Clinical inertia in sexual medicine practice

Abstract

Clinical inertia (CI) is common in clinical practice. Sexual health issues are common in society, and CI is ubiquitous in sexual medicine practice. CI influences all aspects of healthcare, including prevention, diagnosis, and treatment. In this short review, we briefly describe the various aspects of CI in sexual medicine practice and ways to tackle them

Key Words: Clinical inertia; Sexual medicine; Sexual dysfunction; Erectile dysfunction; Vaginismus

Core Tip: Clinical inertia (CI) occurs in various disease conditions and is very common in sexual medicine practices. It exists in all stages of healthcare such as prevention, diagnosis, and management. Various factors contributing to CI can be divided into physician or provider-, patient-, and system-related factors. It results in improper evaluation and treatment. Tackling CI helps to improve patient outcomes.

INTRODUCTION

Clinical inertia (CI) denotes the physician’s tendency to remain unchanged in the preventive, diagnostic, and or therapeutic aspects even when the changes are warranted[1]. CI occurs in various disease conditions, including both symptomatic and asymptomatic, acute and chronic[1,2]. In simple words, it is the ‘recognition of the problem, but failure to act’.

CI is very common in sexual medicine practices. In comparison with other diseases such as diabetes, hypertension, dyslipidemia, and rheumatoid arthritis where CI is well documented, there is significant delay in diagnosing and treating various sexual health issues, because of the stigma associated with sexual health problems, in addition to other usual causes of CI, which discourage people from seeking medical help[3-7]. CI exists in all stages of healthcare such as prevention, diagnosis, and management, and they are no well-demarcated compartments as there is overlap between all these types of inertia (Figure 1A). They are related to one another. For example, if there is diagnostic inertia, it will subsequently lead to a delay in the initiation of treatment (i.e. therapeutic inertia).

Figure 1 Interrelated and overlapping factors. A: Preventive, diagnostic, and therapeutic aspects of clinical inertia, which are interrelated and overlapping; B: Interrelated and overlapping factors in clinical inertia.

PREVENTIVE INERTIA

Inertia in preventing the development and progression of sexual dysfunction (SD) constitutes preventive inertia. It can be at any stage of prevention such as primordial prevention, primary prevention, secondary prevention, tertiary prevention, or quaternary prevention. The classical example of preventive inertia is erectile dysfunction (ED) due to atherosclerotic vascular disease, whereas the delay in preventing the development of lifestyle diseases such as obesity, diabetes, hypertension, and dyslipidemia (primordial prevention) and the delay in early diagnosis, treatment (primary prevention), and prevention of progression (secondary prevention) and complication (tertiary prevention) of these lifestyle disorders in those who already have it constitutes preventive inertia in the development of ED. Stages of prevention vary with the disease under consideration. In those with diabetes-related vascular ED, steps related to primary and secondary prevention of DM can be an example of primordial prevention of vascular ED. Usually, primordial prevention targets the community, whereas other stages of prevention target the individual. Hence, CI can be at the community or individual levels (Table 1). Childhood sexual trauma and sexual abuse can lead to vaginismus in women. Social and legal strategies to prevent childhood sexual abuse help to prevent the development of vaginismus. Our inertia in properly implementing these can lead to the development of various SD associated with childhood sexual trauma. This is an example of inertia at the community level in preventing SD.

Table 1 Overview of clinical inertia in sexual medicine practice.

CI at the population level
Primordial prevention
CI to follow a healthy lifestyle (e.g., eating habits and physical activity to reduce the development of risk factors). Inertia in preventing sexual abuse in society
CI at the patient level
Primary prevention
CI in identifying and intervening susceptible individuals (e.g., identifying people with diabetes with risk of ED at the earlier stage and intervening)
Secondary prevention
CI in identifying and intervening those with subclinical disease (e.g., identifying people with diabetes with early ED at the earlier stage and intervening)
CI in identifying and intervening those with the clinical disease (e.g., identifying people with diabetes with established ED and intervening)
Tertiary prevention
CI in appropriately treating those with clinical disease (e.g., identifying people with diabetes with established ED and intervening)
Quaternary prevention
CI in appropriately down-titrating the dose of medication in those with the clinical disease who do not require (overmedication) (e.g., identifying people with established ED on multiple medications for ED, which are ineffective in that particular patient and intervening by stopping ineffective medications)
Quinary prevention
CI in identifying and intervening misinformation/misconception regarding the clinical disease. CI in identifying and correcting misconceptions such as “there is no treatment for sexual problems” and “ED is a part of aging”

CI: Clinical inertia; ED: Erectile dysfunction.

