems [3]. The authors had found that almost two third of the sampled GPs had cited lack of time or lack of competence as reasons for not actively interrogating a patient when an erection problem was suspected [4]. Similar findings were found in a local study, where the constraints identified by GPs in dealing with sexual problems, including time constraints, lack of training and knowledge on sexual problems, being the opposite sex to their patients and the fear of offending patients [5].

However, the issue of diagnosis and treatment of erectile dysfunction involved a complex interplay of factors. Doctor's prescribing behavior can be influenced by the doctor themselves, the patient, the drug, the doctor-patient relationship, as well as the effects of academic detailing, advertising, financial incentives and disincentives to all parties involved [6]. The different levels of understanding and expectations between the patients and the health care providers and other factors revolved around the issue of ED had lead to a delay of proper diagnosis and treatment. With this purview, this study was conducted to identify and explore barriers that GPs faced when they managed patients with ED.

This study was conducted based on 28 GPs practising in Klang Valley, an urban area in Malaysia. Participants were recruited via convenient sampling on a voluntary basis. The inclusion criterion for participants was that they must have managed patients with ED and have prescribed some forms of anti-impotence drugs. The GPs were selected from a list of private clinics in the Valley. Invitation letters clearly stating the objectives of the study were sent to them. Follow-up calls were made to the GPs to confirm their participation.

The study utilized focus group discussions (FGD) and in-depth interviews (IDI) to capture information on GPs' prescribing behaviour and practices. FGD and IDI are among the most widely used research tools to examine people's experiences of the disease and health services. A focus group takes advantage of the interaction between a small group of people with the presence of the moderator and note-taker [7].

A total of seven FGDs and two IDIs were conducted based on a semi-structured focus group discussion guide (Appendix). The guide covered GPs' experiences in the management of ED, focusing on the barriers encountered during such consultations. All FGDs were conducted by the first two authors (LOW and NG) in English at the University Malaya Medical Center, Kuala Lumpur. The objectives of the session were explained to the GPs and confidentiality of their identities was ensured. Consent and basic socio-demographic data were obtained from each GP. The FGDs and IDIs were audio-taped with permission and detailed notes were taken during the session.

The tape-recorded interviews were transcribed in full and the analysis was based on these typed transcripts. The transcripts were read and checked independently by the researchers to ensure consistencies. Content analysis technique was used to analyze the data by identifying broad themes first. Content analysis is a research method, which allows valid inference to be made from the text by extracting patterns of themes in the data [8]. The data was then subjected to detailed investigation by selecting and reorganizing responses according to the themes. These was performed using a qualitative data management software NUD*IST Version 6.0TM [9]. Quotes included in the results were typical views expressed by the GPs and they were used to exemplify the emergent themes.

The socio-demographic background of the GPs and characteristics of their clinical practices are shown in Table 1. The study showed that there were inherent problems that GPs encountered when treating patients with ED. The barriers identified from the interviews could be organized into four main themes: doctors, patients, drug and others issues, such as over the counter sales and bulk purchase of drug imposed by the manufacturer.

The GP's perception of ED as 'less important disease' was a major barrier in the treatment of ED, while others were more conservative in their approach towards treating ED. For example, one GP quoted that "I probably would agree with you in that sense that it is not as important as a lot of other more serious diseases like diabetes or hypertension. I suppose some people will even say it's a lifestyle kind of thing."

The gender, particularly being a female doctor, and the age (being younger than the patients) of the GPs could be a hindrance in prescribing an anti-impotence drug, although it could be overcome by appropriate training. The lack of time in a busy clinic also made treatment of ED difficult "...being so busy, and when you touch on this type of topic, it actually takes a lot of time there."

