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Biomedical subjects

R Schneeweiss

Publications and source records attributed to R Schneeweiss.

At least 19 recordsLinked to original sources
PubMed2001

Volunteer physician faculty and the changing face of medicine.

OBJECTIVE: To determine the extent to which current changes in the American health care system might adversely effect the willingness of community physicians to volunteer to teach medical students. DESIGN: Surveys in the form of 2 mailings were sent to 466 physicians in the Pacific Northwest who volunteer to teach first- and second-year medical students. The physicians were categorized into medical specialty or primary care, urban or rural location, and type of practice. PARTICIPANTS: A total of 333 physicians completed the surveys on which responses were analyzed. RESULTS: Respondents noted that clinical and nonclinical workloads had increased (n=211 [63%] and n=276 [83%], respectively) in the past 5 years. One hundred eighty-six respondents (56%) said that they had less time for teaching medical students. Forty-five physicians (14%) indicated that they had discontinued their volunteer teaching activities altogether. During the past 5 years, solo practitioners had the lowest dropout rate (7% [4/57]), and physicians at health maintenance organizations had the highest (23% [7/30]). Primary care physicians were more likely to indicate that they had decreased time for each patient encounter (P=0.006). CONCLUSIONS: Increasing nonclinical workload demands and higher patient loads are a substantial threat to the recruitment and retention of volunteer faculty. In particular, the involvement of urban, HMO, and primary care physicians may decrease disproportionately in the future.

Adult↗
PubMed1999

Rural and urban physicians: does the content of their Medicare practices differ?

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

Aged↗
PubMed1998

The generalist role of specialty physicians: is there a hidden system of primary care?

CONTEXT: Despite increased emphasis on primary care in the United States, most care continues to be provided by specialists. The extent to which specialists incorporate elements of primary care in their approach to ambulatory patients is unknown. OBJECTIVES: To examine the extent to which selected medical and surgical subspecialties provide generalist care to Medicare patients, and to compare patterns of care between specialists and generalists. DESIGN: A cross-sectional study of all ambulatory care recorded in Part B of the Washington State Medicare Claims Database in 1994 and 1995. SETTING: Ambulatory practices in Washington State. PATIENTS: Medicare beneficiaries 65 years or older who made office visits to the study physicians. MAIN OUTCOME MEASURES: The extent to which individual specialties accounted for the majority of visits made by patients to physicians (a measure of continuity), provided care outside the traditional domain of their specialty (a measure of comprehensiveness), and provided influenza immunization. RESULTS: A total of 373 505 patients constituted the sample. Patients had an average of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and family physicians differ systematically from the practices of most specialists. Approximately half (49.8%) of all ambulatory visits to general internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medical specialist and 11.7% of surgical specialist visits. The rate of influenza immunization was 55.4% for patients who received the majority of their care from generalists, 47.7% from medical specialists, and 39.6% from surgical specialists. Pulmonologists, general surgeons, and gynecologists were more likely than other specialists to provide services outside their specialty. CONCLUSIONS: Most specialists do not assume the principal care responsibility for elderly patients, although a substantial proportion of patients see only specialists for their care. Selected specialties assume the generalist role more often, particularly when they provide the majority of outpatient care for an individual patient.

Aged↗
PubMed1997

Interspecialty differences in the obstetric care of low-risk women.

OBJECTIVES: This study examined differences among obstetricians, family physicians, and certified nurse-midwives in the patterns of obstetric care provided to low-risk patients. METHODS: For a random sample of Washington State obstetrician-gynecologists, family physicians, and certified nurse-midwives, records of a random sample of their low-risk patients beginning care between September 1, 1988, and August 31, 1989, were abstracted. RESULTS: Certified nurse-midwives were less likely to use continuous electronic fetal monitoring and had lower rates of labor induction or augmentation than physicians. Certified nurse-midwives also were less likely than physicians to use epidural anesthesia. The cesarean section rate for patients of certified nurse-midwives was 8.8% vs 13.6% for obstetricians and 15.1% for family physicians. Certified nurse-midwives used 12.2% fewer resources. There was little difference between the practice patterns of obstetricians and family physicians. CONCLUSIONS: The low-risk patients of certified nurse-midwives in Washington State received fewer obstetrical interventions than similar patients cared for by obstetrician-gynecologists or family physicians. These differences are associated with lower cesarean section rates and less resource use.

Adult↗
PubMed1995

Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations.

This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.

Chi-Square Distribution↗
PubMed1994

National survey on hospital-based privileges in family practice obstetrics.

