Importance of and satisfaction with work and professional interpersonal issues: a survey of physicians practicing general internal medicine in Ontario.

OBJECTIVES: To explore the importance of and satisfaction with clinical responsibilities, teaching, research and interpersonal issues among general internists; to understand the barriers to satisfaction in these domains and the usefulness of potential solutions to these problems. DESIGN: Cross-sectional survey conducted from November 1992 to June 1994. SETTING: Ontario. PARTICIPANTS: General internists who were fellows of the Royal College of Physicians and Surgeons of Canada and members of the Ontario Medical Association. Of 1192 physicians, 1007 (84.5%) returned a completed questionnaire; only the 199 who devoted at least 50% of their time to the practice of general internal medicine were included in this analysis. RESULTS: The respondents were satisfied with their primary role as clinicians dealing with complex, undifferentiated problems caring for the total patient and providing consultation. Guidelines for the referral of patients to general internists, computerization of test results, recruitment of general internal medicine fellows and more confidence in the future of general internal medicine were some of the solutions considered likely to increase professional satisfaction. The respondents involved in teaching suggested additional solutions, such as an opportunity to improve their teaching and evidence-based medicine skills and a greater recognition for their teaching efforts. Few of the general internists conducted research, barriers included lack of personal and project funding, and pressure to generate clinical earnings. In the domain of professional interpersonal issues, women were significantly more likely than men to rate having a mentor, peer support groups, ongoing career counselling, promotion and tenure guidelines for parental leave, availability of on-site day care, addressing gender discrimination and adoption of gender-neutral language as likely to improve the work environment. CONCLUSIONS: The primary role of general internists is that of patient-centred clinician. Our findings suggest that general internists want to take responsibility for revitalizing this discipline. The potential solutions generated in this survey may help to promote action that will improve professional satisfaction in the area of clinical responsibilities, teaching, research and interpersonal issues.     

Training in a primary care internal medicine residency program. The first ten years

We surveyed all 49 graduates of the University of California, San Francisco, residency program in primary care internal medicine to determine whether they chose careers as general internists and whether training in ambulatory care at the expense of hospital-based medicine is adequate preparation for general internal medicine practice. Graduates rated adequacy of training and relevance to their current clinical practice of 87 content and skill areas on five-point Likert scales. Of the 44 respondents, 39 (89%) chose careers as general internists and five (11%) as subspecialty internists. Training in nine of 11 internal medicine disciplines (eg, cardiology) was rated as highly adequate, and the areas as highly relevant. For ten of 15 non-internal medicine areas (eg, ear, nose, and throat), mean relevance scores significantly exceeded adequacy scores, suggesting training underemphasis. Mean relevance scores also significantly exceeded adequacy scores for seven of 11 basic knowledge/skill areas (eg, patient interviewing) and 13 of 14 areas related to clinical practice (eg, quality assurance). We conclude that the vast majority of graduates of the University of California, San Francisco, primary care residency program became general internists and that, rather than feeling deficient in training in hospital-based medicine, graduates reported unmet needs for ambulatory-care experiences and skills related to general internal medicine practice.     

The timing of career decisions in internal medicine

The creation of new residencies in primary care internal medicine is aimed at increasing the number of individuals entering careers as general internists. This strategy assumes that final career decisions are made prior to application for residency training. A survey of all graduates of internal medicine residencies at the University of California, San Diego, during 1969-1979 resulted in 155 respondents (an 86 percent response rate) and revealed that only 30 percent had no change in career plans regarding general versus subspecialty practice since medical school and 41 percent had made final decisions during residency training. Inpatient care experiences, peer interactions, and faculty role models were the training factors which most influenced final career choice. The goal of increasing the number of general internists may be better served by strengthening the role of generalist faculty members in traditional internal medicine residencies rather than creating new programs which force trainees to make premature career choices.     

An elective in primary care internal medicine for students in the preclinical years

A two-week elective to introduce first- and second-year medical students to primary care internal medicine was developed and evaluated. Course time is divided between conference sessions (25 percent) provided by full-time clinical faculty members and office experience (75 percent) provided by volunteer clinical faculty members (general internists in private practice and in prepaid health plans). Evaluations by the students (n = 58) who took the elective consisted of a questionnaire assessment of the conference session topics, the student's ability to carry out course objectives, and the preceptor's teaching activities. The conference topics were highly rated, with a mean score of 4.1 on a rating scale ranging from 1 (unfavorable) to 5 (favorable). The course objectives and teaching activities were also well rated, with a mean score of 4.1 and 3.9, respectively, on a rating scale ranging from 1 (none) to 5 (outstanding).     

