The present study shows that the majority of physicians who answered to the questionnaire on QoL are aware of its usefulness in clinical management. More than 80% of participants would like to use QoL in their daily clinical practice but only one third of the physicians who participated to the survey know QoL measures. To our knowledge, this is the first survey that on physicians of different specialities of a tertiary level academic hospital to evaluate their knowledge and perception of QoL.
Indeed, little is known about physicians' attitudes towards QoL and rate of physicians adopting QoL measures in clinical practice. An Italian study exploring the knowledge of hospital physicians on QoL assessment revealed that 62% had some knowledge of QoL assessment in oncology but that most tended to rely on a physician-base assessment rather than patient-based instruments . In 1998, a survey of family physicians reported that for 78% of them it was possible to measure QoL, that 89% believed that QoL issue should be discussed with patients and that 89% would use a validated QoL measure if one were devised . Meanwhile, Bezjak et al  collected information from a group of oncologists of a large Canadian cancer care centre on their perspectives on QoL and QoL information, through a self-administered questionnaire containing 75 items with a 4-point Likert categorical response scale. Of 67 eligible respondents, 54 replied. A total of 87% felt that published QoL data are useful for individual patient care, but 69% indicated that, at present, they would be more likely to base their recommendations on personal experience rather than on published literature and 57% felt that decisions were made more difficult when QoL issues were considered. Padua et al  conducted a fact-finding study among Italian neurologists to evaluate the degree of knowledge in the QoL field. Most responders indicated that it would be important either to increase knowledge of the real impact of a disease on a patient's QoL or to better evaluate the effects of therapy. More recently, Skevington et al.  approached 800 general practitioners in UK through the national postal system to find out if they used quality of life information in primary care, to explore their reasoning and to assess any barriers to use. Two hundred eighty physicians (38%) provided qualitative and quantitative information. The majority said that QoL was interesting and important. Users had seen more information and scales, and were more aware of their use; only 8% had ever used formal standardised questionnaires. The main barriers to implementation were a shortage of time and information, and experience with QoL assessment. A sizable minority wanted to know more. Seventy-one percent would use QoL to monitor treatment effectiveness.
Results from the present survey suggested that the importance of assessment of QoL is highly perceived. Many institutions are implementing programs including the assessment of patient-reported outcomes and, particularly, of QoL. The National Health Service (NHS) in Great Britain, for example, asks all patients who are having hip or knee replacements, varicose vein surgery or groin hernia surgery to fill in a questionnaire on patient-reported outcomes to help improving the quality of care. http://www.nhs.uk/NHSEngland/thenhs/records/proms/Pages/aboutproms.aspx. The gap between the knowledge of QoL and the perception of its importance documented in the present study merits further attention especially in order to find strategies to reduce this gap. Several causes may explain the gap: first, QoL methodology is scarcely taught during education courses ; second, papers including or primarily focusing on QoL are still rarely published in medical journals other than oncology journals . Moreover, physicians caring for acute patients may pay a greater attention to survival rather than to QoL. We warrant that further studies may demonstrate whether education courses or spread of guidelines on QoL methodology for students, residents and physicians would result in decreasing the gap between perception of importance and feasibility of the QoL methodology in daily routine clinical practice and clinical trials.
Another interesting finding of this study is that, comparing the characteristics of physicians who answered to know or not to know the SF-36, we did not find significant differences. It seems that the knowledge of QoL measures is independent of age, gender, academic role, and medical speciality.
Also interesting is the finding that to the question Who should measure the quality of life? most answered that physicians should do so. We think that this is a topical issue. Some authors believe that physicians' perceptions of QoL may be at odds with those held by the patients and QoL assessment should be performed by the patients themselves using adequate and valid measures or, in alternative, by someone who acts as a proxy or surrogate, such as a family member or a health professional . However, it is well known that many patients are unable to assess their own QoL and complete a QoL measure because of cognitive impairment, difficulties in communication, symptom-related distress, or complexity of QoL measure. Moreover, the high percentage of physicians answering they should personally measure QoL highlights the perception of the great importance of the QoL issue.
This study has several limitations. First, less than one fourth of the physicians answered the questionnaire and we do not know why about 70% of the physicians did not answer. It could be that they were not interested in the target of the study and in this case the conclusion of the study could be different. However, it is useful to underline that the rate of answer in surveys involving a large number of physicians may be low or very low . Second, this is the result of one single Academic Center and findings can not be generalized to other settings. Third, since the questionnaire was built specifically for the purpose of the study, it was not previously validated. Finally, the meaning for some questionnaire items (for example for knowledge) can be differently interpretated by participants. However, the simplicity of the questions may have reduced the bias of variability in interpretation.
In summary, the present study shows that, in a tertiary level academic Italian hospital, one third of the physicians who answered to a questionnaire on QoL, reported to know QoL measures and over 80% of them would like to use QoL in their daily clinical practice. Further studies, also in different medical settings, could assess whether increasing the knowledge on health-related QoL could lead to a growing use of QoL measures in daily clinical practice, possibly increasing also the quality of clinical care.