PURPOSES: To document the content and level of obstetrical hospital-based privileges for members of the American Academy of Family Physicians and to describe variations between regions, rural vs urban practices, and various physician characteristics. METHODS: About 12% of the active members of the American Academy of Family Physicians listed as offering obstetrical care by the Academy as of March 1991 were randomly sampled by mailed questionnaire. Samples were drawn from three national regions. Privileges were grouped by degree of restriction, based on whether consultation or transfer was required. RESULTS: Of 1464 surveys mailed, 1026 physicians (70%) responded. Only 740 (72%) stated that they still practiced obstetrics. Privileges ranged from least restricted (100% provided vaginal vertex delivery, with no consultation required) to most restricted (79% provided amniocentesis, with consultation or transfer required). A surprisingly large proportion of physicians reported having fewer routine and more advanced privileges without consultations being required, such as ultrasonography (53%), vaginal breech delivery (41%), and cesarean section (25%). Physicians having more advanced privileges tended to be located in the West or mountain-plains region; be trained in the Midwest, mountain-plains region, or the West; work in middle-sized, nonteaching hospitals in more rural countries; have completed advanced obstetrical training (> or = 6 months); and deliver more than 40 infants per year. CONCLUSIONS: Overall, a considerable number of hospital-based obstetrical privileges are granted to family physicians. No uniformity in privileges prevails, owing to significant regional and practice variations. Teaching hospitals reportedly restrict obstetrical care by family physicians more than other hospitals. The variations in restrictions could not be explained by degree of training.

Adult↗
PubMed1993

A comparison of student clerkship experiences in community practices and residency-based clinics.

BACKGROUND: In our required family medicine clerkship, we used data from student logbook records of clinical experience to compare the learning experiences of students in community practices and residency-based clinics. METHODS: Sixty-eight University of Washington students collected data on patients seen during the final two weeks of their family medicine clerkships. We compared patient demographics, location of patient encounters, and clinical problems seen at nine residency and eight community locations in a four-state area. National Ambulatory Medical Care Survey data were used to compare student experiences to national practices. RESULTS: Log data documented that both community practices and residency sites met the course curriculum goals. Some variations occurred between the two types of clerkship sites, however. Students at community practices saw a higher mean number of patients and did more procedures than students at residency sites. Students at residencies were more likely to see patients for health maintenance and pregnancy care and less likely to see lacerations, sprains or strains, and some chronic diseases. CONCLUSION: Episodic log data were successfully used to monitor the objective educational strategies for residency- and community-based student clerkship sites. Although all students met clerkship objectives, there were significant differences in certain aspects of students' clinical experiences at the two types of clerkship sites.

Ambulatory Care Facilities↗
PubMed1992

Rural training tracks in four family practice residencies.

The use of rural training tracks (RTTs) in family practice residencies is a new strategy (beginning in the late 1980s) to increase the number of residents selecting rural careers. The authors describe the four residencies (in Washington, Nebraska, New York, and Kentucky) that have established RTTs. The first residency year is completed in an urban tertiary care center, and the second and third years are completed in a distant rural community wherein the primary faculty are the members of a rural family practice group. Inpatient experience for the residents is provided by community hospitals that offer obstetrics, emergency room care, and first-line critical care. The residents' training is supplemented by specialty faculty practicing in the rural communities. The curricula are highly structured and are evaluated to ensure training experiences of high quality. The RTTs' financial support comes from state initiatives, hospital reimbursement, recruitment budgets, and outpatient care revenues. The authors conclude that the RTT concept has the potential to lessen the shortage of rural physicians.

Family Practice↗
PubMed1991

Recruiting physicians to rural practice. Suggestions for success.

Medical school graduates from 1986 to 1988 and current residents in 12 family practice residency programs in the Northwest (N = 302) were surveyed to identify important factors in the recruitment process for their first postresidency placement. The study sought to compare the recruitment practices of rural communities and urban sites. Specific questions addressed in the study concerned sources of information about practice opportunities, stage in training when job search was initiated, factors related to unsuccessful site visits, and activities scheduled in the visit. Results indicated that referrals from faculty were the most valued source of information. Most job searches were initiated in the first 6 months of the third year in training. An unreceptive physician community and a reluctant spouse or partner were substantial problems for residents making site visits to rural communities. Rural sites tended to provide a broader mix of professional and personal activities during the visit.

Career Choice↗
PubMed1991

A system for drug utilization review in ambulatory care.

