Two studies of good clinical judgment

There is a continuing controversy about the quality of unaided clinical judgment. This paper reports two studies that show that experienced medical providers made accurate probability assessments and applied those assessments to patient care in a manner consistent with principles of optimal decision making. In the first study, experienced clinicians and physician assistants accurately judged the relative frequency of three cough-related diagnoses in an outpatient population, suggesting that their encounter with several "unrelated" diagnostic problems does not interfere with their ability to judge accurately the frequency of any single diagnostic problem. In the second study, a group of clinicians assessed the probability that each patient seen in an outpatient clinic had pneumonia. Physicians were more likely to assign a pneumonia diagnosis and to order a radiograph for patients with a greater assessed probability of pneumonia (p less than 0.05). Most of the physicians appeared to use cutoff probabilities or "thresholds" above which they acted as though the patient had the disease and below which they acted as though the patient did not have the disease, consistent with rational decision-making principles. However, the threshold probabilities being used were quite different from physician to physician, implying that the physicians managed the patient population in a nonuniform manner. Thus it may be desirable to supplement "good" clinical judgment with decision aids to ensure standardized medical care.     

Gaining Physician Buy-In for Disease Management Initiatives

Achieving the support of physicians is perhaps the most difficult challenge to successfully implementing a disease management programme. Most physicians are sceptical of disease management initiatives. Many perceive these programmes to be a threat to their professional autonomy or an unreasonable demand on their limited time with patients. Nonetheless, failure to achieve high levels of physician support results in suboptimal levels of patient identification, enrolment and effectiveness of interventions. Therefore, it is impossible to achieve good outcomes across a large population without achieving physician buy-in.Leaders of organisations implementing disease management programmes can use 5 core strategies to achieve physician buy-in for disease management programmes. These are: education, enlisting champions, ‘creating a box’, building on success, and sharing the gains. Providing education corrects misconceptions many physicians have about disease management. Champions are respected clinicians who are willing to share their positive views of a disease management programme. ‘Creating a box’ sets clear goals and expectations for physicians who consider building a disease management programme. Building on success involves demonstrating that a relatively easy programme works before attempting a more complex or controversial programme. Finally, sharing the gains means that physicians should be rewarded for their time and effort supporting disease management programmes.     

Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education

Twenty percent of the US population lives in rural communities, but only about 9% of the nation's physicians practice in those communities. There is little doubt that the more highly specialized physicians are, the less likely they are to practice or settle in rural areas. There is clearly a population threshold below which it is not feasible for specialist (in contrast to generalist) physicians to pursue the specialty in which they have trained. Much of rural America falls below that threshold. This leaves large geographic areas of America to the primary care physician. The proportional supply of family physicians to specialists increases as urbanization decreases. Family physicians are the largest single source of physicians in rural areas. Family medicine residency programs based in rural locations provide a critical mechanism for addressing rural primary care needs. Graduates from rural residency programs are three times more likely to practice in rural areas than urban residency program graduates. There are two primary goals of training residents in rural areas: producing more physicians who will practice in rural areas and producing physicians who are better prepared for the personal and professional demands of rural practice. Rural Training Tracks, where the first year of residency is completed in an urban setting and the second and third years at a rural site (1-2 model), initially proposed by Family Medicine Spokane in 1985, have been highly successful in placing and maintaining more than 70% of their graduates in rural communities. Similar and modifications of the "Spokane RTT model" have been established around the country. Now, more than 24 years of educational experience has been accumulated and can be applied to further development of these successful family medicine residency programs.     

Primary care physician turnover in HMOs.

OBJECTIVE. We assess whether physician turnover stems from incorrect physician expectations about the practice environment or from actual constraints or rewards in that environment. DATA SOURCES. Our primary data source contains information about individual HMOs' primary care physicians incentive mechanisms and general HMO characteristics. Our secondary data source is the area resource file (ARF), which contains countywide information about the HMOs' market areas, including physician characteristics, population characteristics, and other market characteristics. DATA COLLECTION. Our primary data source is from a nationwide survey of all HMOs in operation in 1987-1988, as reported to Interstudy. PRINCIPAL FINDINGS. We find that turnover is higher on the part of physicians whose HMO enrollment comprises a greater percentage of their total practice. Our results further indicate that physicians whose compensation is dependent on the behavior of a group of other physicians are more likely to leave the plan than those who bear the risk (and control it) more directly. On the other hand, turnover is increased by basing bonuses on individual productivity and by not sharing surpluses among a group. Market characteristics also are significant in explaining physician turnover in HMOs. CONCLUSIONS. It appears that physicians accurately forecast how they will react to individual financial risk, although they dislike restrictions imposed by HMOs.     

