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PubMed1978

Comparing clinic and private practice of psychiatry.

The author compared data on 2,020 cases treated by private psychiatrists with those on 2,052 cases treated by clinic psychiatrists in California. He also compared data on private treatment in California with those from a national survey of private psychiatrists. Private psychiatrists in California treated as many psychotic patients and used relatively brief psychotherapy about as often as clinic psychiatrists and were more likely to use hospitalization and to see patients individually. In comparison with the national sample, private psychiatrists in California treated more children and patients with situational disturbances and were more likely to receive payment from government sources.

California↗

PubMed2003

What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?

OBJECTIVE: Because career satisfaction among general internists is relatively low, we sought to understand the impact on satisfaction of general internists managing patients both in and outside of the hospital. Using data from a national survey, we asked, "Among outpatient-oriented general internists (i.e., internists who spend less than 50% of their clinical time caring for inpatients), what effect does time spent in the hospital have on physician satisfaction, stress, and burnout?" DESIGN/PARTICIPANTS: The Physician Worklife Study, in which 5,704 physicians in primary and specialty nonsurgical care selected from the American Medical Association's Masterfile were surveyed (adjusted response rate = 52%), was used. Our analyses focused on clinically active outpatient-oriented general internists (N = 339). MEASUREMENTS AND MAIN RESULTS: We constructed multivariate linear models to test for statistically significant associations between the amount of time spent seeing inpatients and physician satisfaction as measured by several satisfaction scales. Even after controlling for total hours worked and other possible confounding variables, we found that increased time working in the hospital was significantly associated with decreases in satisfaction with administration, specialty, autonomy, and personal time, and significantly associated with an increase in life stress. There was also a significant association between increased time spent in the hospital and burnout. CONCLUSIONS: Our findings imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists, and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. Although additional studies are warranted in order to better understand why these relationships exist, our data suggest that the hospitalist model of inpatient care might be one approach to alleviate stress and improve satisfaction for many general internists.

Adult↗

PubMed1979

The psychiatrist's role at a local hospital in the northern part of Norway and his cooperation with the primary health service in the area.

This paper describes a practical working situation for a psychiatrist situated in the northern part of Norway. The psychiatrist is attached to the local hospital on a part time basis and takes care of the psychiatric cases in the medical ward together with somatic cases. In addition, he works in a polyclinical setting in town, in close contact with several health and social services, and tries to be close to where the problems originate. The psychiatrist deals mainly with crisis interventions and has a social psychiatric approach.

Arctic Regions↗

PubMed1975

Psychiatric training and practice in the People's Republic of China.

Improved political relations between the United States and the People's Republic of China have led to closer contact in many areas. The authors trace the development of psychiatric training and practice in China with emphasis on the years after 1949. Since then, China has expanded psychiatric services to meet the needs of a vast population and has developed a theoretical approach to psychiatry that emphasizes sociopolitical factors. Additional information given to the authors in 1973 by psychiatrists in Nanking and Shanghai is presented and correlated with reports by other recent visitors to the People's Republic of China.

Ambulatory Care↗

PubMed2004

Strategies to reduce medication errors in ambulatory practice.

Medication errors generally refer to mistakes made in the processes of ordering, transcribing, dispensing, administering or monitoring of pharmaceutical agents used in clinical practice. The Institute of Medicine report, To Err Is Human: Building a Safer Health System, has helped raise public awareness surrounding the issue of patient safety within our hospitals. A number of legislative and regulatory steps have resulted in hospital authorities putting in place various systems to allow for error reporting and prevention. Medication errors are being closely scrutinized as part of these hospital-based efforts. Most Americans, however, receive their healthcare in the ambulatory primary care setting. Primary care physicians are involved in the writing of several million prescriptions annually. The steps underway in our hospitals to reduce medication errors should occur concurrently with steps to increase awareness of this problem in the out-patient setting. This article provides an overview of strategies that can be adopted by primary care physicians to decrease medication errors in ambulatory practice.

Ambulatory Care↗

PubMed2000

Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey.

