The views of U.S. medical school deans toward academic primary care.

PURPOSE: To understand the views of U.S. medical school deans about their primary care faculties. METHOD: In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools. RESULTS: Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support. CONCLUSIONS: Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.     

The effect of medical education on primary care orientation: results of two national surveys of students' and residents' perspectives.

PURPOSE: To examine changes among a nationally representative sample of students and residents in their orientations toward primary care as reflected in their attitudes toward the psychosocial and technical aspects of medicine and their perceptions of the academic environment for primary care. METHOD: Confidential telephone interviews of stratified national probability samples of first- and fourth-year medical students and residents were conducted in 1994 and 1997. The 1997 survey included 219 students and 241 residents who had also been interviewed in 1994. Participants were asked about their attitudes toward addressing psychosocial issues in medicine and their perceptions of faculty and peer attitudes toward primary care. Responses were compared over time and across groups. RESULTS: Between the first and fourth years of medical school, there was a decline over time in students' reported orientations to socioemotional aspects of patient care (61.6% versus 42.7%, p =.001) and their perceptions that working with psychosocial issues of patients made primary care more attractive (56.3% versus 43.5%, p =.01). This pattern continued for 1997 residents (PGY-3), who were even less likely to say that addressing psychosocial issues made primary care more attractive (26.9%). For fourth-year students in 1994 who became PGY-3 residents in 1997, there was an increased perception that non-primary-care house officers and specialty faculty had positive attitudes toward primary care (20.8% versus 33.0%, p =.005; 28.3% versus 45.7%, p <.0001; respectively). CONCLUSIONS: Between 1994 and 1997 students and residents perceived a positive shift in the attitudes of peers and faculty toward primary care. During the course of their education and training, however, the students experienced an erosion of their orientations to primary care as they progressed through medical school into residency.     

The impact of the changing health care environment on the health and well-being of faculty at four medical schools.

PURPOSE: Increased pressure for clinical and research productivity and decreased control over the work environment have been reported to have adverse impacts on academic faculty in limited studies. The authors examined whether work-related stressors in academic medicine negatively affected the physical and mental health, as well as life and job satisfaction, of academic medical school faculty. METHOD: A 136-item self-administered anonymous questionnaire modified from a small 1984 study was distributed to 3,519 academic faculty at four U.S. medical schools following institutional review board approval at each school. Validated scales measuring depression, anxiety, work strain, and job and life satisfaction; a checklist of common physical and mental health symptoms; and questions about the impact of institutional financial stability, colleague attrition, and other work-related perceptions were used. Responses were analyzed by sex, academic rank, age, marital status, faculty discipline, and medical school. RESULTS: Responses were received from 1,951 full-time academic physicians and basic science faculty, a 54.3% response rate. Twenty percent of faculty, almost equal by sex, had significant levels of depressive symptoms, with higher levels in younger faculty. Perception of financial instability was associated with greater levels of work strain, depression, and anxiety. Significant numbers of faculty acknowledged that work-related strain negatively affected their mental health and job satisfaction, but not life satisfaction or physical health. Specialties were differentially affected. CONCLUSIONS: High levels of depression, anxiety, and job dissatisfaction-especially in younger faculty-raise concerns about the well-being of academic faculty and its impact on trainees and patient care. Increased awareness of these stressors should guide faculty support and development programs to ensure productive, stable faculty.     

Specialty choices, compensation, and career satisfaction of underrepresented minority faculty in academic medicine.

PURPOSE: Despite efforts to increase the numbers of underrepresented minorities (URMs), only 3.9% of medical school faculty are URMs. The authors compared the specialty choices, compensation, and career satisfaction of minority faculty with those of their majority counterparts to determine whether there were differences that might affect the recruitment and retention of minority faculty. METHOD: In 1995, the authors mailed a self-administered survey to a stratified random sample of 3,013 eligible full-time salaried faculty in 24 randomly selected medical schools. Those schools, which had at least 200 faculty, did not include the Puerto Rican or historically black medical schools. RESULTS: Of the eligible faculty surveyed, 1,807 (60%) responded; 1,463 were majority faculty, 195 were URM faculty, and 149 were other-minority faculty. Similar proportions of the three groups were in the primary care specialties. Only 11% of the URM respondents were in basic science departments. There was no significant difference in adjusted mean compensation between majority, URM, and other-minority faculty. However, URM faculty were significantly less satisfied with their careers (adjusted scores: 60 versus > 65; p = .001) and more often considered leaving academic medicine within five years (58% versus < 45%). CONCLUSION: Given the demographic changes of the U.S. population, these issues should be addressed by deans and department heads in order to enhance recruitment and facilitate retention of URM faculty in academic medicine.     

Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows.

PURPOSE: Medical schools and residency programs are placing additional emphasis on including clinical geriatrics competencies within their curricula. An eight-station, Geriatric Medicine Standardized Patient Examination (GSPX) was studied as a method to assess bedside geriatrics clinical skills over the continuum of medical education from medical school through residency and fellowship training. METHOD: The GSPX was administered to 39 medical students, 49 internal medicine residents, and 11 geriatrics medicine fellows in 2001-02. Reliability of standardized patient (SP) checklists and rating scales used to assess examinees' performance was measured by Cronbach's alpha. Validity was measured by surveying the examinees' assessment of fairness, individual case length, difficulty, and believability, and by faculty standard setting for each level of trainee. RESULTS: Reliability was high (alpha =.89). All levels of examinees found the SPs to be believable, station lengths to be adequate, and rated the GSPX as a fair assessment. Students rated the cases as more difficult. Previous experience with similar real patients increased significantly with level of training (Pearson's r =.48, p <.0001). Faculty set passing scores that increased from students to residents to fellows. However, GSPX scores decreased with level of training (r = -.25, p =.01). CONCLUSION: The GSPX is a reliable measure of geriatrics medicine skills with adequate face validity for examinees at all levels. However, GSPX scores did not increase with level of training, suggesting that a single form of the examination cannot be used across the continuum of training. Potential modifications to the GSPX that might provide more discrimination between levels of training are currently being explored.     

Specialty selection and relative job satisfaction of family physicians and medical specialists in Austria

Aim

To estimate the relative job satisfaction of Austrian family physicians and other specialists with respect to whether or not they obtained training in the desired specialty.

Methods

In this cross-sectional study, we re-examined the previous data on allocation of medical training posts in Austria. All board-certified physicians practicing in Vienna were surveyed with a 12-item questionnaire. We analyzed the association between respondents’ desired and practiced medical specialty and their answer to the question of whether they thought they would have had greater job satisfaction in a different medical specialty. We also calculated their relative job satisfaction.

Results

Of 8127 licensed physicians, 2736 (34%) completed the questionnaire in two mailings. Of physicians who completed the questionnaire, 50.3% (43.2% of men) did not obtain the training in their desired specialty and 65.1% stated that they had originally desired a different specialty. There was a significant difference in relative job satisfaction between specialists who got their desired medical specialty (n = 1005) and those who did not (n = 697) (0.95 vs 0.62 of maximum 1, P<0.001). No significant difference in relative job satisfaction was found between family physicians who had originally wanted to become specialists (n = 679) and specialists who had originally wanted to become family physicians (n = 533; 0.89 vs 0.81; P = 0.01; χ² test).

Conclusion

A high percentage of family physicians in Austria had originally wanted to become practitioners of a different specialty. Among physicians who did not receive training in their desired medical specialty, family physicians showed a significantly higher relative job satisfaction than specialists. Obtaining the desired medical specialty is a strong predictor of relative job satisfaction among specialists, but not among family physicians.A number of framework conditions for the work of family physicians in Austria and in other European health systems (1,2) are still not well defined.In Austria, it is not clear what services have to be provided in primary care and when patients should be referred to a specialist. Due to the non-remuneration for some services and procedures, the spectrum of care generally provided by family physicians is limited. Specialists can be consulted not only in hospital outpatient departments, but also in private offices under contract with the national health insurance board. Patients have a more or less free choice to consult a family physician, one or more self-employed specialists under contract with the national health insurance board, or specialists in hospital outpatient departments.There are many self-employed specialists, especially in larger cities like Vienna (3). As family physicians in Austria often fail to play the role of gatekeepers, private practice specialists frequently see patients with complaints that, in a well-defined primary care system, would be treated by family physicians. This situation creates a competitive relationship between family physicians and private practice specialists.Academic family medicine in Austria is still underdeveloped in comparison with other countries in Europe with more advanced health care systems (4). It is also not recognized as a medical specialty, which is reflected in the quality and duration of training and many other aspects. Even within the medical profession, there is sometimes little understanding for the competencies and skills of family physicians and the possible benefits of a well-defined primary care system (5,6). As has been widely discussed, the quality of vocational training for both family medicine and various specialties is often far from satisfactory (7-10).The European Academy of Teachers in General Practice considers it essential that the right career opportunities be given to right candidates (11). However, there is a question of whether the candidates who are particularly interested in and suitable for family medicine end up practicing that discipline. If residency programs were designed to impart the knowledge, skills, and attitudes needed to care for patients with chronic diseases, students and interns who were genuinely interested in providing high-quality ambulatory care would recognize the exciting opportunities offered within primary care (12). The graduates who are likely to acquire the competencies needed for family medicine (13) should be given a chance to become family physicians.The aim of this study was to determine if family physicians had originally desired to work as family physicians and if the relative job satisfaction of family physicians and other medical specialists depended on whether they obtained their training in desired medical specialty.     

