Is there a doctor in the house? . . . Or the Senate? Physicians in US Congress, 1960-2004

Context  The legislative and fiscal influences of Congress, as well as the continuing overall growth in health care spending as a portion of the gross domestic product, make congressional representation by physicians important because physicians have unique expertise in the impact of legislation on patient care and medical practice. Objectives  To describe physician representation in the US Congress between 1960 and 2004 and relate the results to past representation of physicians in Congress. Design and Setting  A retrospective observational study of members of the US Congress from all 50 states and all represented territories, who served from January 1960 to April 2004 (including 108th Congress), using data available in public access databases and congressional biographical records. Main Outcome Measures  Physician representation in Congress, including occupation before taking office, state/territory of representation, sex, party affiliation, and time served. Results  During the past 44 years, 25 (1.1%) of 2196 members of Congress were physicians. Physicians in Congress were more likely to be members of the Republican Party (60% vs 45.1% of all members, P = .007) and were similar to other members of Congress in mean years of service (9.2 years for physicians vs 12.3 years for all members, P = .09) and in sex distribution (4.0% female physicians vs 6.8% all female members, P = .57). Physicians in Congress represented 17 states, the Virgin Islands, and Puerto Rico. Conclusions  Physician representation in Congress is low and is in stark contrast with physician roles during the first century of the United States. However, the 8 physicians currently serving in Congress may be indicative of a shift toward more direct influence of physicians in national politics.      

Geographic Variation in Physician Visits for Uninsured Children: The Role of the Safety Net

Context  Although an extensive literature exists comparing national access to health care for uninsured vs insured children, few data exist regarding differences in access across states. Objective  To examine variation in access to physician services for uninsured children in 10 states, the safety net's role in explaining this variation, and the potential effects of the State Children's Health Insurance Program (CHIP) on insurance coverage and access. Design and Setting  The population-based Robert Wood Johnson Foundation Family Health Insurance Survey, conducted between summer 1993 and spring 1994 in 10 states (Colorado, Florida, Minnesota, New Mexico, New York, North Dakota, Oklahoma, Oregon, Vermont, and Washington), with a response rate of families by state ranging from 61% to 83%. Participants  A total of 8565 children who were uninsured (1586), covered by Medicaid (2723), or covered by employer-sponsored private insurance (4256) for 1 full year prior to the survey. Main Outcome Measures  Percentage of low-income children who are uninsured and predicted annual physician visits by state if insurance was provided to uninsured children in families with incomes of less than 200% of poverty level. Results  In the 10 study states, low-income children ranged from 61% to 86% of all uninsured children and the uninsured rate for low-income children varied from 9% to 31%. On average, providing public coverage would increase annual physician visits from 2.3 to 4.6 (a 105% increase), but the increase would range from 41% to 189% across states. The annual physician visit rate in the 3 states with the highest access for the uninsured was 160% of that in the 3 lowest-access states. Safety net capacity in the high-access states ranged from 120% to 220% of that in the low-access states. Conclusions  Our data suggest that the potential effects of CHIP vary substantially across states. Notably, improvements in access to health care by uninsured low-income children should be greater in states with the fewest safety net resources.      

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment

Context  How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate. Objective  To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment. Design, Setting, and Participants  Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003. Main Outcome Measures  Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior). Results  A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums. Conclusion  Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.      

The Unreliability of Individual Physician "Report Cards" for Assessing the Costs and Quality of Care of a Chronic Disease

