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PubMed1979

The physician assistant in rural primary care practices: physician assistant activities and physician supervision at satellite and non-satellite practice sites.

Nineteen practice sites in Iowa were studied to determine the differences in the types of physician (MD) supervision the physician assistant (PA) received at work at satellite (separate from the major practice site of the supervising MD) and non-satellite practice sites. The MDs supervised PA functions in 12.9 per cent of the patients seen by the PAs at non-satellite and 15.9 per cent of patients they saw at satellite practice sites. All patients with presenting manifestations that suggested life-threatening conditions were seen by MDs at satellite and non-satellite sites. The MD spent 9.2 minutes per patient at satellite clinics, compared to 4.4 minutes per patient at non-satellite clinics. PAs working at satellite sites appeared to receive as much supervision as PAs working at non-satellite clinics.

Clinical Competence↗
PubMed1997

The changing interface between district hospital cardiology and the major cardiac centres. British Cardiac Society, with the Royal College of Physicians of London, the Royal College of Physicians of Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow.

The national priority for reducing mortality and morbidity from cardiovascular disease, the resulting expansion in the number of consultant cardiologists, and the reforms of the National Health Service have produced significant changes in delivery of care for cardiac patients and in the relations between district general hospitals (DGH) and the old regional cardiac centres. 1.2 The British Cardiac Society, the Medical Royal Colleges of Physicians of London and Edinburgh, and the Royal College of Physicians and Surgeons of Glasgow established a working group to make recommendations on the most appropriate evolution of these changes to secure high quality care in a cost-effective and professionally rewarding environment. The principal conclusions of the working group were: i) The establishment of new cardiac catheterisation laboratories in DGHs remote from a major cardiac centre should be encouraged provided the workload is adequate to ensure efficient use of the facility. ii) Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre. iii) Close liaison of the district cardiologist with a cardiac surgeon and interventionist is vitally important. iv) The centres will be required to provide tertiary care for emergency and urgent cases from their traditional catchment area, specialised expertise for the management of rare and difficult cases, and angioplasty. Some centres will also offer complex electrophysiology, and ablation techniques. v) The centres must also provide routine cardiology services for their local district, facilities for cardiac catheterisation for DGH cardiologists, and training for doctors, nurses, technicians, and radiographers. vi) Some centres will be linked with paediatric cardiology and paediatric cardiac surgical units. vii) District cardiac centres will be required to provide a full non-invasive diagnostic service and emergency care for patients referred by general practitioners and hospital colleagues as well as facilities for preventative and rehabilitation cardiology. Arrangements for invasive investigation and treatment of their patients will vary according mainly to the distance from the major centre. viii) Both the major centres and the district cardiac units should participate in training and research.

Cardiac Care Facilities↗
PubMed1996

[Physicians pilloried? On physicians' blunders and blundering physicians in Norwegian tabloids].

Doctors frequently claim that the tabloid press focuses too much on malpractice cases and that the identity of the individual physicians is also revealed. A systematic review of two Norwegian tabloids over six months in 1994 showed that articles on malpractice occurred less often than expected. We found 1.6 articles each week, on average. In addition, the doctors were identified in only three of 42 articles. The situation leading to the complaint was commented by the doctor involved in one article, while criticism from a colleague who was not directly involved was included in two of 42 articles. The results indicate that doctors need to be trained to handle the press.

Confidentiality↗
PubMed1999

The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making.