PURPOSE: We sought to determine the availability and utilization of, as well as physician attitudes toward, the hospitalist model in the United States. SUBJECTS AND METHODS: Using a telephone survey, we asked physicians who were board certified in internal medicine about their inpatient practice arrangements, the availability of hospitalist services, and their attitudes toward the hospitalist model. All physicians were generalists in active clinical practice. Using multivariable methods, we determined factors associated with attitudes toward the hospitalist model. RESULTS: We were able to contact 787 of 2,829 physicians who were randomly selected from a national list of board-certified internists, of whom 400 agreed to participate. Most respondents were familiar with the term "hospitalist" and had hospitalist services available in their community, and 28% used hospitalists for their inpatients. Few (2%) reported the presence of the "mandatory" hospitalist model. Physicians reported that the model was more commonly available in Western states (84% vs. 55% to 63% in other regions, P<0.0001). Seventy-three percent thought hospitalist systems would reduce continuity of care. Only 28% thought that patients would prefer care from an inpatient specialist, but 51% thought patients might get better care, and 47% thought patients might get more cost-effective care in a hospitalist system. In multivariable models, physicians who were in solo practice, those in specialties with more inpatient practice, and those who had more patients hospitalized each month responded more negatively about the model, whereas those with hospitalists in their community were more positive. CONCLUSIONS: Although agreeing that quality of care and efficiency might be improved, physicians were concerned about patient-doctor relationships and patient satisfaction in a hospitalist model. Future studies should determine the effect of the hospitalist model on these outcomes.

Attitude of Health Personnel↗

PubMed1998

Managing quality in hospital practice.

BACKGROUND: While routine clinical decision-making has a substantial effect on quality, most practising physicians do not routinely examine their outcomes. OBJECTIVES: To set up a practical process for identifying problems in hospital practices of primary care physicians, examine their causes, and develop a quality improvement process that intimately involves practising physicians in problem-solving. DESIGN: All hospital admissions to the Primary Care Service were screened over a 14-month period using simple pre-specified criteria. Quality problems were verified by medical record reviews carried out by two physicians. These problems were discussed at monthly meetings of physicians to characterize the problems fully, identify their causes, and document adverse effects on patient outcomes. SETTING: One community hospital. PARTICIPANTS: Primary care physicians from three group practices and four solo practices who admit patients to the Primary Care Service. INTERVENTIONS: Monthly group discussions plus discussions with individual physicians when time did not permit all quality problems to be discussed at group meetings. Certain issues of high sensitivity were also discussed with the individuals rather than in an open forum. OUTCOME MEASURES: Missed or delayed diagnoses, inappropriate treatments, and complications and their root causes. RESULTS: Quality problems were identified in 6% of all admissions. Of these, 60% were missed or delayed diagnoses, 22% were iatrogenic complications and 18% were inappropriate treatments. Root cause analysis suggested that physician behaviors led to 75% of problems; systems problems to 20% and inadequate knowledge to 5%. Process improvements included development of a call-in system to reduce delays in obtaining X-ray reports; implementation of an anticoagulation monitoring system in one group practice; and a protocol of regular feedback of errors in diagnosis to emergency room physicians. Participating physicians reported increased awareness of common errors and greater attention to detail in patient evaluations. CONCLUSIONS: Knowledge of root causes of quality problems is essential for improving quality of care. A simple routine approach to examining adverse outcomes and how care might be improved in the future was set up. Active participation of practising physicians is essential. Other organizations could use this process for routinely reviewing and improving quality.

Adult↗

PubMed1999

Physician recruitment: understanding what physicians want.

One of the more dramatic changes in the healthcare industry has been the movement of physicians, particularly younger professionals, from private practice to some type of healthcare organization. In this study we examine the importance attached to specific incentives by physicians in making an affiliation decision and healthcare administrators. Our results suggest significant differences between the importance placed on certain recruiting incentives by physicians and healthcare administrators. Further, they suggest distinct differences in importance ratings by different types of physicians. Implications of this study argue for developing different compensation packages to appeal to different segments of physicians.

Attitude of Health Personnel↗

PubMed1999

Reduction in methicillin-resistant Staphylococcus aureus infection rate in a nursing home by aggressive containment strategies.

For the month of October, 1993, the Methicillin-Resistant Staphylococcus aureus nosocomial infection rate in our 42-bed Extended Care Unit/Nursing Home was 33% (8.5% for the 1993 year). Our facility was committed to decrease colonization and infection rates and to prevent the introduction of additional colonized patients into the closed environment. Methicillin-Resistant Staphylococcus aureus containment practices were instituted and consisted of total population and staff surveillance, aggressive containment measures and followed by maintenance containment protocols. The aggressive plan included contact isolation, baths with chlorhexagluconate, treatment of nasal carriers with mupiricin and treatment of both colonized and infected patients. This was followed by maintenance measures of screening new admissions for Methicillin-Resistant Staphylococcus aureus with contact isolation and treatment for positive as described during the aggressive phase. Total population surveillance was repeated after one year. Results showed that no employees were colonized with Methicillin-Resistant Staphylococcus aureus. The initial colonization rate in residents/patients was 52%. After one year the colonization rate dropped to 2% and the infection rate to 1.4%. Molecular epidemiology demonstrated that there was limited acquisition of new strains of Methicillin-Resistant Staphylococcus aureus within the Extended Care Unit. The process was shown to be cost effective. Aggressive containment practices applied to a nursing home with a high Methicillin-Resistant Staphylococcus aureus infection rate not only reduced rates of colonization, but also markedly reduced infections. This reduction was maintained over time.