"No fear" curricular change: monitoring curricular change in the W. K. Kellogg Foundation's National Initiative on Community Partnerships and Health Professions Education.

PURPOSE: To assess the effect of the W. K. Kellogg Foundation's five-year (9/91 to 9/96) primary care curricular change initiative involving seven sites and 27 schools with respect to courses offered, graduates' specialty choices, and valued school features (e.g., reputation, research, productivity, school climate) and to track how well the schools possessed or developed the processes associated with enduring curricular change. METHOD: Information was collected via pre- and post-surveys of faculty and students, site visits, annual reports, and medical students' specialty match results. RESULTS: In general, the schools either possessed or developed the institutional, curricular design, and curriculum features associated with successful curricular change. Further, the initiative had a positive or neutral impact on most of the valued features: 199 courses were revised or developed, including 138 offered in the community, involving 141 interdisciplinary faculty. Comparing 1991-1997 data, the average percentage increases in students' selecting primary care from the involved schools were greater than the national percentages. In 1997, a larger percentage of project school graduates selected primary care than the national average. CONCLUSION: Medical schools can make major curricular changes and achieve intended outcomes (e.g., new and/ or revised courses, multidisciplinary instruction, instruction in the community, and changes in specialty choice), and this can occur without negatively impacting other valued school aspects.     

中小学教师工作满意度与自我和谐的关系研究

目的探讨中小学教师工作满意度与自我和谐之间的关系。方法采用工作满意度量表和自我和谐量表(SCCS)对736名中小学教师进行测量。结果中小学教师的工作满意度处于中等偏下水平,大多数中小学教师自我处在比较和谐状态,但有一部分教师自我和谐水平不高;中小学教师的工作满意度和自我和谐在性别、学校类型等人口学变量上存在显著性差异;工作满意度与自我和谐总分(r=0.162,P<0.01)、自我与经验的不和谐(r=-0.150,P<0.01)呈显著负相关,与自我刻板性(r=-0.008,P>0.05)没有显著相关,与自我灵活性显著正相关(r=0.135,P<0.01)。结论工作满意度是影响中小学教师自我和谐的重要因素,中小学教师工作满意度越高,其自我和谐程度也越高。     

Specialty choices at one medical school: recent trends and analysis of predictive factors

Recent reports have raised the concern that personal care specialties, especially primary care specialties, are attracting fewer medical school graduates. In the present study, the authors evaluated the proportions of University of California, San Francisco (UCSF), medical school graduates entering personal care specialties and technology-oriented specialties from 1982 through 1988 and found no significant trend away from personal care specialties such as internal medicine, family practice, pediatrics, and psychiatry during these years. For the graduating class of 1988, admissions and questionnaire data were used to evaluate the importance of pre-admission, medical school, and postgraduate factors as determinants of specialty choice. The group entering personal care specialties (66% of all 1988 graduates) was significantly older and included more women and fewer minority students than the group entering technology-oriented specialties. Students rated income and lifestyle factors as being less important determinants of specialty choice than are medical school experiences and intrinsic qualities of the chosen specialties. However, compared with the students who entered personal care specialties, those who chose technology-oriented specialties over an alternate choice in personal care rated as significantly more important the opportunity to do procedures (p less than .001), income (p less than .005), the lesser degree of diagnostic uncertainty (p less than .005), and the rejected specialty's allowing less time for family (p less than .005) and for other interests (p less than .008). Exposure to acquired immunodeficiency syndrome and loan indebtedness were rated the least significant influences on specialty choice.(ABSTRACT TRUNCATED AT 250 WORDS)     

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

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

Views of managed care--a survey of students, residents, faculty, and deans at medical schools in the United States

BACKGROUND AND METHODS: Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. RESULTS: Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. CONCLUSIONS: Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans.     

The University of Missouri-Kansas City School of Medicine: thirty-five years of experience with a nontraditional approach to medical education.