OBJECTIVE: To determine whether physicians' preferences for end-of-life decision-making differ between blacks and whites in the same pattern as patient preferences, with blacks being more likely than whites to prefer life-prolonging treatments. DESIGN: A mailed survey. SETTING AND PARTICIPANTS: American Medical Association (AMA) and National Medical Association (NMA) databases. To enrich the sample of black physicians, we targeted physicians in the AMA database practicing in high minority area zip codes and graduates of the traditionally black medical schools. MAIN OUTCOME MEASURES: Self-reported physician attitudes toward end-of-life decision-making and preference of treatment for themselves in persistent vegetative state or organic brain disease compared by race, controlling for age and gender. RESULTS: The 502 physicians (28%) who returned the questionnaire included 280 white and 157 black physicians. With regard to attitudes toward patient care, 58% of white physicians agreed that tube-feeding in terminally ill patients is "heroic," but only 28 % of black physicians agreed with the statement (P < .001). White physicians were more likely than black physicians to find physician-assisted suicide an acceptable treatment alternative (36.6% vs 26.5% of black physicians) (P < .05). With regard to the physicians preferences for future treatment of themselves for the persistent vegetative state scenario, black physicians were more than six times more likely than white physicians to request aggressive treatments (cardiopulmonary resuscitation, mechanical ventilation, or artificial feeding) for themselves (15.4% vs 2.5%) (P < .001). White physicians were almost three times as likely to want physician-assisted suicide (29.3% vs 11.8%) (P < .001) in this scenario. For a state of brain damage with no terminal illness, the majority of all physicians did not want aggressive treatment, but black physicians were nearly five times more likely than white physicians (23.0% vs 5.0%) (P < .001) to request these treatments. White physicians, on the other hand, were more than twice as likely to request physician-assisted suicide (22.5% vs 9.9%), P < .001 in this scenario. CONCLUSIONS: Physicians preferences for end-of-life treatment follow the same pattern by race as patient preferences, making it unlikely that low socioeconomic status or lack of familiarity with treatments account for the difference. Self-denoted race may be a surrogate marker for other, as yet undefined, factors. The full spectrum of treatment preferences should be considered in development of guidelines for end-of-life treatment in our diverse society.

Adult↗
PubMed1996

Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses.

OBJECTIVES: To estimate how often physicians receive requests for physician-assisted suicide and euthanasia and to describe a case series of patient requests for physician-assisted suicide and euthanasia, including physician responses to these requests. DESIGN: A mailed, anonymous two-part questionnaire. PARTICIPANTS: A total of 828 physicians returned questionnaires sent to 1453 potential respondents, for a response rate of 57%. Questionnaires were mailed to random sample (25%) of primary care physicians and all physicians in selected medical subspecialties in Washington State. MAIN OUTCOME MEASURES: The frequency of explicit patient requests for physician-assisted suicide and euthanasia reported by physicians and individual case descriptions of patient characteristics, physician perceptions of patient concerns, and physician responses to patient requests. RESULTS: In the past year, 12% of responding physicians received one or more explicit requests for physician-assisted suicide, and 4% received one or more requests for euthanasia. These physicians provided 207 cases descriptions. The diagnoses most often associated with requests were cancer, neurological disease, and the acquired immunodeficiency syndrome (AIDS). The patient concerns most often perceived by physicians were worries about loss of control, being a burden, being dependent on others for personal care, and loss of dignity. Physicians provided assistance more often to patients with physical symptoms. Physicians infrequently sought advice from colleagues. Of 156 patients who requested physician-assisted suicide, 38 (24%) received prescriptions, and 21 of these died as a result. Of 58 patients who requested euthanasia, 14 (24%) received parenteral medication and died. CONCLUSIONS: Patient request for physician-assisted suicide and euthanasia are not rare. As perceived by physicians, the most common patient concerns at the time these requests are made are nonphysical. Physicians occasionally provide these practices, even though they are currently illegal in Washington State. Physicians do not consult colleagues often about these requests. These findings raise the question of how to ensure quality in the evaluation of patient requests for physician-assisted death.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians.

BACKGROUND: Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. OBJECTIVES: To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. METHODS: A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year. RESULTS: Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. CONCLUSIONS: Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.

Adult↗
PubMed2006

Job satisfaction among obstetrician-gynecologists: a comparison between private practice physicians and academic physicians.