Tailoring hospital marketing efforts to physicians' needs.

Marketing has become widely recognized as an important component of hospital management (Kotler and Clarke 1987; Ludke, Curry, and Saywell 1983). Physicians are becoming recognized as an important target market that warrants more marketing attention than it has received in the past (Super 1987; Wotruba, Haas, and Hartman 1982). Some experts predict that hospitals will begin focusing more marketing attention on physicians and less on consumers (Super 1986). Much of this attention is likely to take the form of practice management assistance, such as computer-based information system support or consulting services. The survey results reported here are illustrative only of how one hospital addressed the problem of physician need assessment. Other potential target markets include physicians who admit patients only to competitor hospitals and physicians who admit to multiple hospitals. The market might be segmented by individual versus group practice, area of specialization, or possibly even physician practice life cycle stage (Wotruba, Haas, and Hartman 1982). The questions included on the survey and the survey format are likely to be situation-specific. The key is the process, not the procedure. It is important for hospital marketers to recognize that practice management assistance needs will vary among markets (Jensen 1987). Therefore, hospitals must carefully identify their target physician market(s) and survey them about their specific needs before developing and implementing new physician marketing programs. Only then can they be reasonably confident that their marketing programs match their customers' needs.     

Compliance with physician advice to quit smoking: A review of the literature

The variety of roles that the physician can assume with patients who smoke cigarettes ranges from providing a model by being a nonsmoker to active management of the quitting process. The literature dealing with effectiveness of physician advice with the following patient groups is presented: general practice, pregnant, pulmonary, and cardiac patients. It is concluded that, in general, the more severe the disease and the more imminent the danger from continued smoking, the more likely patients are to comply with advice to quit. Statistical consideration of the interrelationships between patient and physician characteristics ultimately may lead to providing the most effective methods to the largest number of patients. Some practical recommendations for physicians are presented.     

Patient satisfaction with family physicians and general internists: is there a difference?

Although general internists and family physicians see similar types of patients, they have been found to have different styles of practice. It is not known whether these differences in practice style are associated with differences in outcomes of care such as patient satisfaction. This study examined whether patients of family physicians and general internists have different perceptions of the care they receive. National samples of recently trained family physicians and general internists were asked to complete questionnaires about their practices and to record information on all patient encounters during a three-day period. Three patients were randomly sampled from among those seen by each physician during the study period and were sent questionnaires that included questions about their satisfaction with the medical care they were receiving from the physician. Two hundred thirteen adult patients who saw 124 family physicians and 218 adult patients who saw 98 general internists participated in this study. Patients of general internists and of family physicians reported similar levels of satisfaction on all four dimensions measured (access, humaneness, quality, and general satisfaction) even after controlling for the effects of a variety of patient, practice, physician, and encounter characteristics. It is concluded that the fundamental differences in practice style that have been reported between family physicians and general internists do not seem to be associated with differences in patient satisfaction.     

Physicians' capability in home health practice: home health nurses' perceptions.

OBJECTIVES: To examine home health nurses' attitudes towards physician capabilities in home health care, and whether nurses' attitudes are associated with their experience, practice setting, degree of physician interaction, or use of home health guidelines. DESIGN: A multiple regression analysis of a 90 item survey on agency characteristics, degree of interaction with physicians, and ratings of physicians capabilities across multiple dimensions of home health practice. SETTING/PARTICIPANTS: 86 registered visiting nurses from seven Chicago-area home health agencies, who averaged 25 home visits and over one hour of direct contact with physicians weekly. MEASUREMENTS: Nurses' ratings of physician capability in home health practice were scaled from 18 survey items with high internal consistency reliability and correlated with nurses' practice characteristics. RESULTS: While most nurses (72%) felt that physicians responded adequately in emergencies and respected them as colleagues (70%), over 70% of respondents did not agree that physicians were adequately trained in home health. A majority of respondents rated physicians negatively on patient education, cross-coverage and availability, discharge planning, support and medical supply services, and insurance issues. Respondents' years of home health experience correlated negatively (p = .004) and degree of contact with physicians correlated positively (p = .05) with ratings of physician capabilities. CONCLUSION: Nurses' attitudes about physicians' performance can provide important insights for improving the effectiveness of specialized disease and outcomes management programs which rely on care in the home setting.     

