Readability of British and American medical prose at the start of the 21st century.
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Language↗
Biomedical subjects
William B Weeks
Publications and source records attributed to William B Weeks.
Long-term financial implications of specialty training for physicians.
PURPOSE: Given the recent changes in physician reimbursement and managed care penetration, we examined the financial returns that might be anticipated when considering different medical careers. METHODS: We used survey data from the American Medical Association and standard financial techniques to calculate the return on educational investment (as the discounted, annual hours-adjusted, net present value of additional training) over a working lifetime for six different specialties (family practice, pediatrics, general internal medicine, gastroenterology, cardiology, and general surgery). RESULTS: From 1992 to 1998, the annual yield on specialty training (hours-adjusted internal rate of return) declined for all specialty groups, especially for primary care specialties. The difference in the average income between a given specialty and general practice decreased for general internal medicine, from $5400 (95% confidence interval [CI]: $5000 to $5800) in 1992 to $1180 (95% CI: $1160 to $1205) in 1998, and became negative for family practice (from $5200 [95% CI: $1000 to $9500] to -$2500 [95% CI: -$5800 to $800]) and pediatrics (from $4000 [95% CI: $1200 to $6800] to -$6300 [95% CI: -$9700 to -$2900]). Values for surgery decreased from $33,100 (95% CI: $29,400 to $36,400) in 1992 to $27,200 (95% CI: $21,700 to $32,100) in 1998, whereas there were increases for cardiology, from $35,100 (95% CI: $30,000 to $39,700) to $36,700 (95% CI: $26,500 to $45,700), and for gastroenterology, from $30,000 (95% CI: $21,800 to $37,200) to $34,700 (95% CI: $22,700 to $45,300). CONCLUSION: Our analysis suggests that recent efforts to use financial incentives to make primary care fields more attractive have not been effective. Financial returns and the incentives they create should be carefully considered as part of health care reform.
Adult↗
The costs of making practice more cost-effective.
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Cost-Benefit Analysis↗
Financial returns on specialty training for surgeons.
BACKGROUND: Because of recent changes in physician reimbursement and managed care penetration, we wanted to examine the financial returns that medical students might anticipate when considering different careers. METHODS. We used standard financial techniques to calculate the return on educational investment for 5 surgical specialties (general surgery, otolaryngology, ophthalmology, orthopedic surgery, and urology) and primary care medicine between 1992 and 1998. RESULTS: The annual yield on specialty training fell for all specialties examined, from an average of 15% to 3% for primary care specialties, and from an average of 36% to 19% for surgical specialties. The difference in the average future hourly income between a given specialty and general practice decreased for all surgical specialties (for general surgery, from $12.03 in 1992 to $9.89 in 1998; otolaryngology, from $21.37 to $5.56; ophthalmology, from $14.12 to $7.15; orthopedic surgery, from $21.16 to $18.91), except urology (from $13.81 in 1992 to $14.84 in 1998). Returns became negative for primary care medicine, dropping from $1.72 to -$1.21. CONCLUSION: Efforts to create a "level playing field" within medicine have resulted in decreased returns on educational investment across all specialties. Financial returns and the incentives they create should be carefully considered as part of health care reform.
Income↗
The more things change: revisiting a comparison of educational costs and incomes of physicians and other professionals.
The authors previously compared the 1990 educational costs and incomes of physicians and other professional groups. Since then, there have been dramatic changes in the market for the groups examined. This article reports their update of the previous analysis, using 1997 data. For this update, the authors applied standard financial techniques to expected incomes and educational costs to determine the return on educational investment over the working lifetime for five professional groups: primary care physicians, procedure-based physicians, dentists, attorneys, and graduates of the top 20 business schools. The hours-adjusted net present values of the educational investments for attorneys ($10.73) and procedure-based physicians ($10.40) are considerably higher than those for dentists ($8.90) and businessmen ($8.27); the return for primary care physicians ($5.97) remains much lower than all others. Primary care physicians have an hours-adjusted internal rate of return on their educational investment equal to 16%, compared with 18% for procedure-based medicine, 22% for dentistry, 23% for law, and 26% for business. Although it remains the lowest of all professional groups examined, primary care medicine has made the largest percentage gain in net present value of all groups. Although anticipated changes in physician incomes have occurred, the standing of physicians relative to other professional groups has not changed. Students can still anticipate relatively poorer returns on their educational investment when they choose a career in primary care medicine as compared with careers in procedure-based medicine or surgical specialties, business, law, or dentistry.
