Is private practice experience necessary?
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To test the contention that patients in outpatient departments and private practices differ, variables were assessed that might affect both the process and the outcome of medical care. Two groups of 60 patients consulting nine Montreal internists who worked in both private practice and in an outpatient department of a university teaching hospital were surveyed. The internists served as their own controls. The two groups of patients were compared for 57 demographic, socioeconomic, access, utilization, attitudinal and current medical status variables. Financial factors were minimized by the existence of universal health insurance. The outpatient group was found to be older, less fluent in English, less likely to be employed, less educated, less wealthy, more dependent on public transportation, more disabled, more likely to use ambulatory services, more anxious about health, and more sceptical about physicians, yet more dependent on them than the private practice group. The outpatient group tended to have more active, significant medical conditions and to receive more prescriptions for medication than the private practice group, in contrast to the national patterns in the practice of internal medicine in the United States. Medical educators, researchers, administrators and providers of health care who have assumed that these two groups of patients are comparable must re-evaluate their practices.
OBJECTIVE: To compare preventive screening for children in Medicaid managed care (MMC) with children in Medicaid fee for service (M-FFS) in private and institutional settings. METHODS: The sample included randomly selected institutions and private practice physicians in New York City. Within setting, children in MMC and M-FFS were sampled randomly and charts reviewed for immunizations and lead and anemia screening. RESULTS: In both institutions and private practices, children enrolled in MMC appeared more likely to be up-to-date than their M-FFS counterparts for immunizations (institution, P <.01; private practice, P <.05), lead screening (institution, P <.01; private practice, P <.01), and anemia screening (institution, P <.01; private practice, P <.01). However, children in MMC had more visits (P <.01) and were followed up for a longer time (P <.01). After controlling for these variables, effects of MMC diminished and only remained significant for screening among private physicians. When considering 10 different attributes of managed care plans, no clear pattern of association with better preventive care services was observed. CONCLUSION: The positive effect of managed care on preventive care services was largely explained by more visits and longer follow-up time; however, there were differences between institutions and private practices, with enrollment in MMC associated with some positive effect on screenings in private practices.
Flexible endoscopy is essential for the practice of modern medicine. However, with inadequate reprocessing of endoscopes and additional instruments, infections can be transmitted. Therefore, guidelines for reprocessing flexible endoscopes have been published in many countries. The goal of the present survey was to examine the current compliance with German Guidelines in a German urban region, covering all hospitals (15 hospitals) and private practices (23 practices) of this area, without any exception. All endoscopic units in Frankfort on the Main were visited by members of the Public Health Service, using a checklist based on the recommendations of the German Guidelines. In 2004, a reevaluation of 14 hospitals and 20 private practices took place, either by analysing the written reports of the institutions or by revisiting the institutions. In 2003, compliance with the guidelines in hospitals was satisfactory. In practices, however, many problems were identified in 2003. Between 2003 and 2004, great improvements could be seen (data of 2003 in parentheses). At the end of 2004, in 90% of the practices adequate storage of the endoscope without risk of recontamination (2003:52%), correct reprocessing the bottle and the tube for air/water channel flushing including filling with sterilized water was observed (2003:74% and 52%). In 100% of the practices, ultrasonic cleaning (2003:26%) and sterilizing of endoscopic accessories was guaranteed (2003:57%) and routine tests of endoscopes after reprocessing (2003:56%) were performed. In conclusion the relevance and the effect of the advising and control of public health have been so efficient that between 2003 and 2004 most faults have been corrected. Therefore control visits of the Public Health Services should not only cover hygiene in reprocessing the endoscopes but also hygiene in reprocessing endoscopic accessories as well.
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.
The changing Australian health care system is creating new opportunities for nurses who work directly with clients in private practice settings. This study examines the scope of practice of a cohort of nurses in private practice. In a questionnaire sent to 106 self-employed nurse entrepreneurs, questions were asked pertaining to the participants' scope of practice, their clients, the types of services offered, and their fee structures. Questions about scope of practice were divided into domains of clinical practice, business consultancy, education, and research. Quantitative and qualitative data were collected for a final sample 54 eligible responses. Participants had been in private practice for an average of 7.6 years (range: 1-20) and reported a mean of 21 years of nursing experience (range: 4-42) before entering private practice. Over half held diplomas in specialty areas. Most participants reported clinical practice, consultancy, or education as the primary work domain; research was much less important as a work activity. Nurses reported difficulties with building client base and receiving adequate fees for service, particularly in clinical practice. Increasing awareness within the nursing profession and health sector about various aspects of private practice nursing could improve service quality for their clients.