Context  Physician profiling is widely used by many health care systems, but little is known about the reliability of commonly used profiling systems. Objectives  To determine the reliability of a set of physician performance measures for diabetes care, one of the most common conditions in medical practice, and to examine whether physicians could substantially improve their profiles by preferential patient selection. Design and Setting  Cohort study performed from 1990 to 1993 at 3 geographically and organizationally diverse sites, including a large staff-model health maintenance organization, an urban university teaching clinic, and a group of private-practice physicians in an urban area. Participants  A total of 3642 patients with type 2 diabetes cared for by 232 different physicians. Main Outcome Measures  Physician profiles for their patients' hospitalization and clinic visit rates, total laboratory resource utilization rate and level of glycemic control by average hemoglobin A_1c level with and without detailed case-mix adjustment. Results  For profiles based on hospitalization rates, visit rates, laboratory utilization rates, and glycemic control, 4% or less of the overall variance was attributable to differences in physician practice and the reliability of the median physician's case-mix–adjusted profile was never better than 0.40. At this low level of physician effect, a physician would need to have more than 100 patients with diabetes in a panel for profiles to have a reliability of 0.80 or better (while more than 90% of all primary care physicians at the health maintenance organization had fewer than 60 patients with diabetes). For profiles of glycemic control, high outlier physicians could dramatically improve their physician profile simply by pruning from their panel the 1 to 3 patients with the highest hemoglobin A_1clevels during the prior year. This advantage from gaming could not be prevented by even detailed case-mix adjustment. Conclusions  Physician "report cards" for diabetes, one of the highest-prevalence conditions in medical practice, were unable to detect reliably true practice differences within the 3 sites studied. Use of individual physician profiles may foster an environment in which physicians can most easily avoid being penalized by avoiding or deselecting patients with high prior cost, poor adherence, or response to treatments.      

Improving the use of hospice services in nursing homes: a randomized controlled trial

Context  Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients’ preferences. Objective  To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care. Design, Setting, and Participants  Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes. Intervention  A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents’ physicians were notified and asked to authorize a hospice informational visit. Main Outcome Measures  The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families’ ratings of the quality of care for residents who died during the 6-month follow-up period. Results  Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident’s care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]). Conclusion  A simple communication intervention can increase rates of hospice referrals and families’ ratings of end-of-life care and may also decrease utilization of acute care resources.      

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

Context  Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives  To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources  MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection  Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data Extraction  Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Data Synthesis  Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Conclusions  Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.      

Physician gender effects in medical communication: a meta-analytic review

Context  Physician gender has been viewed as a possible source of variation in the interpersonal aspects of medical practice, with speculation that female physicians facilitate more open and equal exchange and a different therapeutic milieu from that of male physicians. However, studies in this area are generally based on small samples, with conflicting results. Objective  To systematically review and quantify the effect of physician gender on communication during medical visits. Data Sources  Online database searches of English-language abstracts for the years 1967 to 2001 (MEDLINE, AIDSLINE, PsycINFO, and Bioethics); a hand search was conducted of reprint files and the reference sections of review articles and other publications. Study Selection  Studies using a communication data source, such as audiotape, videotape, or direct observation, and large national or regional studies in which physician report was used to establish length of visit, were identified through bibliographic and computerized searches. Twenty-three observational studies and 3 large physician-report studies reported in 29 publications met inclusion criteria and were rated. Data Extraction  The Cohen d was computed based on 2 reviewers' (J.A.H. and Y.A.) independent extraction of quantitative information from the publications. Study heterogeneity was tested using Q statistics and pooled effect sizes were computed using the appropriate effects model. The characteristics of the study populations were also extracted. Data Synthesis  Female physicians engage in significantly more active partnership behaviors, positive talk, psychosocial counseling, psychosocial question asking, and emotionally focused talk. There were no gender differences evident in the amount, quality, or manner of biomedical information giving or social conversation. Medical visits with female physicians are, on average, 2 minutes (10%) longer than those with male physicians. Obstetrics and gynecology may present a different pattern than that of primary care, with male physicians demonstrating higher levels of emotionally focused talk than their female colleagues. Conclusions  Female primary care physicians engage in more communication that can be considered patient centered and have longer visits than their male colleagues. Limited studies exist outside of primary care, and gender-related practice patterns in some subspecialties may differ from those evident in primary care.      