OBJECTIVE: Physician job satisfaction has been the subject of much research. However, no studies have been conducted comparing academic and private practice physician satisfaction in obstetrics and gynecology. This study was undertaken to measure satisfaction levels for academic and private practice obstetrician-gynecologists and compare different aspects of their practice that contributed to their satisfaction. STUDY DESIGN: A survey was mailed to randomly selected obstetrician-gynecologists in Memphis, TN; Birmingham, AL; Little Rock, AR; and Jackson, MS. Physicians were asked to respond to questions concerning demographics and career satisfaction. They were also asked to assess the contribution of 13 different aspects of their practice in contributing to their job selection and satisfaction using a Likert scale. A score of 1 meant the physician completely disagreed with a statement regarding a factor's contribution or was completely dissatisfied; a score of 5 meant the physician completely agreed with a factor's contribution or was completely satisfied. Simple descriptive statistics, as well as the 2-sample t test, were used. Likert scale values were assumed to be interval measurements. RESULTS: Of the 297 questionnaires mailed, 129 (43%) physicians responded. Ninety-five (74%) respondents rated their overall satisfaction as 4 or 5. No significant difference was found between academic and private physicians when comparing overall job satisfaction (P = .25). When compared to private practice physicians, the aspects most likely contributing to overall job satisfaction for academic physicians were the ability to teach, conduct research, and practice variety (P = .0001, P = .0001, and P = .007, respectively). When compared with academic physicians, the aspects most likely contributing to job satisfaction for private practice physicians were autonomy, physician-patient relationship, and insurance reimbursement (P = .0058, P = .0001, and P = .0098, respectively). When choosing a practice setting, academic physicians found variety, teaching, and research to be more important (P = .0027, P = .0001, and P = .0001, respectively). In contrast, private practice physicians found autonomy, physician-patient relationship, coworkers, and geographic location to be more important (P = .0005, P = .0001, P = .0035, and P = .0016, respectively). CONCLUSION: Academic and private practice physicians are equally satisfied with their careers. However, teaching, research and variety contribute more to academic satisfaction, whereas autonomy, physician-patient relationship, and coworkers contribute more to satisfaction for the physician in private practice. This study may be used when counseling residents concerning their career options.

Adult↗
PubMed2000

Physician-patient communication in HIV disease: the importance of patient, physician, and visit characteristics.

BACKGROUND: Although previous work that considered a variety of chronic conditions has shown that higher quality physician-patient communication care is related to better health outcomes, the quality of physician-patient communication itself for patients with HIV disease has not been well studied. OBJECTIVE: To determine the relationship of patient, visit, physician, and physician practice characteristics to two measures of physician-patient communication for patients with HIV disease. DESIGN: Cross-sectional survey of physicians and patients. SETTING: Cohort study enrolling patients from throughout eastern Massachusetts. STUDY SUBJECTS: 264 patients with HIV disease and their their primary HIV physicians (n = 69). MEASUREMENTS: Two measures of physician-patient communication were used, a five-item general communication measure (Cronbach's alpha = 0.93), and a four-item HIV-specific communication measure that included items about alcohol, drug use, and sexual behaviors (Cronbach's alpha = 0.92). RESULTS: The mean age of patients was 39. 5 years, 24% patients were women, 31.1% were nonwhite, and 52% indicated same-sex contact as their principal HIV risk factor. The mean age of physicians was 39.1 years, 33.3% were female, 39.7% were specialists, and 25.0% self-identified as gay, lesbian, or bisexual. In multivariable models relating patient and visit characteristics to general communication, longer reported visit length (p<.0001), longer duration of the physician-patient relationship (p =.02), and female gender (p =.04) were significantly associated with better communication. The interaction of patient gender and visit length was also significant (p =.02); longer visit length was more strongly associated with better general communication for male than female patients. In similar models relating patient and visit characteristics to HIV-specific communication, longer visit length (p <.0001) and less advanced disease stage (p =.009) were associated with better communication. In multivariable models relating physician and practice characteristics to general communication no variables were significant. However, both female physician gender (p =.002) and gay/lesbian/bisexual sexual preference (p =.003) were significantly associated with better HIV-specific communication. CONCLUSIONS: In this study, female and homosexual physicians provided higher quality HIV-specific communication than male and heterosexual physicians. Better understanding the processes by which female and homosexual physicians achieve higher quality communication may help other physicians communicate more effectively. Health care providers and third-party payers should be aware that shorter visits may compromise physician-patient communication, and that this effect may be more consequential for male patients.

