The relationship between the race/ethnicity of generalist physicians and their care for underserved populations.

OBJECTIVES: The purpose of this study was to examine empirically the relationship between physicians' race or ethnicity and their care for medically underserved populations. METHODS: Generalist physicians who received the MD degree in 1983 or 1984 (n = 1581) were surveyed. The personal and background characteristics of four racial/ethnic groups of physicians were compared with the characteristics of their patients. RESULTS: When the potentially confounding variables of gender, childhood family income, childhood residence, and National Health Services Corps financial aid obligations were controlled, generalist physicians from underrepresented minorities were more likely than their nonminority counterparts to care for medically underserved populations. CONCLUSIONS: Physicians from underrepresented minorities are more likely than others to care for medically underserved populations.     

Comparisons among three types of generalist physicians: Personal characteristics, medical school experiences, financial aid, and other factors influencing career choice

A national survey of family physicians, general internists, and general pediatricians was conducted in the US to examine differences among the three groups of generalists physicians, with particular regard to the factors influencing their choice of generalist career. Family physicians were more likely to have made their career decision before medical school, and were more likely to have come from inner-city or rural areas. Personal values and early role models play a very important role in influencing their career choice. In comparison, a higher proportion of general internists had financial aid service obligations and their choice of the specialty was least influenced by personal values. General pediatricians had more clinical experiences either in primary care or with underserved populations, and they regarded medical school experiences as more important in influencing their specialty choice than did the other two groups. Admission committees may use these specialty-related factors to develop strategies to attract students into each type of generalist career.     

The impact of perceived barriers on primary care physicians' screening practices for female partner abuse

OBJECTIVES: Our purpose was to examine primary care physicians' screening practices for female partner abuse in different clinical situations and to investigate the relationship between perceived barriers and screening practices. METHODS: A cross-sectional survey was mailed to Alaska physicians practicing in the following specialties: family practice, internal medicine, obstetrics/gynecology and general practice. RESULTS: The survey response rate was 80 percent (305/383). The majority (85.7%) of primary care physicians screened often or always when a female patient presents with an injury, but they rarely screened at initial visits (6.2%) or annual exams (7.5%). More than one-third of respondents estimated that 10% or more of their female patients had experienced some type of intimate partner abuse. Several barriers to screening described in the literature were not predictive of physicians' screening practice patterns. Physicians' perceptions that abuse is prevalent among their patients and physicians' beliefs that they have a responsibility to deal with abuse were the only variables independently associated with screening at initial visits and annual exams. The only variable predictive of screening when a patient presents with an injury was physicians' perceived prevalence of abuse. CONCLUSION: Primary care physicians have not integrated screening for partner abuse into routine care. Strategies to increase awareness of the high prevalence of abuse in the primary care setting and to educate providers on the negative health effects of victimization can help physicians to acknowledge their responsibility in addressing abuse and the importance of screening at routine visits. Further rigorous studies are needed to identify and evaluate predictors of screening for abuse.     

The Physician Pipeline to Rural and Underserved Areas in Pennsylvania

ABSTRACT: Context: An implicit objective of a state's investments in medical education is to promote in‐state practice of state educated physicians. Purpose: To present a tool for evaluating this objective by analyzing the “pipeline” from medical education to patient care, primary care, rural areas, and underserved areas in Pennsylvania. Methods: AMA Masterfile data (2004) including all physicians with a Pennsylvania address or who received medical education in Pennsylvania were analyzed. These data were combined with local physician supply data. Results: About 36% of Pennsylvania medical school graduates provide patient care in the Commonwealth, 16% primary care, 7% rural care, 4% rural primary care, and 0.5% primary care in a rural underserved area. Fifty‐four percent of physicians who received both undergraduate and graduate medical education in‐state are retained. Conclusions: These retention rates have developed within the context of a middle‐of‐the‐road educational pipeline policy. If Pennsylvania policy makers consider that further pipeline development is advisable, there is room to amend current policy to that end. Conditions are favorable for other states to consider similar policy amendments.     

Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends

Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010. Using a cross-sectional study design, logistic regression analysis was performed to examine association between maternity care provision and various physician demographic and practice characteristics. Maternity care provision by family physicians declined from 23.3 % in 2000 to 9.7 % in 2010 (p < 0.0001). Family physicians who were female, younger and US medical graduates were more likely to practice maternity care. Practicing in a rural setting (OR = 2.2; 95 % CL 2.1–2.4), an educational setting (OR = 6.4; 95 % CL 5.7–7.1) and in either the Midwest (OR = 2.6; 95 % CL 2.3–2.9) or West (OR = 2.3; 95 % CL 2.1–2.6) were the strongest predictors of higher likelihood of providing maternity care. While family physicians continue to play an important role in providing maternity care in many parts of the United States, the steep decline in the percentage of family physicians providing maternity care is concerning. Formal collaborations with midwives and obstetrician-gynecologists, malpractice reform, payment changes and graduate medical education innovations are potential avenues to explore to ensure access to maternity care.     

Prostate-specific antigen for prostate cancer screening. Do physician characteristics affect its use?

PURPOSE: Screening for prostate cancer with the prostate-specific antigen (PSA) test remains controversial. This controversy is reflected in a lack of consensus in the medical literature and among professional and policy organizations regarding routine screening by PSA. It is not known how physicians respond when recommendations from experts are inconsistent. METHODS: A questionnaire was mailed to 1369 primary care physicians in active practice in Washington State in 1994. Response rate to the survey was 63%. Chi-square tests and multivariate logistic regression analysis were used to examine the effects of physician characteristics on physicians' self report of use of the PSA test for screening asymptomatic male patients, aged 50 to 80, for prostate cancer. RESULTS: Of the 714 physicians included in the analysis, 68% reported routine use of PSA. Use of PSA varied among physicians on the basis of practice setting, years since medical school graduation, and whether compensation was fee-for-service or salaried. Male physicians trained before 1974 and physicians receiving fee-for-service were significantly more likely than other physicians to recommend screening by PSA. CONCLUSIONS: Results suggest that physicians' personal characteristics such as year of medical school graduation, gender, and mode of reimbursement are related to self-reported PSA use.     

Physicians' Perceptions of the Changing Health Care System: Comparisons by Gender and Specialties

This study was designed to investigate physicians' perceptions of changes in the United States health care system impacting academic medicine, quality of care, patient referrals, cost, ethical and sociopolitical aspects of medicine. A survey was mailed in 1998 to 1,272 physicians (graduates of Jefferson Medical College between 1987 and 1992); 835 physicians (66%) responded. Results showed that a substantial majority (92%) believed that learning to work in a managed care environment should become an essential component of medical education. Physicians perceived that current changes impair physicians' autonomy (94%), and restrain physicians' freedom to provide optimal care (84%). A sizable majority (76%) endorsed patients' freedom to seek specialist care, and 55% believed that capitation reduces physicians' motivation for long-term monitoring of patients. The majority endorsed universal health coverage (80%), and agreed to support rather than resist the changes (62%). Only 18% hold a positive view of the changes in the future. The majority believed that medical education should prepare physicians to provide end-of-life care (92%), and that organized medicine should take a stand on social issues that can influence the well-being of society (79%). Only 34% endorsed the legalization of physician-assisted suicide. No gender differences were observed, but a few differences were found between generalists and specialists. Results can help in understanding physicians' perceptions of current changes in the United States health care system, and in providing guidelines for the development of educational programs to prepare physicians to face new challenges.     