Comparison of activity level and service intensity of male and female physicians in five fields of medicine in Ontario.

OBJECTIVE: To examine the extent to which physician's sex explains variation in the activity level and service intensity of a cohort of physicians in each of five medical fields after other sources of variation are taken into account. DESIGN: Data from the Ontario Ministry of Health (MOH) and the CMA were analysed by means of multivariate regression techniques for panel data. SETTING: Ontario. PARTICIPANTS: A total of 137 dermatologists, 974 general internists, 330 pediatricians and 941 psychiatrists and a random sample of 2771 family physicians and general practitioners who met the eligibility criteria. Physicians were eligible if they billed the MOH for at least three quarters in 1983, did not bill as a medical laboratory director, provided direct patient care, did not have an alternative funding arrangement with the MOH, remained in the same specialty throughout the study period (1983-90) and billed from an Ontario address. OUTCOME MEASURES: Three measures of total activity level (annual number of services provided, annual fee-for-service billings and annual mean number of patients seen per quarter) and one measure of service intensity (annual mean number of services per patient per quarter). RESULTS: Although several variables (e.g., full-time work status, age, type of practice and recent practice move) influenced the four measures examined, physician's sex contributed significantly to explaining variation in activity in 70% of the regression equations. The women provided 33.0% fewere services per year than the men in family and general practice (p < 0.001), 25.0% fewer services in general internal medicine (p < 0.01), 22.1% fewer services in pediatrics (p < 0.05) and 22.3% fewer services in psychiatry (p < 0.001). Total billings by the women in these fields were also significantly less than those of their male colleagues, the difference being greatest among the family physicians and general practitioners (28.0%) and the general internists (27.0%) (p < 0.001). The women in these four fields saw significantly fewer patients per quarter than their male colleagues, the difference being greatest in psychiatry (33.0%) (p < 0.001). Sex affected service intensity in three fields. The female psychiatrists (14.8%) (p < 0.001) and general intenists (5.5%) (p < 0.10) provided more services per quarter than their male colleagues, whereas the female family physicians and general practitioners delivered 2.2% fewer services per patient per quarter than their male colleagues (p < 0.01). In two specialties differences between women aged 40 years or less and those over 40 years were observed. In general internal medicine the younger women had higher activity levels than the older women (p < 0.01). Conversely, in dermatology the younger women had lower activity levels (p < 0.05) and provided fewer services per patient per quarter (p < 0.001) than the older women. CONCLUSIONS: Although physician's sex explained much of the variation in activity level and service intensity, even after other important correlates were controlled for, the type and extent of differences observed between female and male physicians depended on the particular medical field examined. To understand the effect of the large increase in the number of women on the physician workforce, more detailed analyses by medical field are needed of the volume, mix and intensity of services provided by men and women, with adjustment for any possible differences in the patients seen in their practices.     

A 'firm' system for graduate training in general internal medicine.

The faculty of the Department of Medicine at Cleveland Metropolitan General Hospital has responded to the challenge of fostering general internal medicine in a graduate training program by organizing a "firm" system of medical care which has appealed to academic internists with broad interests in clinical medicine. This firm system consists of four medical teams which care for distinct patient populations, closely integrating their outpatient and inpatient care. The firms are made up of all the house staff in training in internal medicine together with senior and junior faculty members who are directors for the firms. Medical students in general medicine are also assigned to firms. This firm system is relatively simple to understand and establish and is readily applicable to other academic departments with general medical responsibilities.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Medical education for practice in nonmetropolitan areas

A study of patient records sampled from the office practices of 28 family practitioners and general surgeons in a 16-county nonmetropolitan area revealed that a sizable percentage of the diagnoses of problems encountered by family practitioners concern conditions the management of which is primarily taught on a residency service other than family practice, internal medicine, or pediatrics. Surgeons, conversely, are seeing a large percentage of patients with conditions the management of which is generally taught on a primary care residency service. Data from office records were augmented by interview responses of 32 family practitioners and general surgeons to questions about the training that family practice and general surgical residents should receive if they are to be well prepared for practice in nonmetropolitan areas.     