Adult↗
PubMed2006

German physicians "on strike"--shedding light on the roots of physician dissatisfaction.

BACKGROUND: Over the past few years, students in Germany have been dropping out of medical school at increasing rates, and the number of physicians choosing to work abroad or in non-medical professions has been growing. A recent study (the "Ramboll Study") commissioned by the Health Ministry concluded that German physicians' dissatisfaction with existing monetary and non-monetary incentive systems during training and subsequent practice was the main reason for these trends. Among those physicians who have remained in the workforce, there is a similar dissatisfaction, reflected in part by a general strike in 2006 by German physicians in favour of higher wages and better working conditions. OBJECTIVE: To better understand the decision-making process of physicians which is highly determined by the satisfaction they experience in their work life and to extract the factors that contribute to their satisfaction. METHODS: We surveyed all physicians who spent more than 50% of their time in patient care (and less than 50% in research) at the teaching hospital of the Hannover Medical School (839, after exclusion of pre-test participants). Based on existing satisfaction studies, we designed a self-administered questionnaire that contained 28 items, including items measuring several dimensions of physician job satisfaction; the monetary and non-monetary incentives the physicians experienced in the recent past; other job-related potential confounding factors and socio-demographic questions. Respondents were asked to rate each job satisfaction item on five-point Likert scales regarding both satisfaction with and importance of the item. Data were analysed using descriptive statistics, factor and correlation analyses. RESULTS AND DISCUSSION: Our data suggest that non-monetary factors are important determinants of physician job satisfaction, perhaps more important than monetary incentives that may augment or reduce physicians' base incomes. Factor analysis revealed seven principal factors of which decision-making and recognition, continuous education and job security, administrative tasks and collegial relationships were highly significant, specialized technology and patient contact were significant and research and teaching and international exchange were not significant in contributing to physician job satisfaction. CONCLUSION: This study sheds light to the underlying factors that contribute to physician job satisfaction in Germany, and it provides insights into the reasons for physicians leaving medical practice. In order for a health system to recruit and retain physicians, it may be necessary for a system's physician strategy to shift from focusing primarily on hard, monetary and compensation-related factors to a broader focus that incorporates the soft, non-monetary factors. The implementation of policies and management practices that reduce the time burden on physicians, and enhance physicians' participation in the development of patient care management processes and in managerial decisions that affect patient care appears to be crucial. The result will be increased job satisfaction among physicians, which is important to the future recruitment and retention of doctors, as well as to the productivity and quality of the services provided by this essential component of our medical care systems.

Academic Medical Centers↗
PubMed2005

Physician assistants as physician extenders in the pediatric intensive care unit setting-A 5-year experience.

OBJECTIVE: To describe the scope of practice and complementary role of physician assistants as physician extenders in the pediatric intensive care unit. DESIGN: Descriptive report of a 5-yr experience using a physician assistant-resident staffing model in comparison to the traditional resident-only coverage. SETTING: Six-bed pediatric intensive care unit at a tertiary care center subject to longstanding New York Hospital Code 405 restrictions on resident work hours. INTERVENTIONS: Orientation, training, credentialing, and evaluation of physician assistants. MEASUREMENTS AND MAIN RESULTS: New Accreditation Council for Graduate Medical Education regulations based on the longstanding New York Hospital Code 405 limit the number of resident hours worked per week. Our hospital employs physician assistants as physician extenders in the pediatric intensive care unit to enable regulatory compliance. Physician assistants were oriented for a period of 6 months to 1 yr to develop skill competencies, observe and learn pediatric intensive care unit practices and procedures, and complete credentialing to perform traditionally physician, nursing, and respiratory therapist functions. Physician assistants were then assigned to an independent but supervised patient care role similar to that of a resident physician. The impact of the physician assistant program was assessed by the attending physicians, and resident opinions were surveyed. CONCLUSIONS: Physician assistants play a complementary role as physician extenders in the pediatric intensive care unit, enabling compliance with New York state and Accreditation Council for Graduate Medical Education resident work hour regulations. Physician assistants perform similar tasks and activities as the pediatric intensive care unit residents and integrate well with them in enhancing bedside patient care. Over time, physician assistants provide additional direction to the residents by virtue of their familiarity with unit-specific policies and procedures and repetitive pediatric intensive care unit practice patterns. As multifunctional members of the health care team, they support nursing and respiratory therapy functions and improve the day-to-day functioning of the unit. The physician assistant serves as a key member of the pediatric intensive care unit transport team. Limitations observed include high job turnover rates among the physician assistants and confusion between their role as shift workers or professional employees.