A comparative analysis of factors that hinder primary care physicians' and specialist physicians' ability to provide high-quality care

A study was undertaken to examine factors that hinder primary care physicians' and specialist physicians' ability to provide high-quality care. The study used data collected by the Center for Studying Health System Change's 2008 Health Tracking Physician Survey. The 2008 Health Tracking Physician data set consisted of 4720 physicians belonging to the American Medical Association. Both primary care physicians and specialists rated care decisions rejected by insurance (49%, 51%), followed by patient being unable to pay for needed care (45%, 43%), and patient noncompliance with treatment recommendation (43%, 37%) as the top major problem areas in providing quality care to patients. In addition, 36% of primary care physicians and 27% of specialists reported that inadequate time with patients during visit was a major problem in providing quality care to patients. Primary care physicians reported significantly more problems associated with having adequate time with patients during office visits, ability of patients to pay for needed care, availability of qualified specialists in the area, receiving timely reports from other doctors, and patient noncompliance with treatment recommendations. On the other hand, primary care physicians reported significantly lower communication difficulties with patients due to language or cultural barriers. Care decisions rejected by insurance, patient being unable to pay for care, and patient noncompliance with treatment recommendation were the top 3 hindrances in providing quality care to patients for both physician types. For 6 of the 8 hindrance factors, there were significant differences in the level of problems identified by primary care physicians and specialist physicians.     

Physician-patient discussions of controversial cancer screening tests

BACKGROUND: Screening mammography for younger women and prostate-specific antigen (PSA) measurement have controversial benefits and known potential adverse consequences. While providing informed consent and eliciting patient preference have been advocated for these tests, little is known about how often these discussions take place or about barriers to these discussions. METHODS: We administered a survey to medical house staff and attending physicians practicing primary care. The survey examined physicians' likelihood of discussing screening mammography and PSA testing, and factors influencing the frequency and quality of these discussions. RESULTS: For the three scenarios, 16% to 34% of physicians stated that they do not discuss the screening tests. The likelihood of having a discussion was significantly associated with house staff physicians' belief that PSA screening is advantageous; house staff and attending physicians' intention to order a PSA test, and attending physicians' intention to order a mammogram; and a controversial indication for screening. The most commonly identified barriers to discussions were lack of time, the complexity of the topic, and a language barrier. CONCLUSIONS: Physicians report they often do not discuss cancer screening tests with their patients. Our finding that physicians' beliefs and intention to order the tests, and extraneous factors such as time constraints and a language barrier, are associated with discussions indicates that some patients may be inappropriately denied the opportunity to choose whether to screen for breast and prostate cancer.     

Primary care and nonprimary care physicians' concerns in practice and perceptions of medical school curriculum

The purpose of the present study is to address the issue of physicians' concerns in practice and their perception of a medical school's curriculum with an emphasis on comparisons between primary and nonprimary care physicians. The sample consisted of 663 physicians who graduated from Jefferson Medical College (JMC) between 1982 and 1986, and also responded to a mailed questionnaire. Comparisons were made between physicians in primary care (n=234) and in nonprimary care (n=429) specialties on their responses regarding concerns in medical practice and evaluation of the medical school curriculum. Primary care physicians were more concerned about the time for their professional development whereas nonprimary care physicians were more concerned about an oversupply of physicians in their specialties, prospective hospital payment, and malpractice litigation. Regardless of the specialties, the physicians overall seemed very concerned about their personal time. Interpersonal skills were regarded by all respondents as an important aspect of the medical school's curriculum. The importance of psychological, social, and cultural factors in the curriculum was strongly supported by these physicians' responses, particularly among primary care and women physicians.     

Clinician-patient communication about physical activity in an underserved population.

BACKGROUND: The 5A (Ask, Advise, Agree, Assist, Arrange) model, used to promote patient behavior changes in primary care, can also be applied to physical activity. Our goal was to assess primary care physicians' use of the 5A model in discussions with underserved populations about physical activity. METHODS: We analyzed 51 audio-recorded, transcribed office visits on randomly selected patient care days and after-visit patient surveys with adults in 2 community health centers in Rochester, New York. RESULTS: The patient sample was 51% African-American and predominantly female (70%), with the majority having a high school-level education or less (66%) and an annual household income < dollars 39,000 (57%). Physical activity was discussed during 19 of the 51 visits, which included 16 (84%) visits with "Ask"; 10 (53%) with "Advise"; 4 (21%) with "Agree"; 5 (26%) with "Assist"; and 0 with "Arrange" statements. Most discussions of physical activity contained several Ask or Advise statements but few Agree, Assist, or Arrange statements. CONCLUSION: Communication about physical activity that included Agree, Arrange, and Assist statements of the 5A model was infrequent. Health promotion interventions in underserved populations should target these steps and prompt patients to initiate communication to improve physical activity.     