Spectrum of diseases for house staff education on a VA general medicine inpatient service

A significant portion of internal medicine residency training in the United States today occurs in general medicine sections of Veterans Administration hospitals. The authors studied the demographic, diagnostic, and prognostic characteristics of the patients treated by house staff members rotating through the general medical wards of the Houston, Texas, Veterans Administration (VA) Medical Center. In 2,131 admissions over 13 months, the most frequent primary causes of admissions included congestive heart failure, pneumonia, exacerbation of chronic obstructive lung disease, and malignancy. In 85 percent of the admissions, two or more chronic diseases were present. In 53 percent of admissions, the patients were deemed to be moderately or severely ill on admission. The data indicate that the residents' experience is representative of problems encountered by practicing internists and that VA hospitals make a significant contribution to internal medicine training and thus to the provision of health care for the nation.     

Rural and urban differentials in primary care management of chronic heart failure: new data from the CASE study

OBJECTIVE: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia. DESIGN: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study. SETTING: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998. MAIN OUTCOME MEASURES: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study. RESULTS: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of beta-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended "evidence-based practice" diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%). CONCLUSIONS: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.     

Physician supply and distribution in Georgia

Physician supply in Georgia must be considered an urgent issue. Several important points must be recognized and addressed. The lowest physicians rates are in the more rural county population groupings. The only county population grouping with a surplus of physicians is in the over 150,000 population. The majority of physicians are concentrated in the metropolitan counties. Sixteen percent of all physicians practice in the 134 counties having less than 50,000 population. The majority of physicians are in primary care specialties. Family practice is the most dominant specialty in rural areas. By the year 2000, Georgia can expect to add 5,600 physicians due to growth. By the year 2000, Georgia can expect to lose 2,600 physicians due to retirement. Family practitioners are the most uniformly distributed of the specialties examined. They are also the specialty most needed. The average age of Georgia physicians is 46. General surgeons are in the oldest average age group (50), whereas internists are in the youngest (44). Older physicians are concentrated in the more rural areas. A significant number of all physicians are over age 55. The majority of these will be retired by the year 2000. Physicians over age 65 represent 9.2% of all physicians from the survey. In Georgia, 13.6% of all physicians were Foreign Medical School Graduates. They tend to locate their practices in medically underserved areas. The specialty choices most frequently favored by FMGs are: pediatrics, internal medicine, family practice, and obstetrics/gynecology. A total of 71.2% of all physicians accept Medicare patients; 83.8% accept Medicare patients. Ninety-two percent of all obstetricians accept obstetric patients, but this participation is threatened by problems with malpractice insurance.     

Public policy and the supply of primary care physicians

The decline in general practice, the arrested growth of family medicine training programs, and the increased subspecialization of internal medicine and pediatrics are responsible for the continuing decrease in the proportion of physicians in the United States who practice a primary care specialty. Since 1963, the number of physicians has more than doubled, but the ratio of office-based primary care physicians to the national population has decreased. This trend has been especially pronounced in rural areas and impoverished urban communities. There is evidence that the proportion of young physicians entering primary care specialties is declining. Medical education has become increasingly reliant on service income, making it difficult to fund training in primary care specialties. Grants for graduate training in primary care specialties have not increased with inflation, and outright elimination of these programs is under consideration. Public programs that fund medical education must be reformed to improve the geographic and specialty distribution of physicians.     

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.     

三级医院中全科医学的定位和作用

2010年3月国家颁发的《以全科医生为重点的基层医疗卫生队伍建设规划》中提出,鼓励三级医疗机构建立全科医学科。2014年6月上海市卫计委批复同意同济大学附属杨浦医院(上海市杨浦区中心医院)设立全科医学执业科目,医院设立全科医学科,开设全科门诊与全科病房。全科医学科致力于健康管理、慢病管理、全科医学人才培训与学术研究等,是上海2家具备全科医学诊疗资质的三级医院之一。本文通过介绍同济大学附属杨浦医院全科医学科开设1年来门诊和病房的临床实践、总结与社区卫生服务中心的各项合作、开展多层次的人才培养和面向我国全科医学发展与社区卫生服务的科学研究这四大方面分析三级医院中全科医学的临床功能定位,即体现在为患者提供连续性、综合性,符合全科思维、全科理念的具有人文关怀的医疗服务过程;指明三级医院建立全科医学科的必要作用,为大医院与社区卫生服务中心搭建沟通桥梁,并促使双向转诊顺利进行;指导社区全科医生理论和临床知识的学习,为广大全科医生搭建高层次培训平台;探讨构建三级医院与社区卫生服务中心协同发展模式,强调三级医院的全科医学科在区域卫生协同发展中产生的重要作用,实现资源互补和资源利用最大化,推进医疗机构间的互相协作、协同发展。      

