Presenting the problem in pediatric encounters: "symptoms only" versus "candidate diagnosis" presentations

This article examines 2 practices that are used to present children's problems to their pediatricians in acute care encounters. Using the methodology of conversation analysis, this article examines the alternative stances embodied by problem presentations, which offer "symptoms only" versus problem presentations, which also include a "candidate diagnosis." This article suggests that parents who offer only symptoms in their problem presentations are hearable as adopting a stance that they are primarily seeking medical evaluations of their children. By contrast, a parent who includes a candidate diagnosis of the problem is hearable as adopting a stance that he or she is seeking confirmation of the diagnosis and treatment for that illness condition. This communication practice may be treated by physicians as placing pressure on them to prescribe treatment-in particular antibiotic treatment. The implications of this are discussed.     

Thoughts on "defensive" medicine

"Defensive" medicine is called medical behaviour characterized by deformation of diagnostic and therapeutic activities due to fears endangering existence and work, thus some interventions are omitted or, on the contrary, superfluous examinations are proposed on account of internal uncertainty, the patient's distrust or hostile social environment. Trust relation between patient and physician is the most gravely damaged because of aggravation and distortion of some conscienceless physicians' abuses by the media; patient-physician relations may not be degraded to contractual legal relations. Young physicians must get acquainted with the joy of success in diagnostics that enriches the personality. They shall have healthy self-esteem and be ready to take diagnostic and therapeutic challenges on themselves. All of us have to fight against social atmosphere hostile to physicians, against causes inducing and augmenting practice of defensive medicine.     

Better off alone? Why physicians don't merge

The era of the small medical practice is over. How many times have we heard that? It was widely proclaimed back in the 90s, in the wake of the Clinton administration's healthcare reform proposal. But 15 years have passed, and there are stillplenty of physicians working in solo and small group practices. Despite all the predictions that small practices could not survive in an environment of "big healthcare," they persist. A report published recently by the U.S. Centers for Disease Control and Prevention estimated that as of 2003-2004 more than 35% of office-based physicians were in solo practice, and roughly 66% practiced in groups of five or fewer. This article examines why, in spite of the challenges of being in solo and small group practices, many physicians still prefer the status quo and resist forming or joining larger groups.     

Assessing the quality of medical death certification: a case study of concordance between national statistics and results from a medical record review in a regional hospital in the Philippines

Background

Medical certificates of cause of death (MCCOD) issued by hospital physicians are a key input to vital registration systems. Deaths certified by hospital physicians have been implicitly considered to be of high quality, but recent evidence suggests otherwise. We conducted a medical record review (MRR) of hospital MCCOD in the Philippines and compared the cause of death concordance with certificates coded by the Philippines Statistics Authority (PSA).

Methods

MCCOD for adult deaths in Bohol Regional Hospital (BRH) in 2007–2008 and 2011 were collected and reviewed by a team of study physicians. Corresponding MCCOD coded by the PSA were linked by a hospital identifier. The study physicians wrote a new MCCOD using the patient medical record, noted the quality of the medical record to produce a cause of death, and indicated whether it was necessary to change the underlying cause of death (UCOD). Chance-corrected concordance, cause-specific mortality fraction (CSMF) accuracy, and chance-corrected CSMF were used to examine the concordance between the MRR and PSA.

Results

A total of 1052 adult deaths were linked between the MRR and PSA. Median chance-corrected concordance was 0.73, CSMF accuracy was 0.85, and chance-corrected CSMF accuracy was 0.58. 74.8% of medical records were deemed to be of high enough quality to assign a cause of death, yet study physicians indicated that it was necessary to change the UCOD in 41% of deaths, 82% of which required addition of a new UCOD.

Conclusions

Medical records were generally of sufficient quality to assign a cause of death and concordance between the PSA and MRR was reasonably high, suggesting that routine mortality statistics data are reasonably accurate for describing population level causes of death in Bohol. While overall agreement between the PSA and MRR in major cause groups was sufficient for public health purposes, improvements in death certification practices are recommended to help physicians differentiate between treatable (immediate) COD and COD that are important for public health surveillance.