DIAGNOSTIC INERTIA

Diagnostic inertia is very common in sexual medicine practice. People with SD are reluctant to disclose their sexual problems because of the associated stigma, and even if they disclose, they use vague terminologies to express their sexual health issues. For example, people with ED may say that they are feeling excessive tiredness or have weakness denoting ED, which may be difficult to recognize especially in a busy outpatient department, leading to delays in diagnosing ED. Similarly, even if the patient says that he has ED, the healthcare provider most of the time prescribes some multivitamins without properly paying attention and without proper evaluation of SD. Time constraints in busy out-patient departments (OPDs), stigma associated with sexual health issues, hesitation to discuss sexual problems, and lack of experience in the evaluation and treatment of SD are a few reasons behind this attitude[7].

THERAPEUTIC INERTIA

Inertia in initiating treatment of sexual health issues is widespread in day-to-day clinical practice. Clinicians are reluctant to discuss sexual health issues most of the time with the patient, even if the patient discloses their sexual problems, leading to barriers in the evaluation and specific management of sexual problems[7]. Healthcare providers usually buy time by prescribing multivitamins, antioxidants, or other placebos instead of doing a proper evaluation and starting specific treatment for SD (Figure 2).

Figure 2 Clinical inertia at various stages of sexual medicine practice.

Even after diagnosing underlying SD, specific therapy is often delayed especially due to multiple reasons such as time constraints, lack of training in sexual medicine, and lack of confidence to manage SD. Patients on polypharmacy receive delayed treatment for their SD because of the fear of aggravating the underlying disease and drug interaction. In people with ED and coronary artery disease (CAD) or heart failure, treatment of ED is often delayed. In patients with ED who fail to respond to phosphodiesterase inhibitors, there is a significant delay in initiating other treatments such as intracavernosal injections and penile prosthesis implantation.

INERTIA IN ADDRESSING CO-MORBIDITIES AND COMPLICATIONS

Associated co-morbidities and complications need to be properly addressed for optimal benefits in sexual medicine practice, as with any other branch of medicine. ED is considered a forerunner of future cardiovascular events, as people with atherosclerotic ED develop cardiovascular events 3 years to 5 years after the onset of ED[8,9]. Hence, treating ED without addressing the cardiovascular risk factors is a classic example of inertia in addressing the associated co-morbidities and complications. Similarly, females with diabetes and genital infection resulting in dyspareunia need optimal control of diabetes and other risk factors in addition to treatment of genital infection, for optimum results[10].

SPECIAL ISSUES IN SEMANTIC DEMENTIA PRACTICE

Sexual medicine is an evolving discipline and still, not a separate specialty to address sexual health issues under one roof. People approach different specialists such as psychiatrists, gynecologists, urologists, physicians, and endocrinologists[11]. They are all experts in their field but may not be in other dimensions of SD. Therefore, comprehensive training in sexual medicine, even from the undergraduate level, is the need of the hour[7,12,13].

Training in communication skills during the medical curriculum is important for proper sexual history taking and further evaluation[14]. It improves the level of comfort of healthcare providers.

Sex preference by the patient is another issue in dealing with sexual health issues[15]. Female patients usually prefer female healthcare providers, which is why most females initially consult an obstetrician and gynecologist for their sexual issues.

Taboos related to sexual matters; feeling uncomfortable, embarrassed, or anxious about discussing sexual health problems; beliefs and attitudes toward sexual health; cultural restrictions; and religious prohibitions add to CI in sexual medicine practice[7,16,17]. Lack of education about sexual health issues, lack of training programs, and lack of time in the busy OPD add to delays in the proper evaluation of SD, leading to CI[7,17-19].