The University of Missouri-Kansas City (UMKC) School of Medicine is a public medical school that opened in 1971 in response to a need to train more physicians in Missouri. As a six-year, integrated, combined-degree program leading to the baccalaureate and medical degrees, the school offers an innovative, nontraditional approach to medical education. In the past 35 years, UMKC has graduated over 2,400 physicians who are successful according to outcomes measures used at other medical schools. With recent interest in reforming medical education to prepare physicians for a changing world, a review of alternative models may be especially instructive.UMKC's academic plan offers a blueprint for the curriculum plan and governance of the school. The plan is built on four hallmarks: (1) a combined baccalaureate/MD program, (2) early exposure to clinical medicine, (3) small-group learning through the docent system, and (4) a continuing ambulatory care clinic experience for four years.This article catalogs the results of this plan including student, faculty, and graduates' perceptions of and satisfaction with the school's educational approach, students' achievement on licensing examinations and in the residency match, graduates' performance in residency programs, and their subsequent career patterns. The authors also discuss lessons learned and adjustments made in response to local needs in the context of a changing environment in education, health care, and health care delivery while continually improving the school's nontraditional approach to medical education. These include changes in basic and clinical science instruction, student assessment, faculty development, and funding and governance.     

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

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

Comparing the characteristics of schools that produce high percentages and low percentages of primary care physicians.

To examine whether the medical school environment is important in influencing students to choose careers in primary care, the authors in 1991 compared certain characteristics of the environments of schools that produced high percentages of primary care physicians with those of schools that produced low percentages over a five-year period. The authors used the American Medical Association Physician Masterfile to identify the percentage of graduates of each of 121 medical schools for the period 1981-1985 who entered primary care specialties. They then compared the 25 schools that produced low percentages (22-29%) with the 25 schools that produced high percentages (39-56%). The results demonstrate important differences between the two groups of schools in their commitments to primary care education, their research programs, and their clinical environments supporting required clerkships. The authors conclude that a school's educational environment is an important factor in influencing some students to pursue careers in primary care medicine.     

PhD faculty in clinical departments of U.S. medical schools, 1981-1999: their widening presence and roles in research.

PURPOSE: To analyze the growth, research activities, and academic status of PhD faculty in U. S. medical school clinical departments between 1981 and 1999. METHOD: Full-time U.S. medical school faculty who had PhDs and appointments in clinical departments in 1981 and 1999 and junior PhD faculty who became assistant professors between 1981 and 1990 were selected from the Faculty Roster System of the Association of American Medical Colleges. Their research activities and academic statuses were compared with those of MD or MD/PhD faculty in clinical departments or PhD faculty in basic science departments in the same years. RESULTS: The number of PhD faculty in clinical departments now exceeds the number of PhD faculty in basic science departments. PhD faculty in clinical departments come from diverse research backgrounds, contribute substantially to the research intensity of their institutions, and are more likely than their counterparts in basic science departments to become involved in research involving human participants or human tissues. PhD faculty in clinical departments are less likely than their counterparts in basic science departments, but are as likely as physicians in clinical departments, to be rewarded with academic promotion. They are less likely than their physician colleagues to be promoted in research-intensive departments such as departments of medicine and at top 20 research-intensive schools. CONCLUSIONS: The burgeoning career opportunities for PhD faculty in clinical departments should be reflected in the course work, mentorship, and potential thesis topics of PhD training programs. In lieu of tenure, research-intensive medical schools should develop alternative career tracks providing somewhat greater job stability for these faculty.     

Evaluation of a faculty development program in managing care.

PURPOSE. To evaluate a faculty development program that teaches quality improvement and cost-effectiveness. METHOD. From October 2000 to February 2001, a two-part faculty development program was offered to 39 physicians from 19 U.S. medical schools supported by grants from the Partnerships for Quality Education (PQE) and Undergraduate Medical Education in the 21st Century (UME-21). Special features of the program included partnerships between academic and community physicians from each school, development of an educational innovation of interest to the participants, concurrent development of teaching skills and new medical knowledge, learning leadership skills (e.g., how to train colleagues to teach), and practice periods. The program focused on quality improvement and cost-effectiveness, but included other "managing care" topics. Prior to and after the course, participants assessed their knowledge of and competence to teach these topics, as well as other managing care topics. They also assessed their competence as medical educators and leaders. After the course, they indicated their progress in implementing their proposed educational innovations. RESULTS. Thirty-two of the 39 physicians completed evaluations both before and after the program. Self-assessed knowledge and competence to teach quality improvement and cost-effectiveness were significantly higher at the end of the course, as were all self-assessed teaching and leadership skills. The largest change scores occurred in assessments of competency to teach the new topics and to teach in new ways. Participants who implemented their innovations rated their competencies to teach quality improvement and cost-effectiveness higher than did non-implementers. CONCLUSION. Opportunities for faculty to learn how to teach a topic of stated importance to them, to practice what they have learned, and to work collaboratively with partners improved teaching skills.     