Managed care and physicians' provision of charity care

Context  Health system changes may be affecting the ability of physicians to provide care with little or no compensation from patients who are uninsured and underinsured and may result in decreased access to physicians for uninsured persons. Objective  To examine the association between managed care and physicians' provision of charity care. Design  The 1996-1997 Community Tracking Study physician survey. Setting and Participants  A nationally representative sample of 10,881 physicians from 60 randomly selected communities. Main Outcome Measure  The number of hours in the month prior to the interview that the physician provided care for free or at reduced fees because of the financial need of the patient. Results  Overall, 77.3% of respondents provided an average of 10.3 hours of charity care per week. Physicians who derive at least 85% of their practice revenue from managed care plans were considerably less likely to provide charity care and spend fewer hours providing charity care than physicians with little involvement in managed care plans (P=.01). In addition, physicians who practice in areas with high managed care penetration provided fewer hours of charity care than physicians in other areas, regardless of their own level of involvement with managed care (P<.01). Differences in charity care provision were also shown for other important factors, including ownership of the practice and practice arrangements (more charity care occurred in solo and 2-physician practices; P<.01). Conclusion  Physicians involved with managed care plans and those who practice in areas with high managed care penetration tend to provide less charity care.      

Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial

Context  Numbers of diagnostic tests ordered by primary care physicians are growing and many of these tests seem to be unnecessary according to established, evidence-based guidelines. An innovative strategy that focused on clinical problems and associated tests was developed. Objective  To determine the effects of a multifaceted strategy aimed at improving the performance of primary care physicians' test ordering. Design  Multicenter, randomized controlled trial with a balanced, incomplete block design and randomization at group level. Thirteen groups of primary care physicians underwent the strategy for 3 clinical problems (arm A; cardiovascular topics, upper and lower abdominal complaints), while 13 other groups underwent the strategy for 3 other clinical problems (arm B; chronic obstructive pulmonary disease and asthma, general complaints, degenerative joint complaints). Each arm acted as a control for the other. Setting  Primary care physician groups in 5 regions in the Netherlands with diagnostic centers recruited from May to September 1998. Study Participants  Twenty-six primary care physician groups, including 174 primary care physicians. Intervention  During the 6 months of intervention, physicians discussed 3 consecutive, personal feedback reports in 3 small group meetings, related them to 3 evidence-based clinical guidelines, and made plans for change. Main Outcome Measure  According to existing national, evidence-based guidelines, a decrease in the total numbers of tests ordered per clinical problem, and of some defined inappropriate tests, is considered a quality improvement. Results  For clinical problems allocated to arm A, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 12% among physicians in the arm A intervention, but was unchanged in the arm B control, with a mean reduction of 67 more tests per physician per 6 months in arm A than in arm B (P = .01). For clinical problems allocated to arm B, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 8% among physicians in the arm B intervention, and by 3% in the arm A control, with a mean reduction of 28 more tests per physician per 6 months in arm B than in arm A (P = .22). Physicians in arm A had a significant reduction in mean total number of inappropriate tests ordered for problems allocated to arm A, whereas the reduction in inappropriate test ordered physicians in arm B for problems allocated to arm B was not statistically significant. Conclusion  In this study, a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in test ordering by primary care physicians.      

Patients' Views of Direct Access to Specialists: An Israeli Experience

Hava Tabenkin, MD, MS; Revital Gross, MA; Shuli Brammli, BA; Pesach Shvartzman, MD

JAMA. 1998;279:1943-1948.

Context.— Surveys carried out among users of medical services can be a useful tool for health care organizations in designing proper services. Specifically, patients' views of direct access to specialists can be useful to health organizations considering the gatekeeper model.

Objective.— To assess patients' opinions about direct access to specialists and referral to specialists through their primary care physician.

Design.— An intercept survey, in which patients were interviewed at the randomly selected service provision sites, was carried out in 3 districts in Israel during 1995. A total of 1445 and 1289 patients were interviewed in primary care and specialty clinics, respectively.

Setting.— Primary care and specialty clinics in 3 regions in Israel serving 750000 members of Kupat Holim Clalit, Israel's largest sick fund.

Participants.— Hebrew-speaking members of Kupat Holim Clalit who visited the primary care or specialty clinics in the 3 regions during the study period.

Main Outcome Measures.— Rate of preferences for direct access to specialists and preferences for referral through primary care physician.