Physician management in primary care.

Minimal explicit consensus criteria in the management of patients with four indicator conditions were established by an ad hoc committee of primary care physicians practicing in different locations. These criteria were then applied to the practices of primary care physicians located in a single community by abstracting medical records and obtaining questionnaire data about patients with the indicator conditions. A standardized management score for each physician was used as the dependent variable in stepwise regression analysis with physician/practice and patient/disease characteristics as the candidate independent variables. For all physicians combined, the mean management scores were high, ranging from .78 to .93 for the four conditions. For two of the conditions, care of the normal infant and pregnant woman, the management scores were better for pediatricians and obstetricians respectively than for family physicians. For the other two conditions, adult onset diabetes and congestive heart failure, there were no differences between the management scores of family physicians and internists. Patient/disease characteristics did not contribute significantly to explaining the variation in the standardized management scores.     

Practice variation and physician-specific effects

This study provides estimates of practice variation for primary physician services in Norway. Nearly all previous studies on practice variation have encompassed mainly specialist and hospital services. Thus we provide evidence for treatment variation for a health care sector where information about treatment variation is relatively scarce. Our analyses were carried out on a large set of data from individual physician practices. We estimated the extent of practice variation according to type of diagnosis and type of treatment option. The main finding is that variation in clinical practice between physicians is an important determinant of expenditure for primary physician services. Depending on the type of diagnosis, physician-specific effects explained 47-66% of the variation in expenditure for laboratory tests, 59-66% of the variation in expenditure for consultations lasting over 20min and 49-61% of the variation in expenditure for specific procedures. The age and gender of the patients explained only about 1% of the variation in expenditure. This finding supports the results from previous studies, which have shown that patients' age and gender are inadequate when used as risk adjusters. We also identified physicians who moved their practice from one municipality to another, i.e. they changed their patient population completely. Our results showed that those physicians who moved did not change practice style after they moved, i.e. that physician's style of practice is stabile. This indicates that practice style reflects a deeply rooted behaviour with respect to how to practice medicine.     

Physician organization and care management in California: from cottage to Kaiser

Data from a survey of practicing physicians in California's thirteen largest urban counties were used to ascertain differences in care management processes, financial incentives for quality, and practice pressures by type of practice setting. Physicians in the Permanente medical groups have adopted and value quality-oriented, system-level care management tools to a much greater degree than physicians in independent practice association (IPA) networks or traditional "cottage-industry" practices. Our findings raise disturbing questions about how the health system will close the "quality chasm" in medical care without transforming the underlying organization of physician practices.     

Establishing a group practice "without walls"

The group practice "without walls" has become a health care delivery system that is preferred by an increasing number of physicians. This article traces the experience of Premier Medical Group, PC, a "second generation" clinic without walls in the Denver Metropolitan area, to highlight the potential benefits and the key issues related to the development and implementation of a group practice-without-walls model of health-care delivery. The model promises to address physician business and professional needs by building on the best aspects of a traditional group practice, in an overall organizational structure that maximizes each physician's autonomy, individual practice style, and practice identity. The successful implementation of a group practice without walls depends upon physician leadership and impetus, clear goals-and-objectives, competent professional staff, and legal-and-financial guidance.     

Utilization of computers in clinical practice--role of physician networks: preliminary communication.

This study examines the influence of physician networks on the utilization of computers in clinical practice. Data on patient referrals, consultations, professional discussions, and on-call coverage were collected from 24 physicians who comprise a private group practice. Their utilization of a computerized hospital medical information system (HIS) in caring for patients admitted to a 1160-bed private, university affiliated, teaching hospital was determined. A matrix representing the professional relations among these physicians was subjected to smallest space analysis, a form of multidimensional scaling. Also, a number of indices that describe structural and interactional properties of the network and individual physicians were computed. The three-dimensional representation of the network that resulted from the analysis suggests a two-step process of adoption and utilization of medical technology. Physicians who were engaged in outside professional activities and in the training of medical students and house staff were more likely to utilize the system in caring for patients. These physicians, who were more centrally located and dominant in the referral and consultation process, were more likely to influence the practice patterns of their colleagues. The use of network analysis to identify influential physicians whose involvement is essential to the success of efforts aimed at introducing computers into clinical practice is discussed.     