Aged↗

PubMed2004

A survey of tuberculosis hospitals in India.

SETTING: Hospitals with beds for tuberculosis (TB) in India. OBJECTIVES: To assess diagnostic and treatment practices at institutions offering secondary or tertiary level care for TB patients, and to determine the resources being used at these institutions. DESIGN: Countrywide cross-sectional survey of TB hospitals using a mailed semi-structured questionnaire sent to all 105 hospitals with 100 or more beds and to all State Directorate Health Services. RESULTS: The 94 hospitals that returned the questionnaire had 15773 TB beds, one third of the total TB beds in the country. Nearly 1 million patients sought treatment in the TB hospitals and one third were diagnosed with TB; the ratio of smear-positive to smear-negative patients was 1:2.7. Sixty-four per cent of hospitals prescribed unobserved rifampicin in the continuation phase, and 56% of sputum smear-positive patients were hospitalised. The annual expenditure for the TB hospitals was more than the total annual budget for the TB control programme of the country. CONCLUSIONS: In view of the high number of patients seen and the suboptimal practices observed, urgent steps should be taken to ensure implementation of correct diagnostic and treatment policies in hospitals with TB beds.

Cross-Sectional Studies↗

PubMed1990

Orthopaedic training in private practice.

The background philosophy, structure and training experience offered by a new free-standing clinic set up purely to facilitate orthopaedic post-graduate training is described. Emphasis is placed on the ethical issues involved. The educational programme, which includes involvement in all local and national activities, is summarized. The registrars' operative experience is recorded using log-sheet criteria. This venture has predated the major restructuring of the health care system in Auckland, which is anticipated in the next few years, and will therefore allow the training programme to evolve appropriately, employing the educational opportunities of all sectors of health care.

Education, Medical, Graduate↗

PubMed2005

Introduction to pediatric hospital medicine.

This article provides a brief summary of the past, present, and future of pediatric hospital medicine. In its short history, it already has made an impact on the way pediatrics is practiced and taught. There is no denying Dr. Menna's prescience when he wrote his opinion in 1990. As the field continues to emerge and mature, the current leadership is cognizant of the obstacles ahead and the need to maintain the goal of the well-being of all children. Maintaining that goal means redoubling efforts to maintain contact with primary care providers for continuity of care in and out of the hospital. Only by promoting patient- and family-centered care, inclusive of all providers, can children's health best be served.

Hospitalists↗

PubMed1991

A comparison of hospital-based and private outpatient physical therapy practices.

A paucity of data exists about the delivery of contemporary adult outpatient physical therapy services in the United States. Although many debates about this issue have taken place within the physical therapy profession, assumptions about practice patterns have generally not been studied. This article reports some of the first-year findings from a 3-year survey research effort begun in September 1988 by Mathematica Policy Research Inc for the American Physical Therapy Association. Analyses are based on survey data from national probability samples of physical therapy facilities and discharged patients from 155 hospital-based and 166 private outpatient practices. The primary goal was to compare outpatient physical therapy practice patterns in the hospital-based and private practice settings. Findings reveal considerable homogeneity in private and hospital-based outpatient physical therapy practices. Hospital-based and private practices serve predominantly young, white adults who have private health insurance and a prevalence of orthopedic impairments. In both settings, direct access to outpatient physical therapy services was the exception and not the rule. Even in states in which direct access without a physician's referral was permitted by law, the majority of outpatient physical therapy was provided with a physician's referral. Most respondents in direct-access states indicated that reimbursement requirements were the major reason for needing a physician's referral to provide outpatient physical therapy.

Adult↗

PubMed2001

The Freiburg approach to ethics consultation: process, outcome and competencies.