Results.— Fifty-two percent of the respondents preferred direct access to specialists, while 48% preferred a referral from their primary care physician. Multivariate logistic regression analysis indicated that the preference for direct access was significantly lower among patients older than 45 years (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.62-0.91); patients whose primary care physician was a specialist in family medicine (OR, 0.80; 95% CI, 0.67-0.97); and patients who were satisfied with their primary care physician (OR, 0.34; 95% CI, 0.27-0.44). Preference for direct access was significantly higher among more highly educated patients (OR, 1.38; 95% CI, 1.16-1.65) and patients residing in Jerusalem (OR, 2.46; 95% CI, 2.05-2.95) and those younger than 45 years who were dissatisfied with their family physician or a primary care physician who was not board certified. If direct access was not available, 33% of respondents would leave the sick fund and 48% would remain; 19% did not know.

Conclusions.— Informing sick fund members, particularly the younger and more educated among them, about the advantages of consulting with the primary care physician, as well as providing specialty training in family medicine to primary care physicians, may reduce patients' preference for direct access to specialists.

     

Hospital characteristics associated with the management of pediatric splenic injuries

Context  Despite evidence that more than 90% of children with traumatic injuries to the spleen can be successfully managed nonoperatively, there is significant variation in the use of splenectomy. As asplenic children are at increased risk of overwhelming postsplenectomy infection, nonoperative management may be considered a quality of care indicator. Objective  To test the hypothesis that children are more likely to undergo splenectomy in general hospitals than in children’s hospitals. Design  Retrospective cohort study using data from the Kid’s Inpatient Database (KID) for the year 2000. Multivariable regression was used to control for patient and hospital characteristics. Setting and Participants  All children aged 0 to 16 years who were hospitalized with a traumatic (noniatrogenic) spleen injury in nonfederal short-stay hospitals in any of the 27 states participating in KID (N = 2851). Main Outcome Measure  Splenectomy performed within 1 day of arrival. Results  A total of 11 children (3%) with splenic injuries receiving care at children’s hospitals underwent splenectomy compared with 383 children (15.4%) cared for at general hospitals (P<.001). After adjusting for patient characteristics, injury severity, and hospital characteristics, splenectomy was more likely among children treated at general hospitals (odds ratio, 5.01; 95% confidence interval, 2.21-11.36) than among children treated at children’s hospitals. Conclusions  There is considerable variation in the management of pediatric splenic injuries, with significantly lower rates of splenectomy at designated children’s hospitals. Quality improvement interventions, including increased education and training for physicians in general hospitals, may be needed to increase the use of spleen-conserving management practices.      

Physician manipulation of reimbursement rules for patients: between a rock and a hard place

Context  Health plan utilization review rules are intended to enforce insurance contracts and can alter and constrain the services that physicians provide to their patients. Physicians can manipulate these rules, but how often they do so is unknown. Objective  To determine the frequency with which physicians manipulate reimbursement rules to obtain coverage for services they perceive as necessary, and the physician attitudes and personal and practice characteristics associated with these manipulations. Design, Setting, and Participants  A random national sample of 1124 practicing physicians was surveyed by mail in 1998; the response rate was 64% (n = 720). Main Outcome Measure  Use of 3 different tactics "sometimes" or more often in the last year: (1) exaggerating the severity of patients' conditions; (2) changing patients' billing diagnoses; and/or (3) reporting signs or symptoms that patients did not have to help the patients secure coverage for needed care. Results  Thirty-nine percent of physicians reported using at least 1 tactic "sometimes" or more often in the last year. In multivariate models comparing these physicians with physicians who "never" or "rarely" used any of these tactics, physicians using these tactics were more likely to (1) believe that "gaming the system" is necessary to provide high-quality care today (odds ratio [OR], 3.67; 95% confidence interval [CI], 2.54-5.29); (2) have received requests from patients to deceive insurers (OR, 2.44; 95% CI, 1.72-3.45); (3) feel pressed for time during patient visits (OR, 1.69; 95% CI, 1.21-2.37); and (4) have more than 25% of their patients covered by Medicaid (OR, 1.60; 95% CI, 1.08-2.38). Notably, greater worry about prosecution for fraud did not affect physicians' use of these tactics (P = .34). Of those reporting using these tactics, 54% reported doing so more often now than 5 years ago. Conclusions  A sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary. Unless novel strategies are developed to address this, greater utilization restrictions in the health care system are likely to increase physicians' use of such manipulative "covert advocacy" tactics.      