BACKGROUND: It is more difficult to conduct drug utilization reviews in ambulatory care settings than in inpatient care settings. This is true for several reasons: it is harder to identify outpatients who are receiving specific medications; often there is less evidence on which to base clinical standards for drug use; and it is more difficult to ensure patient compliance with drug therapy. METHODS: This article describes a drug utilization review system designed to operate in ambulatory care clinics. The system consists of (1) a computerized database for efficient identification of patients who receive prescriptions for a specific medication, (2) clinic-wide consensus guidelines, (3) reminders in the medical record, (4) regular chart audits, and (5) feedback to physicians. RESULTS: Experience in monitoring the use of serum theophylline assays illustrates how this system can be used in an ambulatory care clinic. According to guidelines adopted in our clinic, overuse of assays is not a problem. The system of physician reminders and chart audits can help prevent underuse. CONCLUSIONS: Despite the difficulties in conducting drug utilization reviews in the ambulatory setting, a system based on clinic-wide guidelines is feasible and should be an integral part of quality assurance programs.

Adolescent↗
PubMed1989

The economic impact and multiplier effect of a family practice clinic on an academic medical center.

Academic medical centers are facing the need to expand their primary care referral base in an increasingly competitive medical environment. This study describes the medical care provided during a 1-year period to 6304 patients registered with a family practice clinic located in an academic medical center. The relative distribution of primary care, secondary referrals, inpatient admissions, and their associated costs are presented. The multiplier effect of the primary care clinic on the academic medical center was substantial. For every $1 billed for ambulatory primary care, there was $6.40 billed elsewhere in the system. Each full-time equivalent family physician generated a calculated sum of $784,752 in direct, billed charges for the hospital and $241,276 in professional fees for the other specialty consultants. The cost of supporting a primary care clinic is likely to be more than offset by the revenues generated from the use of hospital and referral services by patients who received care in the primary care setting.

Age Factors↗
PubMed1988

Physician knowledge and attitudes about health insurance after the introduction of capitated health care plans.

A two-part closed-end survey similar to a survey done in 1980 was given to 25 family physicians at an academic family medical center to assess physician knowledge about five insurance programs covering most of the patients seeking care in the center, and to assess physician attitudes about the capitated insurance plan with which the clinic was affiliated. Results did not differ significantly from those obtained in a similar survey four years earlier at the same center. Physicians correctly identified benefits offered by insurance programs only about one half of the time and many did not ascertain patient insurance coverage at all. Physicians considered the most important advantages of capitated health care to be the patient protection from fees for services obtained, the coverage for health care maintenance, and the potential for controlling health care costs. Physician-perceived disadvantages included difficulties controlling costs generated by other specialists, dealing with after-the-fact authorization requests, controlling access to services, and obtaining information about costs within the capitated system.

Attitude of Health Personnel↗
PubMed1988

Hospital privileges for family physicians: documentation of family practice residents' experiences in training.

This report describes a study of the content and uses of the University of Washington Affiliated Residency Network documentation system for future hospital privileges. The selected procedures and problems considered important to document for future hospital privileges were validated by means of a graduate survey conducted in 1985. Fifty percent of the 43 graduates responding used their personal documentation when applying for hospital privileges. Intermediate-sized hospitals of 50 to 199 beds were significantly more likely to require documentation than either small (fewer than 50 beds) or large (more than 200 beds) hospitals. However, 84 percent of the hospitals where graduates are located either require documentation or would find it helpful for privilege application. The three-year cumulative experiences of the 1986 cohort of graduating residents are also presented. Thirty-six of the residents (71 percent) participated actively in the voluntary network documentation system. None of the items selected as important to document for future hospital privileges were recorded by 100 percent of the residents. Obstetric procedures and problems were the items most commonly documented.

Documentation↗
PubMed1987

Gender differences in practice characteristics of graduates of family medicine residencies.

A survey of 310 graduates of eight university-affiliated family medicine residencies in the northwestern United States conducted in 1985 revealed several significant differences between male and female graduates. The female graduates were significantly (p less than .05) more likely than male graduates to practice in urban settings, taking salaried positions, and work in nonprivate practice. With regard to practice content the women spent significantly (p less than .01) more time in the office setting, worked fewer hours per week in direct patient care, and reported doing fewer complex procedures in their practice than did the men. The women were more satisfied than the men with their income but equally satisfied as the men with their professional and personal lives. There were no significant gender differences with regard to concerns about liability and hospital privileges. The women felt significantly (p less than .05) less well prepared in several subject areas, especially surgical areas; hierarchical multiple-regression analysis showed that this difference persisted when analysis controlled for community size and practice setting. Possible explanations and implications are proposed.

Certification↗