Some GPs felt that the lack of training made them uncomfortable in treating patients with ED. One GP commented, "when we were medical students, treatment of impotence is not very much in the medical curriculum". However, with the launch of Viagra and increasing number of continuing medical education on ED, the GPs were more comfortable in treating ED as they became more familiar with this condition. Knowing that specialists (for example, urologists) using a specific drug gave the confidence to general practitioners in prescribing an anti-impotence drug. For example, "...I think once we had a urologist came in and that helps to build confidence in treating (ED)...Along the way, we also learn that it's OK, it's safe". However, some GPs pointed out that despite adequate training, they still felt incompetent in treating patients with ED because they did not see enough such patients in their practice.

Some GPs faced problem in differentiating the causes of ED, especially between the psychosocial and organic etiologies. Some would end up treating them empirically as an organic illness first "...so we just give (referring to Viagra), assuming that everybody that has this problem is basically physical".

However, as one GP mentioned, to overcome these barriers, the first step is to "get them to open up" and start discussing about their sexual problems "...I think the barrier is to try starting the conversation, breaking the ice and getting them to open up. Once this is done, it's not that difficult". Sometimes the GPs were pressured to prescribe because of patients?help-seeking behavior. Patients tend to doctor-hop and some GPs might feel compelled to satisfy them to keep their clients.

The attitudes and background characteristics of the GPs were associated with their prescribing behaviour. The GPs in this study felt that ED was not a serious medical condition and was a less important condition affecting their prescribing practice. Many viewed ED as a lifestyle problem. Thus, they assumed a passive role when diagnosing and managing ED. They would only discuss if patients brought up the topic. This coincided with another study, which found that generally physicians were hesitant about initiating a discussion about sexual problems [10]. However, GPs reported having more consultations about sexual concerns since the launch of sildenafil. Therefore, the availability of sildenafil and media publicity could have motivated patients suffering from sexual problems to seek treatment from their GPs. In our study, the physicians showed some degree of reluctance and lack of enthusiasm to address the issues of ED in their practice. Other characteristics, like doctor's age, gender, short consultation time and lack of experience were cited as barriers. These findings were consistent with one local study that found doctors of younger age and of female gender were less likely to take sexual histories of patients or treat patients with sexual problems [5]. Further education about this sensitive topic is warranted to modify the current attitudes of the GPs. It is imperative that doctors should be comfortable, well informed and properly trained in the area of sexual medicine, which seems to be lacking in the local medical curriculum [11]. The lack of training in sexual health means that doctors may be ill prepared for this branch of medicine and often, health professionals claim that they are inadequately trained to provide services to help the patients in this area [12].

GPs also faced difficulty when managing patients with ED due to the uncertainty in determining the underlying etiology. This was further complicated by the patients' refusal to undergo proper assessment. Perhaps, improving doctors' lack of knowledge on its etiology could help doctors in its diagnosis and subsequently in treating ED. Patients' coexisting medical conditions, older age, and lower socio-economic status were all perceived as barriers to treatment of ED. Their unrealistic expectation and improper use of the anti-impotence drug also made treating ED difficult. Patients were also found to be embarrassed in bringing up the topic on sexual matters with their doctors. Cultural factors, expectations and preferences of the patients and their partners, as well as communication between the patient and the physician also played a role in the diagnosis and treatment of erectile dysfunction [13-15]. Doctors concerned about the side effects of the drug, which could be overcome by selecting suitable patients for treatment. For example, patients with cardiovascular diseases who were not taking nitrates should not be deprived of the benefits of sildenafil. This barrier could be attributed to the lack of knowledge among doctors. As to its high cost, some GPs had resorted to parallel import to overcome it. Due to the method of recruitment of this study, there is a possibility that GPs who were more open-minded toward sexual problems were more likely to participate in our study. The results of our study may not reflect the general attitudes of those GPs practicing in the less developed and rural areas, as only doctors from urban practices were included. In conclusion, continuing medical education in the area of sexual health is needed to enhance one's knowledge and training and subsequently a better care for patients suffering from ED.

The authors expressed their gratitude to the GPs who participated in this study. This project is funded via an educational grant by the Asia-Pacific Society for Impotence Research (APSIR), GlaxoSmithKline Pharmaceutical (Malaysia) and Bayer Healthcare (Malaysia).