Variation in public and private supply of pneumococcal conjugate vaccine during a shortage

Context  In late August 2001, a serious shortage of the heptavalent pneumococcal conjugate vaccine (PCV7) developed in 34 state immunization programs. In September 2001, the Centers for Disease Control and Prevention published revised recommendations advising physicians to prioritize PCV7 to specific groups of children. The effect of the shortage at the practice level is unknown. Objective  To determine the variation between public and private markets in the supply of PCV7 and the nature and extent of the PCV7 shortage at the practice level. Design, Setting, and Participants  Semistructured interviews with office staff responsible for ordering vaccines at private practices in 12 states were conducted between October 19 and November 2, 2001. Main Outcome Measures  Variation in supply of PCV7 obtained from public sources and through purchase on the private market. Supply was characterized into 3 categories: "no problem," "problem obtaining a consistent supply," and "out of stock." Results  Interviews were completed at 405 practices, representing a response rate of 74%. Overall, 51% of practices reported at least 1 episode of being out of stock of public PCV7 and 64% of private PCV7, with significant state-to-state variation. Only 2 of 12 study states had a substantially higher proportion of practices experiencing out-of-stock episodes for public compared with private PCV7, while in 6 states public PCV7 was less frequently out of stock than private PCV7. Only 23% of practices in this study altered their administration policy for private PCV7, while 27% altered their policy for public PCV7. Conclusions  The distribution and supply of PCV7 varied between public and private supplies and between states during the shortage. Few practices changed their administration schedules in response to revised recommendations.      

Public roles of US physicians: community participation, political involvement, and collective advocacy

Context  Whether physicians have a professional responsibility to address health-related issues beyond providing care to individual patients has been vigorously debated. Yet little is known about practicing physicians' attitudes about or the extent to which they participate in public roles, which we defined as community participation, political involvement, and collective advocacy. Objectives  To determine the importance physicians assign to public roles, their participation in related activities, and sociodemographic and practice factors related to physicians' rated levels of importance and activity. Design, Setting, and Participants  Mail survey conducted between November 2003 and June 2004 of 1662 US physicians engaged in direct patient care selected from primary care specialties (family practice, internal medicine, pediatrics) and 3 non–primary care specialties (anesthesiology, general surgery, cardiology). Main Outcome Measures  Rated importance of community participation, political involvement, collective advocacy, and relevant self-reported activities encompassing the previous 3 years; rated importance of physician action on different issues. Results  Community participation, political involvement, and collective advocacy were rated as important by more than 90% of respondents, and a majority rated community participation and collective advocacy as very important. Nutrition, immunization, substance abuse, and road safety issues were rated as very important by more physicians than were access-to-care issues, unemployment, or illiteracy. Two thirds of respondents had participated in at least 1 of the 3 types of activities in the previous 3 years. Factors independently related to high overall rating of importance (civic-mindedness) included age, female sex, underrepresented race/ethnicity, and graduation from a non-US or non-Canadian medical school. Civic mindedness, medical specialty, practice type, underrepresented race/ethnicity, preceptors of physicians in training, rural practice, and graduation from a non-US or non-Canadian medical school were independently related to civic activity. Conclusions  Public roles are definable entities that have widespread support among physicians. Civic-mindedness is associated primarily with sociodemographic factors, but civic action is associated with specialty and practice-based factors.      

Patient complaints and malpractice risk

Context  A small number of physicians experience a disproportionate share of malpractice claims and expenses. If malpractice risk is related in large measure to factors such as patient dissatisfaction with interpersonal behaviors, care and treatment, and access, it might be possible to monitor physicians' risk of being sued. Objective  To examine the association between physicians' patient complaint records and their risk management experiences. Design, Setting, and Participants  Retrospective longitudinal cohort study of 645 general and specialist physicians in a large US medical group between January 1992 and March 1998, accounting for 2546 physician-years of care. Main Outcome Measures  Computerized records of all unsolicited patient complaints were recorded by the medical center's patient affairs office, coded to characterize the nature of the problem and alleged offender, and compared with each physician's risk management records for the same period. Results  Both patient complaints and risk management events were higher for surgeons than nonsurgeons. Specifically, 137 (32%) of the 426 nonsurgeons had at least 1 risk management file compared with nearly two thirds (137 [63%] of 219) of all surgeons (²₁= 54.7, P<.001). Both complaint and risk management data were positively correlated with physicians' volume of clinical activity. Logistic regression revealed that risk management file openings, file openings with expenditures, and lawsuits were significantly related to total numbers of patient complaints, even when data were adjusted for clinical activity. Predictive concordance of specialty group, complaint count, clinical activity, and sex for risk management file openings was 84%; file openings with expenditures, 83%; lawsuits, 81%; and multiple lawsuits, 87%. Conclusions  Unsolicited patient complaints captured and recorded by a medical group are positively associated with physicians' risk management experiences.      