Comparing virtual consults to traditional consults using an electronic health record: an observational case¿control study

ABSTRACT: BACKGROUND: Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing "better, faster, cheaper" processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR. METHODS: We conducted an observational case-control survey study within Kaiser Permanente, Colorado. A sample of patients who had VC requests (N=270) were matched with patients who had TC requests (N=270) by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed. RESULTS: During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (268 out of 540 patients, 49.6% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p=0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs. CONCLUSIONS: Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient's perception of care.     

Impact of desire to work in underserved communities on selection of specialty among fourth-year medical students

OBJECTIVE: The objective of this study was to explore the specific factors that influence medical student's choice of primary care as a specialty. Special attention is given to the influence of desire to work in underserved communities on selection of a specialty. DESIGN AND SETTINGS: A web-based survey of factors affecting choice of specialty was completed by 668 fourth-year students from 32 medical schools. RESULTS: Students interested in primary care reported an increased likelihood of working with underserved populations when compared with other specialties. The independent impact of both student's social compassion attitudes and values, and subjective and reinforcing influences on the selection of primary care, when compared with all other specialties, was strong. Personal practice-oriented considerations showed an independent negative impact on the selection of primary care when compared with surgery and support specialties. Financial considerations strongly influence the selection of support specialties. Medical training experiences showed an independent influence on the selection of surgery over primary care. CONCLUSION: The need for primary care physicians and specialists in underserved communities is considerable. Addressing health disparities in underserved communities requires a concerted effort to increase the availability of primary care providers in these communities. This study observed that primary care practice or specialty selection by medical students is influenced by individual values and subjective external influences other than predicted by medical training alone. This observation necessitates a closer determination of strategies required to ensure an increase in the number of primary care physicians serving underserved communities.     

Communication between programs and applicants during residency selection: effects of the match on medical students' professional development.

PURPOSE: Communication between programs and applicants during the Match has raised concern among medical educators. This study explores the patterns of such communication and its effect on the ethical and professional development of medical students. METHOD: In March and April 2001, the authors made a secure, anonymous questionnaire available online to 1,362 medical students who were graduating from ten U.S. medical schools and who participated in the 2001 Match. Data analysis included chi square, ANOVA, and correlation tests as appropriate. RESULTS: A total of 740 students (54.3%) completed the questionnaire. Patterns of communication between programs and applicants varied significantly by medical school and specialty. Communication initiated by applicants came predominantly from those from less highly ranked medical schools (p =.000), and those applying to specialties with lower fill rates (p =.000). Programs initiated significantly more communication with applicants from more highly ranked schools (p =.006), and with those applying to specialties with higher fill rates (p =.000). The amount of pressure felt by applicants was related to the level of communication, whether initiated by applicants (p =.028) or programs (p =.000). Applicants who felt more pressure were significantly more likely to make misleading statements to programs (p =.000). CONCLUSIONS: Communication between applicants and programs during the Match varies and may have adverse effects on the ethical and professional development of medical students. This study provides support for proposals to limit communication between programs and applicants during the residency selection process.     

Physician race and ethnicity, professional satisfaction, and work-related stress: results from the Physician Worklife Study

There are limited data about minority physicians' professional satisfaction and job stress. In this study, we describe by race and ethnicity, satisfaction, and job stress among a national sample of physician. We analyzed data from 2,217 respondents to the Physicians' Worklife Survey (PWS), a career satisfaction survey of physicians drawn from the AMA Physician Masterfile. Scales measuring overall job and career satisfaction and work-related stress were constructed from Likert-response items. We examined the association between physician ethnicity and each of these scales. Respondents included 57 black, 134 Hispanic, 400 Asian or Pacific Islander, and 1,626 white physicians. In general, minority physicians appeared to serve a more demanding patient base than did white physicians. Hispanic physicians reported significantly higher job (p=0.05) and career (p=0.03) satisfaction compared to white physicians but no significant difference in stress. Asian or Pacific Islander physicians averaged lower job satisfaction (p=001) and higher stress (p<0.01) compared to white physicians. Black physicians did not differ significantly from white physicians on any of the three measures. Significant racial and ethnic variations were found with respect to several specific satisfaction domains: autonomy, patient care issues, relations with staff, relations with the community, pay, and resources.