     

Why physician groups are self-insuring

Given the medical malpractice crisis in a number of states, many physicians are looking at alternatives to conventional insurance coverage. These options typically involve some form of risk sharing where the medical group assumes additional risks based on experience. This article identifies several options-retrospective payment plans, risk retention groups, captives, and rent-a-captives--and their associated risks and opportunities.     

Methods of reducing the financial risk of physicians under capitation

In today's rapidly changing medical marketplace, managed care plans are not the only entities assuming risk for the care of enrollees through capitation. Increasingly, managed care plans are transferring this risk to their primary care and specialty physicians by paying them on a fully or partially capitated basis. Although capitation provides a strong incentive for physicians to provide cost-effective care, there are concerns that capitation may place some physicians at considerable financial risk. Our purpose is to familiarize physicians with issues they will want to consider when they evaluate capitation options and methods that are available to reduce their financial risk. Specifically, we analyze 3 issues: the range of services that are capitated, who accepts the risk, and size of patient panel. We conclude with a discussion of 3 methods for reducing or limiting risk--reinsurance, "carve outs," and risk adjustment.     

The deprofessionalization of Soviet physicians: a reconsideration

Traditional explanations for the relatively low status of the Soviet medical profession credit the Bolshevik government in the 1920s with deprofessionalizing or "leveling" a once autonomous and powerful occupational group. This article presents new data which challenge that interpretation. The Russian medical profession was never autonomous and powerful. Many physicians cooperated with the Bolsheviks because of shared beliefs regarding the organization of medical care. By the late imperial period, many physicians advocated the inclusion of all medical workers in policy-making administrative organs. Focusing upon Russian psychiatrists, the author analyzes the events that prompted the profession to adopt this position. The finding of greater continuity between prerevolutionary Russian and Soviet physicians suggests that this presumably anomalous case has greater significance for theoretical models of professionalization and occupational prestige than previously supposed.     

Normalizing the exceptional: incorporating the "abortion pill" into mainstream medicine

Mifepristone, also known as RU-486, and in the US known as "the French abortion pill", finally received FDA approval in the United States in September 2000. This paper discusses the steps now in process to integrate this drug into mainstream healthcare and the sociological implications of those efforts. Each of the steps that is normally taken to introduce a newly approved medication in the US context is rendered highly complex in the case of mifepristone--because of the unique circumstances of abortion in both American culture generally, and medical culture specifically. The story of RU-486/mifepristone, as it is currently unfolding, can be understood as one of attempting to "normalize the exceptional". After offering a brief historical overview of the protracted struggle for FDA approval of mifepristone in the US, this paper discusses the typical processes for integration of a newly approved medication into mainstream medicine and contrasts this process with the special challenges posed by a drug that is associated with abortion. We outline the challenges to implementation, including both external and internal obstacles. We compare the traditional role of a pharmaceutical company in drug diffusion and the circumstances of the company that produces mifepristone in the US. We discuss such external obstacles as the conflict between the FDA-approved regime and an evidence-based alternative; the necessity for physicians to order and dispense this drug; the ambiguity over the need for ultrasonography; and insurance reimbursement, malpractice, and other legal issues. Internal issues addressed include "turf issues" between medical specialties and between physicians and advanced practice clinicians as well as concerns over "cowboy medicine", and patient compliance. This paper concludes with an exploration of the sociological implications of this effort to "normalize the exceptional".     

The American Recovery and Reinvestment Act: lessons learned from physicians who have gone electronic

The recently passed American Recovery and Reinvestment Act (the Act) is a landmark piece of legislation that will shape health care informatics in the United States for the foreseeable future. The Act provides financial incentives to hospitals and physicians who upgrade their medical record systems by implementing electronic versions. This article defines health care informatics, outlines the provisions of the Act and associated incentives that are available to hospitals and physicians, discusses the advantages and barriers related to upgrading to an electronic medical records system that have been identified in the literature, and details several case studies where small physician group practices put electronic medical records systems into operation. The analysis of these cases shows that the challenges faced by the physicians and practice administrators reinforce the key challenges identified in the literature. Given these seemingly common impediments, suggestions for overcoming such challenges are summarized. These key lessons should be of interest to any practice looking to upgrade their medical records system.     