Screening and Intervention for Intimate Partner Abuse: Practices and Attitudes of Primary Care Physicians

Context  Although practice guidelines encouraging the screening of patients for intimate partner abuse have been available for several years, it is unclear how well and in which circumstances physicians adhere to them. Objective  To describe the practices and perceptions of primary care physicians regarding intimate partner abuse screening and interventions. Design, Setting, and Participants  Cross-sectional survey of a stratified probability sample of 900 physicians practicing family medicine, general internal medicine, and obstetrics/gynecology in California. After meeting exclusion criteria, 582 were eligible for participation in the study. Main Outcome Measure  Reported abuse screening practices in a variety of clinic settings, based on a 24-item questionnaire, with responses compared by physician sex, practice setting, and intimate partner abuse training. Results  Surveys were completed by 400 (69%) of the 582 eligible physicians, including 149 family physicians, 115 internists, and 136 obstetrician/gynecologists. Data were weighted to estimate the practices of primary care physicians in California. An estimated majority (79%; 95% confidence interval [CI], 75%-83%) of these primary care physicians routinely screen injured patients for intimate partner abuse. However, estimated routine screening was less common for new patient visits (10%; 95% CI, 7%-13%), periodic checkups (9%; 95% CI, 6%-12%), and prenatal care (11%; 95% CI, 7%-15%). Neither physician sex nor recent intimate partner abuse training had significant effects on reported new patient screening practices. Obstetrician/gynecologists (17%) and physicians practicing in public clinic settings (37%) were more likely to screen new patients. Internists (6%) and physicians practicing in health maintenance organizations (1%) were least likely to screen new patients. Commonly reported routine interventions included relaying concern for safety (91%), referral to shelters (79%) and counseling (88%), and documentation in the medical chart (89%). Commonly cited barriers to identification and referral included the patients' fear of retaliation (82%) and police involvement (55%), lack of patient disclosure (78%) and follow-up (52%), and cultural differences (56%). Conclusions  These findings suggest that primary care physicians are missing opportunities to screen patients for intimate partner abuse in a variety of clinical situations. Further studies are needed to identify effective intervention strategies and improve adherence to intimate partner abuse practice guidelines.      

Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial

Context  Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers. Objective  To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. Design  Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment. Setting  Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center. Patients  Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). Main Outcome Measures  Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider. Results  No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05). Conclusions  In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.      

Use of board certification and recertification of pediatricians in health plan credentialing policies

Context  Health plans conduct credentialing processes to select and retain qualified physicians who will provide high-quality care to their subscribers. One of the tools available to health plans to help ensure physician competence is assessment of board certification status. Objective  To determine the credentialing policies of health plans regarding the use of board certification and recertification for general pediatricians and pediatric subspecialists. Design, Setting, and Participants  Telephone survey conducted February through July 2005 of credentialing personnel from a US national sample of 244 health plans stratified by enrollment size, Medicaid proportion, and for-profit or not-for-profit status. Main Outcome Measures  Proportion of health plans that require general or subspecialty board certification at initial contract or at any time during association with the plan and recertification to maintain credentialing or to bill as a specialist or subspecialist; percentage of physicians credentialed in each health plan and credentialing goals for each plan regarding the proportion of physicians to be board certified. Results  Response rate was 193 of 244 (79%). Overall, 174 (90%) of the plans do not require general pediatricians to be board certified at the time of initial credentialing, and only 41% ever require a general pediatrician to become board certified. Similarly, only 80 (40%) ever require subspecialists to become board certified in their subspecialty. Although 80 of 192 (41%) report requiring recertification of general pediatricians, almost half do not have a time frame in which recertification must occur. Seventy-seven percent of plans allow physicians to bill as subspecialists with expired certificates. Conclusions  These findings, although specific to pediatrics, likely apply to other primary care disciplines and raise questions regarding the ability of plans to ensure initial or continued competence of their credentialed physicians. Growing public concern regarding patient safety, as well as demonstrated patient preferences for certified physicians, will likely result in greater emphasis on quality assessments in physician credentialing.      