Accreditation↗
PubMed1998

Minor head injury in children: current management practices of pediatricians, emergency physicians, and family physicians.

OBJECTIVE: To describe variation in the clinical management of minor head trauma in children among primary care and emergency physicians. DESIGN: A survey of pediatricians, family physicians, and emergency physicians drawn from a random sample of members of the American Academy of Pediatrics, the American Academy of Family Physicians, and the appropriate American Medical Association specialty listings, respectively. Physicians were given clinical vignettes describing children presenting with normal physical examination results after minor head trauma. Different clinical scenarios (brief loss of consciousness or seizures) were also presented. Information was gathered on initial and subsequent management steps most commonly used by the physician. RESULTS: Surveys were returned by 765 (51%) of 1500 physicians. Of these, 303 (40%) were pediatricians, 269 (35%) family practitioners, and 193 (25%) emergency physicians. For minor head trauma without complications, observation at home was the most common initial physician management choice (n = 547, 72%). Observation in office or hospital was chosen by 81 physicians (11%). Head computed tomographic (CT) scan was chosen by 7 physicians (1%) and skull x-ray by 24 physicians (3%) as the first management option. Most physicians (n = 445, 80%) who initially chose observation at home would obtain a CT scan if the patient showed clinical deterioration. In the original scenario, if the patient had also sustained a loss of consciousness, 383 physicians (58%) altered management. Of these, 120 (18%) chose CT, 13 (2%) chose skull x-ray, 1 (1%) chose magnetic resonance imaging, 141 (21%) chose inpatient observation, and 125 (19%) chose a combination of CT scanning and observation. With seizures, 595 (90%) altered management, with 176 physicians (27%) choosing CT scan, 5 (1%) skull x-ray, 60 (9%) inpatient observation, and 299 (45%) a combination of radiological evaluation and observation. CONCLUSIONS: Most physicians surveyed chose clinic or home observation for initial management of minor pediatric head trauma. Clinical management was more varied when patients had sustained either loss of consciousness or seizures. Further study of the appropriate management of minor head trauma in children is needed to guide physicians in their care.

Adolescent↗
PubMed1997

Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.

OBJECTIVE: To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons. DESIGN: Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician. SETTINGS: One hundred twenty-four physician offices in Oregon and Colorado. PARTICIPANTS: Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (> or =2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty. MAIN OUTCOME MEASURES: Audiotape analysis using the Roter Interaction Analysis System. RESULTS: Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons. CONCLUSIONS: Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups.

Colorado↗
PubMed2005

Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators.

Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.

Adult↗
PubMed1994

Regional and individual differences in physician practices for joint-ventured versus non-joint-ventured physicians.