Career Choice↗
A curriculum for training quality scholars to improve the health and health care of veterans and the community at large.
In 1998, the Veterans Health Administration invested in the creation of the Veterans Administration National Quality Scholars Fellowship Program (VAQS) to train physicians in new ways to improve the quality of health care. We describe the curriculum for this program and the lessons learned from our experience to date. The VAQS Fellowship program has developed a core improvement curriculum to train postresidency physicians in the scholarship, research, and teaching of the improvement of health care. The curriculum covers seven domains of knowledge related to improvement: health care as a process; variation and measurement; customer/beneficiary knowledge; leading, following, and making changes in health care; collaboration; social context and accountability; and developing new, locally useful knowledge. We combine specific knowledge about the improvement of health care with the use of adult learning strategies, interactive video, and development of learner competencies. Our program provides insights for medical education to better prepare physicians to participate in and lead the improvement of health care.
Adult↗
Improving the effectiveness of physician participation in local quality improvement efforts.
The authors present five success factors for medical students, residents, and fellows to consider when engaged in quality improvement projects: (1) add value, not work; (2) start small and build; (3) move quickly; (4) adapt, innovate, and collaborate; (5) produce understandable results. Using examples from the Veterans Affairs National Quality Scholars Fellowship Program, they describe how these factors were used successfully. While not the only steps to take, these critical success factors proved helpful in defining the problem to be addressed, engaging leadership, and anticipating the resolution of conflict.
Competency-Based Education↗
Baldrige-based quality awards: Veterans Health Administration's 3-year experience.
This article describes the Veterans Health Administration's (VHA's) 3-year experience with an internal, Baldrige-based quality award. The authors examined scores for Veterans Integrated Service Networks (VISNs), which received site visits, variation in year-to-year survey outcomes for repeat applicants, and variation in survey team reports for a VISN with multiple surveys. Individual VISNs that applied in multiple years had mixed results. Variation in feedback reports was not significant. Although some VISNs increased their scores over time, there was not measurable, systemwide improvement. Three years may be too short a time to significantly affect Baldrige scores in an organization as large as VHA.
Awards and Prizes↗
Quality improvement as an investment.
Health care organizations are experiencing increasing internal and external pressures to improve the quality of care that they provide. However, there is not a framework that can be used to help understand the value of quality improvement projects and to prioritize competing projects. By understanding the current processes, costs and outcomes of care, enumerating the costs and benefits of change, anticipating the timing of the costs and benefits, and performing a financial analysis, quality improvement efforts can be evaluated as investments. Only by understanding and adapting to the financial environments in which health care organizations operate can continuous quality improvement in health care succeed.
Cost-Benefit Analysis↗
Primary care practice management in rural and urban Veterans Health Administration settings.
Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care. The authors used survey and administrative data from 1999 from the Veterans Health Administration (VHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally. Rural VHA hospitals were smaller, less likely to be academically affiliated, and had fewer integrated specialty care services. Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services. However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals. Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received. Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones. This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings. Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings.
Female↗
Veterans' care preference for coronary artery bypass grafting in a rural setting.
We wanted to determine what factors were associated with rural veterans' use of Department of Veterans Affairs (VA) facilities over the private sector for coronary artery bypass grafting (CABG) surgery. We reviewed the charts of 137 veterans who were referred for CABG by their VA cardiologists. Most veterans (69%) obtained CABG through the VA system. Although patients who had to drive fewer additional miles to obtain VA care were somewhat more likely to use the VA system, patients who lacked insurance or faced high out-of-pocket cost estimates for care in the private sector obtained care through the VA at dramatically higher rates. Although patients using the VA system were younger and more likely to have significant coronary artery disease, clinical outcomes did not significantly differ across systems of care. As the VA begins to understand veterans' use of multiple systems of care, it will be important to understand what influences veterans' choice of VA or private sector care.
Aged↗
Differences in income between male and female primary care physicians.
OBJECTIVES: to determine whether sex differences in income persist among primary care physicians in light of the increasing proportion of women entering the field. METHODS: We obtained sex- and age-specific self-reported data from the American Medical Association's annual survey of physicians to determine the annual income, annual income per hours worked, proportion of time in direct patient care, and outpatient productivity for family practice physicians, general internists, and pediatricians between 1989 and 1998. We compared female to male results for respondents in the 36- to 45-year-old age group as well as for the age-weighted gender aggregate. RESULTS: Female primary care physicians reported lower annual incomes (between 60% and 85% of those of their male counterparts) and lower incomes per hours worked (between 71% and 98% of those of their male counterparts). The income disparities decreased during the 10 years, at a rate of about 1% per year on average. Although the proportion of time female physicians spent in direct patient care activities was similar to that of their male counterparts, female physicians saw substantially more patients per office hour (about 17% more, on average, over time). CONCLUSIONS: Gender inequities persist in the incomes of primary care physicians. Although the disparities appear to be decreasing, female primary care physicians' increased productivity compared with men's suggests that these inequities are perpetuated in more subtle ways and warrant immediate examination and remediation.