The paper describes how ethics consultation can be valuable to health professionals, patients and their families in understanding and evaluating ethical values and their consequences in a particular situation. Ethics consultation as it is practised at the university hospital of Freiburg is a special professional service offered by members of an academic institution. The practical approach and the goals are illustrated by a case study showing the difficulties of deciding about the limitation of intensive care medicine after heart surgery in the setting of maximum treatment. Here, the ethics consultation was initiated by the relatives of the patient who wanted a decision to withhold further life-sustaining treatment. Following the experiences in Freiburg, it is concluded that clinical ethicists have to cover a variety of relevant fields of knowledge, need special analytical skills, and should have professional competence in counselling, including conflict mediation or crisis intervention.

Ethicists↗

PubMed1991

What obstetricians should know about anesthesia care standards.

In recent years the American Society of Anesthesiologists (ASA) has adopted several practice standards that relate directly to the practice of obstetric anesthesia. In addition, the American College of Obstetricians and Gynecologists and ASA defined, in a joint statement, both organizations' views on optimal goals for anesthesia care in obstetrics. Ostensibly, those documents and a number of others promulgated by the two professional organizations enhance the safety of patient care. Knowledge of the documents is equally important to the obstetrician and the anesthesiologist since care rendered to the parturient by the two specialists is closely intertwined, and so are their respective fates in case of legal action.

Anesthesia, Obstetrical↗

PubMed1989

Hospital practices and breastfeeding duration: a meta-analysis of controlled trials.

Controlled clinical trials studying the influence of hospital practices on breastfeeding duration were combined using meta-analysis. Nine studies were selected. Supplementation demonstrated a negative clinical effect on breastfeeding duration that was not significant. Nursing support demonstrated a positive clinical effect on breastfeeding duration that was not statistically significant if there was no telephone follow-up, but was significant if there was telephone follow-up. Early contact revealed a positive clinical effect that was significant. We conclude that early contact and nursing support with telephone follow-up appear as enhancing factors of breastfeeding duration.

Aftercare↗

PubMed1992

Increasing patient throughput in magnetic resonance imaging: a practical approach. Oxford MRI Group.

A major factor governing the throughput of patients in a magnetic resonance imaging (MRI) service is the number and length of sequences employed. This study investigated the feasibility of prospectively selecting patients for whom a pre-planned examination of the brain, spine or knee could be applied with a high chance of success. The implications on throughput of using these pre-planned examinations were determined. 173 patients were studied. A successful outcome was defined as an examination in which a diagnosis could be made with 100% confidence and without the need for further sequences. Examinations of the brain (n = 113), knee (n = 23) and lumbar spine (for disc degeneration, n = 14) were performed with success rates of 96%, 87% and 64%, respectively. Examinations of the lumbar spine (for radicular symptoms, n = 20) and cervical spine (n = 3) were performed with success rates of 85% and 66%, respectively. The examinations of the brain, knee and lumbar spine (for disc degeneration) were completed within the target time of 20 min in 92%, 95% and 69% of cases, respectively. Examinations of the lumbar spine (for radicular symptoms) and cervical spine were completed within 30 min in 75% and 33% of cases, respectively. Analysis of our results suggests that success rates could be improved by minor changes in sequence design. Carefully selected patients can be successfully examined in short examination times. Instituting these practices would increase the efficiency of MR machine time and improve patient throughput by 80-125%. This would have a marked effect on the length of waiting lists, and would increase the general availability of MRI.

Brain Diseases↗

PubMed2006

Academics or private practice? The future of dermatologic surgery education.

BACKGROUND: The career choices of Mohs fellows have important implications for ensuring the quality of dermatologic surgery training during residency. No published data examine the career choices of fellows in Mohs micrographic surgery. OBJECTIVE: To determine the number of Mohs fellows entering academics and to examine the influence of fellowship characteristics, scholarly activities, and personal background on career decision. METHODS: A voluntary survey was distributed by mail in June 2004 to all Mohs fellows-in-training during 2003-2004. RESULTS: Twenty-nine percent (12 of 42) of the fellows chose jobs in an academic or university setting. The practice setting of the fellowship, personal factors, and scholarly activities prior to fellowship did not correlate with career decision. By contrast, increased scholarly activities during fellowship and an interest in teaching did correlate with the choice to enter academics. CONCLUSIONS: A significant percentage of Mohs fellows pursued academics. Increased academic productivity during the fellowship and an interest in teaching correlated with the decision to pursue an academic career. Fellowship directors interested in encouraging academic careers may find these data useful to structure their curricula and to mentor fellows inquiring about academic careers.

Academic Medical Centers↗