OBJECTIVE: This article compares characteristics of physicians who have invested in health care business (joint ventures) to characteristics of physicians who have not, based on a survey of Florida physicians. DATA SOURCES/STUDY SETTING: In early 1990, a survey was mailed to a stratified random sample of 1,000 Florida physicians. Half were randomly selected from lists of joint-ventured physicians who had been identified as owners in a previous study by the Florida Health Care Cost Containment Board. The remaining half were assumed to be non-joint-ventured (although incomplete results from the previous study meant that some of these physicians would be joint ventured as well). We tagged survey variables with additional variables from the same year representing exogenous influences. STUDY DESIGN: The survey was mailed to a stratified random sample of physicians across specialty and geographic area, with half to identified joint-ventured physicians and half to a control group, some of whom were expected to be joint-ventured. Thus, results regarding differences would be understated. Key variables include referring versus nonreferring physician, to shed light on motivation for joint-venturing; clientele served, to see if systematic differences had implications related to access for poor or underserved persons; geographic area, to see if joint-ventures were undertaken to increase access in rural areas; and other practice variables such as size and type of practice. DATA COLLECTION/EXTRACTION METHODS: Data from all received surveys were encoded and analyzed using SPSS. Incomplete surveys were also encoded so that all information would be available for possible use. PRINCIPAL FINDINGS: Results indicate that joint-ventured physicians are more likely than non-joint-ventured physicians to be referring physicians. Also, joint-ventured physicians report serving lower proportions of Medicaid and self-pay (uninsured) patients and higher proportions of Medicare patients. Joint-ventured physicians are also more likely to practice in urban areas, to practice full time, to be members of larger practices, and to practice in group practices. Further, joint-ventured physicians are more likely to practice in areas with high proportions of Medicare patients. CONCLUSIONS: Policymakers should continue to regard physician joint ventures as problematic, since results of this study indicate that physicians who engage in a joint venture almost always have the ability to refer patients to that joint venture due to the nature of their practices. Results also show that joint ventures are associated with decreased access: that is, they provide care to lower proportions of poor and underserved patients and rural patients than their non-joint ventured counterparts.

Economics, Medical↗
PubMed2005

Factors that influence physicians' detection of distress in patients with cancer: can a communication skills training program improve physicians' detection?

BACKGROUND: No study to date has assessed the impact of skills acquisition after a communication skills training program on physicians' ability to detect distress in patients with cancer. METHODS: First, the authors used a randomized design to assess the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by 2 communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. Then, contextual, patient, and communication variables or factors associated with physicians' detection of patients' distress were investigated. After they attended the basic communication skills training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Interviews with a cancer patient were recorded before training, after consolidation workshops for the group that attended consolidation workshops, and approximately 5 months after basic training for the group that attended basic training without the consolidation workshops. Patient distress was recorded with the Hospital Anxiety and Depression Scale before the interviews. Physicians rated their patients' distress on a visual analog scale after the interviews. Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. Communication skills were analyzed according to the Cancer Research Campaign Workshop Evaluation Manual. RESULTS: Fifty-eight physicians were evaluable. Repeated-measures analysis of variance showed no statistically significant changes over time and between groups in physicians' ability to assess patient distress. Mixed-effects modeling showed that physicians' detection of patients' distress was associated negatively with patients' educational level (P = 0.042) and with patients' self-reported distress (P < 0.000). Mixed-effects modeling also showed that physicians' detection of patient distress was associated positively with physicians breaking bad news (P = 0.022) and using assessment skills (P = 0.015) and supportive skills (P = 0.045). CONCLUSIONS: Contrary to what was expected, no change was observed in physicians' ability to detect distress in patients with cancer after a communication skills training programs, regardless of whether physicians attended the basic training program or the basic training program followed by the consolidation workshops. The results indicated a need for further improvements in physicians' detection skills through specific training modules, including theoretical information about factors that interfere with physicians' detection and through role-playing exercises that focus on assessment and supportive skills that facilitate detection.

Communication↗
PubMed2001

Physician services in an academic neurology department: using the resource-based relative-value scale to examine physician activities.

The inability of physician managers and decision makers to critically analyze the resource utilization of physicians has hindered a more comprehensive understanding of the role of neurologists in the patterns and organization of medical practice. This article outlines an approach for using the physician work relative value units (RVUs) in the Medicare Fee Schedule (MFS) to address this problem and profile physician clinical activities in a comparative manner. These techniques are then used to profile the physician services associated with the neurology department at a large academic hospital. All 28,048 physician services associated with a neurology department in 1995 were studied. Using billing data, physician work RVUs were assigned to each service and the results analyzed by major services, type of service, and physician workload for physician work RVUs and physician charges. For the average service, mean physician charges were $187 per service while median physician charges were $120. Mean physician work RVUs per service averaged 1.3 RVUs, and the median was 0.94 per service. Of all the services provided in the neurology department, 65 percent are visits and consultations, while medicine services (e.g., nerve conduction studies, needle electromyography, neuropsychological testing, and electroencephalogram) make up 31 percent. All the other services combined represented less than five percent of the services in the department. The top five physicians in the department account for 33 percent of all physician work RVUs in the neurology department. Using the physician work relative values in the MFS provides a unique perspective for analyzing and understanding neurologists' work activities.