Shortages of medical personnel at community health centers: implications for planned expansion

Context  The US government is expanding the capacity of community health centers (CHCs) to provide care to underserved populations. Objective  To examine the status of workforce shortages that may limit CHC expansion. Design and Setting  Survey questionnaire of all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia, conducted between May and September 2004. Questionnaires were completed by the chief executive officer of each grantee. Information was supplemented by data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted to be nationally representative. Main Outcome Measures  Staffing patterns and vacancies for major clinical disciplines by rural and urban location, use of federal and state recruitment programs, and perceived barriers to recruitment. Results  Overall response rate was 79.3%. Primary care physicians made up 89.4% of physicians working in the CHCs, the majority of whom are family physicians. In rural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians compared with 38.9% in urban CHCs. There were 428 vacant funded full-time equivalents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were vacancies for 13.3% of family physician positions, 20.8% of obstetrician/gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a higher proportion of vacancies and longer-term vacancies and reported greater difficulty filling positions compared with urban CHCs. Physician recruitment in CHCs was heavily dependent on National Health Service Corps scholarships, loan repayment programs, and international medical graduates with J-1 visa waivers. Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities. Conclusions  CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues.      

Changes in career satisfaction among primary care and specialist physicians, 1997-2001

Context  A number of forces have changed the practice of medicine in the past decade. Evidence suggests that physicians are becoming less satisfied in this environment. Objectives  To describe changes in career satisfaction in a large, nationally representative sample of physicians and to examine market and practice factors associated with changes in physician satisfaction. Design and Setting  Data were collected from the first 3 rounds of the Community Tracking Study (CTS) Physician Survey, a series of nationally representative telephone surveys of physicians in 60 US sites conducted in 1996-1997 (round 1: 12 385 respondents; 65% response rate), 1998-1999 (round 2: 12 280 respondents; 61% response rate), and 2000-2001 (round 3: 12 389 respondents; 59% response rate) for the Center for Studying Health System Change. The second and third rounds of the survey included physicians sampled in the previous round, as well as new physicians. Participants  Primary care and specialist physicians who spent at least 20 hours per week in direct patient care activities. Main Outcome Measures  Changes in physicians' overall satisfaction with their career and the proportion of dissatisfied physicians in particular sites. Results  Physician satisfaction levels declined marginally between 1997 and 2001, with most of the decline occurring between 1997 and 1999. Among primary care physicians, 42.4% were very satisfied in 1997, as were 43.3% of specialists, compared with 38.5% and 41.4%, respectively, in 2001. There were nearly equal increases in those who reported that they were somewhat satisfied. Overall means mask significant differences across the 60 sites. Among 12 sites randomly selected for more intensive study, the proportion of respondents who were somewhat or very dissatisfied ranged from 8.8% of physicians in Lansing, Mich (1999), to 34.2% in Miami, Fla (1997). Between 1997 and 1999, 25.6% of primary care physicians reported decreased satisfaction and 18.1% reported improved satisfaction, while approximately equal percentages reported increased (19.8%) and decreased (20.4%) satisfaction between 1999-2001. Findings were similar for specialist physicians. In multivariable models, the strongest and most consistent predictors of change in satisfaction were changes in measures of clinical autonomy, including increases in hours worked and physicians' ability to obtain services for their patients. Changes in exposure to managed care were weakly related to changes in satisfaction. Conclusions  Our findings demonstrate that overall physician satisfaction levels over this time period did not change dramatically. In addition, satisfaction and changes in satisfaction vary greatly among sites. Rather than declining income, threats to physicians' autonomy, to their ability to manage their day-to-day patient interactions and their time, and to their ability to provide high-quality care are most strongly associated with changes in satisfaction.