Adult↗
Medicare payment changes and physicians' incomes.
An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.
Academic Medical Centers↗
Rural health care ethics: is there a literature?
To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications were original research articles while (12) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues.
Bibliometrics↗
Response to commentaries on "is there a rural ethics literature?".
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Empirical Research↗
A cumulative meta-analysis of selective serotonin reuptake inhibitors in pediatric depression: did unpublished studies influence the efficacy/safety debate?
OBJECTIVE: The aim of this study was to assess whether unpublished trials of serotonin reuptake inhibitors in pediatric depression impacted efficacy or safety conclusions, and to examine the evolution of information contributing to the safety/efficacy debate. METHOD: From 939 potentially relevant studies extracted from Medline, Cinahl, Biosis, and Cochrane databases, and from the United Kingdom's Committee on Safety of Medicines website, we examined 38 studies: Ten published and five unpublished randomized, controlled trials, 22 observational studies, and one crossover trial. We performed cumulative and non-cumulative meta-analyses and generated pooled relative rates of response and serious adverse events for high-quality randomized, controlled trials. RESULTS: Unpublished studies did not substantially alter the risk-to-benefit determination. Cumulative meta-analyses of seven randomized, controlled trials for efficacy and 11 randomized, controlled trials for safety suggest an adverse safety/efficacy profile for selective serotonin reuptake inhibitors (SSRIs) overall. Fluoxetine and citalopram appear to offer favorable risk to benefit profiles, while shorter-acting agents pose greater risks and provide marginal benefit. CONCLUSIONS: While simple meta-analysis across all SSRIs for treatment of pediatric depression provided general efficacy and safety information, meta-analysis of individual drugs and use of cumulative meta-analytic techniques may have expedited our ability to formulate conclusions about safety and efficacy of SSRIs in pediatric depression.
Adolescent↗
Case study: identifying potential problems at the human/technical interface in complex clinical systems.
Many who would like to improve patient safety in health care have advocated for the widespread adoption of computerized physician order entry and electronic medical records. However, unforeseen consequences of this new technology may put patients at greater risk of harm, not less. The authors present a clinical scenario that demonstrates system vulnerabilities in the interface between humans and such technology. Furthermore, the authors suggest that managers could anticipate these vulnerabilities by using techniques such as cause-and-effect analysis or failure mode and effect analysis, both before the installation of electronic medical records and as ongoing surveillance mechanisms. The case study demonstrates that adoption of technology is not a quick fix to the patient safety issue; proactive and ongoing efforts to address the human factors issues raised by the introduction of new technology will be required to prevent patient harm.
Aged↗
The influence of race and gender on family physicians' annual incomes.
PURPOSE: Specialty, work effort, and gender have been shown to be associated with physicians' annual incomes. We hypothesized that provider race might also be associated with differences in family physicians' incomes. Therefore, we conducted a study that used survey data to explore the relationship between provider gender and race and family physicians' annual incomes. METHODS: We used survey responses collected by the American Medical Association (AMA) throughout the 1990s from 786 white male, 20 black male, 159 white female, and 12 black female actively practicing family physicians. We then used linear regression modeling to determine the influence of race and gender on physicians' annual incomes after controlling for work effort, provider characteristics, and practice characteristics. RESULTS: Female family physicians reported seeing substantially fewer patients and working fewer annual hours than their male counterparts. After adjustment for work effort, provider characteristics, and practice characteristics, black men's mean annual income was 178,873 dollars, or 9,309 dollars (5.5%) higher than that for white men (95% Confidence Interval (CI), -18,410 dollars to 37,028 dollars); white women's was 135,531 dollars, or 14,579 dollars (8.6%) lower (95% CI, -25,969 dollars to -3,189 dollars); and black women's was 107,733 dollars, or 36,963 dollars (22%) lower (95% CI, -71,450 dollars to -2,476 dollars). CONCLUSIONS: During the 1990s, female gender was associated with lower annual incomes among family physicians, substantially so for black women. These findings warrant further exploration to determine what factors might cause the gender-based income differences that we found.
Black or African American↗