Some people believe that SD is due to the normal aging process and hence do not seek medical help[7,20]. Patient’s age, culture, sexual orientation, and comorbidities also influence their treatment-seeking behavior. Lack of guidelines regarding sexual assessment and management, lack of specialized referral clinics, lack of support from the institutions, lack of privacy, and work overload are important organizational barriers resulting in CI[21].

There are many sexual problems that interfere with a normal healthy life and relationships but are not described in the current nosography, which also cause limitations in diagnosing and managing SD. One study among males with SD classified such issues as “unmet needs” which included: (1) Lower penile rigidity; (2) Prolonged refractory period; (3) Increased threshold to stimuli; (4) Decreased frequency of spontaneous erections; (5) Delayed orgasm in the female partner; (6) Soft glans; (7) Perceived ejaculate volume reduction; and (8) Decreased force of ejaculation[22].

FACTORS CONTRIBUTING TO CI

Factors contributing to CI can be divided into physician or provider-related, patient-related, and system-related factors, also known as physician inertia, patient inertia, and system inertia, respectively. The stigma associated with sexual health issues, embarrassment, and discomfort in discussing sexual matters leads to delay (from the patient side, approaching healthcare provider) in seeking medical help. Even if the patient discloses their sexual health issues, healthcare providers are reluctant to explore the problem leading to delays in proper evaluation and treatment[7]. Healthcare providers are also embarrassed to discuss sexual issues, fearing that asking about sexual health issues may lead to the loss of patients from their practice[7]. In addition, a lack of proper training about sexual health issues in the medical curriculum adds to the lack of confidence in dealing with sexual health issues. Busy OPD and lack of time are other important factors contributing to physician-related CI. Lack of support, lack of availability of the multidisciplinary team and referral for specialist care, provider’s ability to make appropriate care, and ambiguity in the existing guidelines also contribute to CI[6]. Patient characteristics such as patients with other comorbid diseases like CAD, heart failure, patients on polypharmacy, quality of the relation between patient and healthcare provider, concern about adverse reaction or drug interaction, health literacy, socioeconomic status of the patient, and their affordability all contribute to physician's decision to evaluate and treat sexual health issues. Patient attitudes and preferences, and lack of communication between patient and physician also influence therapeutic decision making. Non-adherence to treatment is an important factor that interferes with the physician’s assessment of treatment response leading to undue delay in optimizing treatment[23]. System-related factors such as time concerns, inconsistencies between guidelines, poor planning, communication and coordination between members of the healthcare team, resource constraints, lack of team approach to care, and lack of decision support system contribute to CI[6] (Figure 3). Various factors such as physician or provider-, patient-, and system-related factors are not isolated compartments but are interrelated and overlapping (Figure 1B).

Figure 3 Physician-, patient-, and system-related factors contributing to clinical inertia in sexual medicine practice. OPD: Out-patient department.

HOW TO TACKLE CI SEXUAL MEDICINE PRACTICE

CI results in improper evaluation and treatment leading to failure to achieve treatment targets, poor control of the disease process, and increased risk of disease-associated complications (Figure 4). Improving awareness regarding CI among physicians, ongoing medical education and training programs, coordination between primary, secondary, and tertiary care, adapting current practice guidelines, self-examination of performance by healthcare professionals, use of computer-based decision support system, and patient education programs and improved communication helps to avoid CI[6]. In addition to that increased direct patient contact time, improvement in the system infrastructure, multi-disciplinary team approach help to tackle CI. A few special factors need to be considered regarding sexual medicine practice. Improving awareness regarding sexual problems in the public, educating the importance of treatment of sexual problems, and training regarding the management of sexual health problems to healthcare professionals, and ensuring privacy for patients with sexual health issues all help to overcome CI[24].

Figure 4 Impact of clinical inertia.

CONCLUSION

CI delays or even denies the best available treatment for the needy patient. CI exists in all aspects of sexual medicine practice. Identifying the factors contributing to CI and tackling it helps to improve patient outcomes.