Physician practice size and variations in treatments and outcomes: evidence from Medicare patients with AMI

Little is known about the relationships between physician practice size and patient treatments or outcomes. We examined whether the practice size of attending physicians was related to within-hospital differences in care for Medicare patients with acute myocardial infarction (AMI). We found that patients treated by solo physicians were less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics were taken into account. These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty.     

Smoking cessation treatment by primary care physicians: An update and call for training

BACKGROUND: Public health and government organizations have invested considerably to increase physician adherence to smoking-cessation practice guidelines. METHODS: A random sample of 2000 U.S. primary care physicians was ascertained from the American Medical Association (AMA) in 2002. Respondents (n = 1120, 62.3%) provided self-reported data about individual and practice characteristics and smoking-cessation practices. Data were analyzed in 2005. RESULTS: Most primary care physicians (75%) advised cessation, 64% recommended nicotine patches, 67% recommended bupropion, 32% recommended nicotine gum, 10% referred to cessation experts, and 26% referred to cessation programs "often or always." Advising cessation was related to being older, having a faculty appointment, having trained staff for smoking counseling, and having confidence to counsel patients about smoking. Physicians who were internists, younger, and those with greater confidence to counsel patients about smoking recommended nicotine replacement more often. Prescribing bupropion was less common among older physicians, in the Northeast, with trained staff available for counseling, and with a greater proportion of minority or Medicaid patients. Prescribing bupropion was more common among AMA-member physicians and physicians with greater confidence to counsel patients about smoking. Providing a referral to an outside expert or program was more common among female physicians, and physicians in the Northeast or West, with larger clinical practices, and with trained staff for cessation counseling. CONCLUSIONS: Current physician self-reported practices for smoking cessation suggest opportunity for improvement. Targeted efforts to educate and support subsets of primary care physicians may improve physician adherence and smoking outcomes.     

Nutrition counseling in private practice: attitudes and activities of family physicians

A community approach to cardiovascular disease control is advocated for the United States because of the high disease incidence and prevalence relative to other countries. The goal of this approach is to change nutrition behavior of all members of the community. As part of a program to identify barriers to physician participation, a survey of a random sample of family practice clinical faculty in a midwestern state was made to determine (a) if physicians agree that it is appropriate to give nutritional advice to a patient who came to the clinic for another reason, (b) the proportion of patients given nutritional advice, and (c) the barriers to giving nutritional advice. Most physicians report that giving nutritional advice to patients visiting them for other reasons is considered appropriate, but almost half the physicians give advice about dietary fat, dietary sodium, or dietary fiber to fewer than 20% of their patients. Only about 10% of physicians give advice to more than 80% of their patients. Absence of elevated risk factor levels or nutritional disease is the most common reason for not giving advice. Perceived lack of patient interest and expectation of patient nonadherence are also barriers. Unpalatability of the diet is occasionally a barrier. Cost of the diet is not a consideration. From these data it is concluded that family physicians consider it appropriate to give nutritional advice to patients who are not necessarily seeking it, but the perception that patients do not need or want, and would not follow, the advice inhibits physicians from delivering nutrition messages in private practice.     

The role of patient,physician and systemic factors in the management of type 2 diabetes mellitus

BACKGROUND: Few studies have explored the contextual dimensions and subsequent interactions that contribute to a lack of adherence in the application of guidelines for diabetes management. OBJECTIVE: The purpose of this qualitative study was to explore family physicians' issues and perceptions regarding the barriers to and facilitators of the management of patients with type 2 diabetes mellitus (DM). METHODS: Four focus groups composed of family physicians (n= 30) explored the participants' experiences in the management of patients with type 2 DM. A semi-structured interview guide began with questions on family physicians' experience of providing care and included specific probes to stimulate discussion about the various barriers to and facilitators of the management of type 2 DM in family practice. RESULTS: Participants clearly identified type 2 DM as a chronic disease most often managed by family physicians. The findings revealed distinct barriers and facilitators in managing patients with type 2 DM which fell into three domains: patient factors; physician factors; and systemic factors. There was a dynamic interplay among the three factors. The important role of education was common to each. CONCLUSIONS: The interactions of patient, physician and systemic factors have implications for the implementation of a diabetes management model. The care of patients with type 2 DM exemplifies the ongoing challenges of caring for patients with a chronic disease in family practice. The findings, while specific to the management of type 2 DM, have potential transferability to other chronic illnesses managed by family physicians.