Academic Medical Centers↗
PubMed1998

Variations in physicians' judgments about corticosteroid induced osteoporosis by physician specialty.

OBJECTIVE: Longterm corticosteroid use is associated with an increased risk of osteoporosis and fractures. Calcium and vitamin D supplementation and estrogen replacement therapy can decrease this risk, but the majority of patients receiving longterm corticosteroid treatment do not receive treatments to prevent bone loss. We assess whether this is due to variations in physicians' judgments about risks and efficacy of treatments to prevent corticosteroid-induced osteoporosis. METHODS: Questionnaires were mailed to 425 physicians, who were sampled so that half were generalists and half were specialists. Physicians were given hypothetical clinical scenarios involving patients taking corticosteroids and asked to judge the importance of osteoporosis as a risk of corticosteroid treatment, the importance of discussing this side effect with patients, and to indicate how often they would use calcium with vitamin D and estrogen for a hypothetical postmenopausal patient receiving longterm corticosteroid treatment. RESULTS: In total 198 physicians (50%) responded to this survey. Most physicians rated osteoporosis as one of the 3 most significant side effects of corticosteroid treatment for postmenopausal women, but there was significant variation in physician judgments about the importance of corticosteroid induced osteoporosis for premenopausal women (p=0.03) and men (p=0.001). There was also significant variation in physician judgments about the importance of discussing osteoporosis as a side effect with patients (p=0.001), and their use of both calcium and vitamin D (p=0.002) and estrogen replacement therapy (p=0.001) for a hypothetical postmenopausal patient. The physician characteristics most associated with these differences were physician specialty and experience with corticosteroid use. Primary care physicians and physicians who more commonly prescribe corticosteroids were more likely to report that they would use estrogen and calcium to prevent corticosteroid induced bone loss. Physician age, sex, and university affiliation had no association with physician assessments. CONCLUSION: Physicians' judgments varied significantly by physician specialty and experience with corticosteroid use. These data suggest that patients cared for by physicians in different specialties will get varying advice about osteoporosis risk and preventive treatments when receiving longterm corticosteroid treatment.

Adrenal Cortex Hormones↗
PubMed2006

Influences on patients' ratings of physicians: Physicians demographics and personality.

OBJECTIVE: There is considerable interest in the influences on patients' ratings of physicians. METHODS: In this cross-sectional study, patients (n = 4616; age range: 18-65 years) rated their level of satisfaction with their primary care physicians (n = 96). Patients and physicians were recruited from primary care practices in the Rochester, NY metropolitan area. For analytic purposes, length of the patient-physician relationship was stratified (< or =1, 1-4, > or =5 years). Principal components factor analysis of items from the Health Care Climate Questionnaire, the Primary Care Assessment Survey and the Patient Satisfaction Questionnaire yielded a single factor labeled "Satisfaction" that served as the sole dependent variable. Higher scores mean greater satisfaction. Predictors of interest were patient demographics and morbidity as well as physician demographics and personality, assessed with items from the NEO-FFI. RESULTS: Patients treated by a physician for 1 year or less rated male physicians higher than female physicians. This gender difference disappeared after 1 year, but two physician personality traits, Openness and Conscientiousness, were associated with patients' ratings in lengthier patient-physician relationships. Patients report being more satisfied with physicians who are relatively high in Openness and average in Conscientiousness. Older patients provide higher ratings than younger patients, and those with greater medical burden rated their physicians higher. CONCLUSION: Patients' ratings of physicians are multidetermined. Future research on patient satisfaction and the doctor-patient relationship would benefit from a consideration of physician personality. Identifying physician personality traits that facilitate or undermine communication, trust, patient-centeredness, and patient adherence to prescribed treatments is an important priority. PRACTICE IMPLICATIONS: Learning environments could be created to reinforce certain traits and corresponding habits of mind that enhance patient satisfaction. Such a shift in the culture of medical education and practice could have implications for patient care.

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