社区转诊指南临床试用评价

目的 探讨在实践中评价临床实践指南开发质量的科学方法,对社区转诊指南的质量和临床效果进行科学评价.方法 采用问卷调查法对北京市城区和远郊区各一个区内试用转诊指南的社区医生进行调查,就指南的质量和效果进行测评.采用"全面性、可理解性、严谨性、清晰性、适宜性、必要性、实施阻碍因素"等作为指南质量评价指标,采用"对专业知识的帮助、对减少误诊漏诊的帮助、对减少过度转诊的帮助"作为效果评价指标.采用百分率、χ2检验、秩和检验、回归分析等统计方法 分析指南的质量和效果及影响指南效果的因素.结果 共回收合格问卷160份,包括宣武区60份、顺义区100份.试用期间,社区医生对转诊指南进行了一定的使用.大多数社区医生对指南的质量和效果持肯定态度.在对专业知识的帮助方面,转诊指南对较低职称的社区医生帮助更大;在减少过度转诊方面,转诊指南对远郊区县的社区医生,从事专业年限较短的社区医生,乡村医生、医士、助理医师、无职称的社区医生取得了更明显的效果.指南全面性、适宜性指标与减少过度转诊指标存在定量关系.结论 应重视社区临床指南的开发与试用评价.评价方法 采用调查问卷的方式,采取质量和效果有关指标进行评价是可行的.为保证实施效果,今后开发社区指南时应该更加注意指南的全面性和适宜性.     

Mental health education in three primary care specialties

The authors used a questionnaire to examine the characteristics of the mental health components of residency training in traditional internal medicine, primary care internal medicine, and family practice. Traditional internal medicine programs relied almost exclusively on the consultation method and inpatient facilities, offered little formal instruction, used the psychiatrist as the primary teacher, and spent considerably less per resident for mental health training than the other programs. Psychologists and social workers as a group were the primary mental health teachers in family medicine residencies. Traditional internal medicine programs emphasized psychophysiological reactions and simple pharmacotherapy, while primary care internal medicine and family practice programs concentrated on life cycle issues, psychosocial awareness, and simple psychosocial management techniques. None of the three types of residencies focused on complex psychiatric disorders or management techniques. The three specialties differed significantly (F = 13, p = .0001) in the total amount of time on average the resident spent in formal mental health instruction. The need for evaluation of the outcome of training is also discussed.     

A proposal for a combined family practice--internal medicine residency

Both family practice and internal medicine currently train graduates for primary care. A single, four-year program is proposed that combines the strengths of family practice and internal medicine, incorporates community needs into the curriculum, and addresses the physician's changed role in a revolutionized health care provision system. Specific training recommendations and the societal and professional advantages of such a program are detailed.     

An agenda for residency training in ambulatory care

The successful practice of internal medicine in the ambulatory setting must take into consideration a number of factors that differ qualitatively and quantitatively from those important to practice on the hospital ward. The physician's intellectual ability, understanding of pathophysiology, and competence in physical examination are indispensable to practicing in both settings. However, due to the nature of presenting problems, the availability of time, and the role of patient cooperation, the application of these skills and knowledge and the decision-making process differ in the two settings. The recognition of these factors by the resident is likely to enhance his understanding of his therapeutic role, further his capacity to provide care to a diverse spectrum of patients, and promote greater satisfaction for himself and his patients. These considerations are especially important because most practicing internists spend most of their clinical time in the ambulatory settings.     

Effect of medicolegal liability on patterns of general and family practice in Canada.

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years.     

Facilitating prevention in primary care

We believe that many general practitioners would practice preventive medicine if they had the opportunity to organise their practice to do this. We therefore provided a "facilitator," who understands the work of a general practice, to help practices that were interested in prevention to set up programmes. She, for example, helped the primary care team to set up objectives, trained practice nurses to measure blood pressure, and set up a system to measure the progress of the programme.