Personal values of family physicians, practice satisfaction, and service to the underserved

BACKGROUND: Personal values are defined as "desirable goals varying in importance that serve as guiding principles in people's lives," and have been shown to influence specialty choice and relate to practice satisfaction. We wished to examine further the relationship of personal values to practice satisfaction and also to a physician's willingness to care for the underserved. We also wished to study associations that might exist among personal values, practice satisfaction, and a variety of practice characteristics. METHODOLOGY: We randomly surveyed a stratified probability sample of 1224 practicing family physicians about their personal values (using the Schwartz values questionnaire), practice satisfaction, practice location, breadth of practice, demographics, board certification status, teaching involvement, and the payor mix of the practice. RESULTS: Family physicians rated the benevolence (motivation to help those close to you) value type highest, and the ratings of the benevolence value type were positively associated with practice satisfaction (correlation coefficient = 0.14, P = .002). Those involved in teaching medical trainees were more satisfied than those who were not involved (P = .009). Some value-type ratings were found to be positively associated with caring for the underserved. Those whose practices consisted of more than 40% underserved (underserved defined as Medicare, Medicaid, and indigent populations) rated the tradition (motivation to maintain customs of traditional culture and religion) value type significantly higher (P = .02). Those whose practices consisted of more than 30% indigent care rated the universalism (motivation to enhance and protect the well-being of all people) value type significantly higher (P = .03). CONCLUSIONS: Family physicians who viewed benevolence as a guiding principle in their lives reported a higher level of professional satisfaction. Likewise, physicians involved in the teaching of medical trainees were more satisfied with their profession. Family physicians who rate the universalism values highly are more likely to provide care to the indigent.     

The impact of medical informatics on the confidence of rural physicians caring for patients with chronic hepatitis C viral infections.

OBJECTIVE: The purpose of the present study was to determine whether CD-based medical informatics enhances rural physicians' confidence in the management of patients with chronic hepatitis C viral infections. METHODS: A total of 385 Canadian rural physicians were mailed a CD-based medical software programme that outlines all aspects of HCV care including diagnosis, counselling, treatment and follow-up. Accompanying the CD was a brief questionnaire that addressed physicians' confidence in the following areas: (i) identifying HCV patients in their practice; (ii) laboratory use and interpretation; (iii) patient counselling; (iv) selection of candidates for treatment; (v) sharing treatment delivery; and (vi) providing follow-up. Three months thereafter, the same questionnaire was repeated. RESULTS: Of the 385 mailings, 59 (15%) physicians returned the initial questionnaire and 57 (15%) the follow-up questionnaire. Twenty-five (44%) respondents indicated they had used the CD. Baseline physician confidence was low in three of the six areas addressed. At follow-up, in addition to now being confident in all areas, CD users were significantly more confident than those who had not used the CD. Increases in physician confidence for CD users were approximately 150-300% in the six areas addressed. The value assigned the CD programme was 8/10. CONCLUSION: The results of this study indicate that: (i) rural physicians are uncomfortable in dealing with many aspects of HCV management; (ii) CD-ROM-based medical informatics can significantly enhance rural physicians' confidence in these areas; (iii) approximately 50% of physicians will employ CD-ROM-based medical informatics in their offices; and (iv) physician level of satisfaction with such programmes is high.     