Factors to be considered by the CNS before implementing the role in private practice with a physician are discussed. Four CNSs were interviewed regarding their experiences in such a practice. The CNS subroles of expert practitioner, educator, consultant, and researcher are described as they apply in private practice with a physician. A four-step process is proposed to guide the CNS considering entry into private practice. The steps discussed are: self-assessment, evaluation of the legal and financial aspects, development of marketing and cost-justification strategies, and negotiating for a position. A method for cost justification is proposed, and some elements of marketing and negotiating are reviewed.
Despite all warnings from the German Ministry of Health, the healthcare insurances and the media, the number of diagnostic (DIAG) and therapeutic (PCI) cardiac catheterizations is continuously growing in hospitals and in private practices. From 1997 to 1999, the number of DIAG increased from 478837 to 561623 and PCI from 135925 to 166132. The average number of DIAG per institution decreased from 1482 in 1997 to 1324 in 1999 and the average number of PCI from 535 to 479. The number of DIAG-performing hospitals increased from 256 to 315 and that of DIAG-performing private practices from 67 to 109. The number of PCI-performing hospitals increased from 211 to 278 and the corresponding private practice locations from 43 to 69. In 1999, 18% of all DIAG and 15% of all PCI in Germany was performed in private practice. Since 1994, the average number of DIAG per private practice continuously decreased as well as the average number of PCI per private practice since 1997. This decrease was more pronounced in private practice (DIAG 378/lab and PCI 111/lab) than in hospitals (DIAG 68/lab and PCI 35/lab). Possible reasons for this trend are an increasing number of low volume centers, a more rigid indication for DIAG and PCI due to quality control programs, and the reduction of reimbursement incentives for social healthcare insured patients in private practice. The real optimal need for DIAG and PCI in Germany, however, has to be determined.
Fifty private practitioners and their office staff members were randomly assigned to one of four groups: participants received a protocol for smoking management and a lecture on the consequences and management of smoking, or in addition, had nicotine gum freely available to patients, had stickers attached to their charts, or had gum and reminders. The percentage of patients in each group who had quit smoking a year later was 7.7, 16.3, 8.6, and 16.9, respectively, indicating a significant main effect for the gum conditions. The availability of nicotine gum also significantly increased the amount of time that patients reported they received smoking cessation counseling from the dentists and office staff.
OBJECTIVES: This study sought to identify provider practices and policies in private pediatric settings that relate to vaccination status, controlling for the characteristics of the children served. METHODS: Vaccination data came from the medical records of 709 randomly selected 2-year-old children at 18 private practices and managed care organizations in Maryland, family data from 466 telephone interviews with the children's parents, and provider characteristics from 18 site questionnaires and 42 individual physician and nurse practitioner questionnaires. Logistic regression and generalized estimating equations were used to estimate the relation of provider characteristics to vaccination status. Three age-appropriate (AA) and two up-to-date (UTD) vaccination status variables characterized successful vaccination. RESULTS: Approximately 70% of the study children were up-to-date by age 2 years for the full vaccination series, excluding hepatitis B vaccine. Family demographic characteristics were the strongest correlates of undervaccination. Neither parents' knowledge and attitudes about immunization nor the children's insurance coverage was statistically related to vaccination status. Site reminder or follow-up systems and provider perceptions about appointment scheduling and receipt of vaccine information from health departments were positively related to vaccination. Concern for liability was associated with a reduced odds of age-appropriate and up-to-date vaccination. CONCLUSIONS: Family demographics strongly correlate with vaccination status; however, they are generally not modifiable. This study's findings encourage providers to operate a tracking system, to remain current on immunization recommendations, to use all clinical encounters to screen and vaccinate children, and to ensure the availability and convenience of vaccination services.
OBJECTIVE: To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. DESIGN: Cross-sectional qualitative survey. SUBJECTS: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tomé and Principe answered a self-administered questionnaire. RESULTS: All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. CONCLUSION: The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life.
Seeing adolescent patients in private practice can be a challenging experience. Practical suggestions concerning the office setting scheduling, staffing, and billing are outlined. Physician attributes seen from an adolescent viewpoint are also enumerated. Finally, indications for pelvic examinations in this age group, interviewing, and confidentiality are discussed.
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