Physicians' Screening Practices for Female Partner Abuse During Prenatal Visits

Objective: Our purpose was to examine physicians' screening practices for female partner abuse during prenatal visits and to identify barriers to screening. Methods: A self-administered questionnaire was developed to collect data on physicians' screening practices and their beliefs about screening for female partner abuse. The survey was mailed to all primary care physicians practicing in Alaska. The response rate was 80% (305/383). These analyses were limited to physicians who indicated that they provided prenatal care (n = 157). Results: More than one-half of respondents providing prenatal care estimated that 10% or more of their female patients had experienced abuse. Less than one-half of respondents had recent training on partner abuse. Only 17% of respondents routinely screened at the first prenatal visit and 5% at follow-up visits. Respondents were more likely to screen at the first prenatal visit compared to follow-up visits. Multivariate analyses failed to support any associations between physicians' characteristics and screening practices. Physicians' perception that abuse was prevalent among their patients and physicians' belief that they have a responsibility to deal with abuse were the only variables that were independently associated with screening at prenatal visits. Other barriers frequently cited in the literature were not predictive of screening. Conclusion: Most Alaskan physicians do not routinely screen for abuse during prenatal visits. Medical education should increase physicians' index of suspicion for abuse, emphasize physicians' responsibility to address partner abuse, and reinforce the importance of routine screening throughout the pregnancy. More research is needed to identify barriers to screening and strategies for integrating routine screening into prenatal care.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

The Correlation between Global Health Experiences in Low-Income Countries on Choice of Primary Care Residencies for Graduates of an Urban US Medical School

This study sought to determine whether medical students who participate in a global health elective in a low-income country select residencies in primary care at higher rates compared with their classmates and US medical graduates in general. Given the projected increase in demand for primary care physicians, particularly in underserved areas, understanding possible factors that encourage training in primary care or enhance interest in the care of underserved populations may identify opportunities in medical school training. The authors used data from the Office of Student Affairs, SUNY Downstate College of Medicine and the National Residency Matching Program to compare rates of primary care residency selection from 2004 to 2012. Residency selections for students who participated in the SUNY Downstate School of Public Health Global Health Elective were compared with those of their classmates and with residency match data for US seniors. In 7 of the 8 years reviewed, students who participated in the SUNY Downstate School of Public Health Global Health Elective selected primary care residencies at rates higher than their classmates. Across years, 57 % of the students who completed the elective matched to primary care residences, which was significantly higher than the 44 % for the remainder of Downstate''s medical student class (p = 0.0023). In 6 of the 8 years, Downstate students who participated in the Global Health Elective selected primary care residencies at rates higher than US medical school seniors in general; rates were the same for both Downstate Global Health Elective students and US medical school seniors in 2009. Students who participated in a global health experience in a low-income country selected primary care residencies at higher rates than their classmates and US medical school graduates in general. Understanding how these experiences correlate with residency selection requires further investigation; areas of future study are discussed.     

Title VII Funding and Physician Practice in Rural or Low-Income Areas

CONTEXT: Whether Title VII funding enhances physician supply in underserved areas has not clearly been established. PURPOSE: To determine the relation between Title VII funding in medical school, residency, or both, and the number of family physicians practicing in rural or low-income communities. METHODS: A retrospective cross sectional analysis was carried out using the 2000 American Academy of Family Physicians physician database, Title VII funding records, and 1990 U.S. Census data. Included were 9,107 family physicians practicing in 9 nationally representative states in the year 2000. FINDINGS: Physicians exposed to Title VII funding through medical school and residency were more likely to have their current practice in low-income communities (11.9% vs 9.9%, P< or =.02) and rural areas (24.5% vs 21.8%, P< or =.02). Physicians were more likely to practice in rural communities if they attended medical schools (24.2% vs 21.4%; P =.009) and residencies (24.0% vs 20.3%; P =.011) after the school or program had at least 5 years of Title VII funding vs before. Similar increases were not observed for practice in low-income communities. In a multivariate analysis, exposure to funding and attending an institution with more years of funding independently increased the odds of practicing in rural or low-income communities. CONCLUSIONS: Title VII funding is associated with an increase in the family physician workforce in rural and low-income communities. This effect is temporally related to initiation of funding and independently associated with effect in a multivariate analysis, suggesting a potential causal relationship. Whereas the absolute 2% increase in family physicians in these underserved communities may seem modest, it can represent a substantial increase in access to health care for community members.