Awareness of and participation in maintenance of professional certification: a prospective study

INTRODUCTION: National health care concerns have led to the emergence of maintenance of certification (MOC) as a means to ensure the competence of practicing physicians. Little is known about physician perceptions of the barriers and/or benefits of MOC or proportions of physicians who participate in MOC programs. The purposes of this study were to assess physicians' plans for participating in MOC and to identify influences on decisions to participate. METHODS: A geographically stratified, random sample of 755 licensed practicing physicians in the state of Oregon were surveyed regarding certification status, awareness of MOC requirements, influences on decision to participate in MOC, and resources available and/or desired to assist with MOC. RESULTS: Three hundred seventy-six of 755 surveys were returned for +/-5% margin of error at 95% confidence level. Of the respondents 91% were board certified; 95% with time-limited certificates planned to recertify. Factors rated "extremely important" in decisions to recertify were to "demonstrate expertise in my specialty" (50%), to "demonstrate my medical knowledge is up to date" (52%), and to "demonstrate my competency to provide patient care in my specialty" (51%). Practice groups provided physicians with few resources for MOC; 29% report that their practices provided no resources for the MOC process. DISCUSSION: These results are important for hospitals, medical institutions, medical educators, and CME program planners. Although the large majority of physicians with time-limited certificates plan to participate in maintenance of certification, lack of some resources (time, money, and administrative support) and reluctance to utilize others (systems-based care) are identified as barriers to the success of MOC.     

Physicians vs. MCOs: can they cooperate to improve care quality?

The notion persists that quality improvement efforts cause more contention than cooperation between health care plans/payers and physicians. Some plans are overcoming this by investing a variety of resources in physician quality improvement projects--and involving physicians from the start. Aetna U.S. Healthcare Research takes a collaborative approach to physician quality improvement. Detroit's Health Alliance Plan has awarded +3.9 million in grants to fund physician quality improvement projects--as drawn up by its physician groups.     

How a successful litigator decides whether or not to sue you

This article aims to help physicians and other healthcare providers understand what prompts plaintiff lawyers to take on medical malpractice cases and to name the healthcare provider as a defendant in the suit. The article provides strategies for reducing the possibility of being named in a suit as well as for creating appropriate, favorable evidence that can be used for the healthcare provider if he or she is named in a suit. By understanding the "pluses" that cause a lawyer to sue, the risk of being sued can be decreased.     

"Directed" self-assessment: practice and feedback within a social context

INTRODUCTION: Accurate self-assessment appears to be difficult and, some would propose, even impossible. Recent reviews suggest that peer assessment may be more accurate and that multisource feedback (MSF) may inform self-assessment. We had conducted a series of studies of family physicians in an MSF program including assessments from patients, medical colleagues, and coworkers and self-assessment. Using this body of research, this article explores self-assessment within the social context of multisource feedback and investigates the influence of feedback from peers and others upon self-assessment. METHODS: This is a review article in which we synthesized findings of the series of studies with respect to self-assessment, used conclusions to propose a model for self-assessment within a social context, and suggest practical and research implications. RESULTS: Physicians compared peers' and others' assessment feedback with global self-perceptions of performance. Negative feedback, especially from medical colleagues, that was inconsistent with self-perceptions was not readily reconciled with self-assessments. Multiple internal and environmental factors influenced reconciliation and assimilation of negative feedback. Reflection upon feedback and self-perceptions appeared to be instrumental to reconciliation, and reflection could be facilitated. DISCUSSION: We propose a model of "directed" self-assessment to facilitate the integration of external feedback, especially negative feedback, with self-perceptions and enable its use for practice improvement. Implications for education and research include increasing understanding of ways physicians assimilate external feedback and of the role of educators as facilitators of "directed" self-assessment and self-learning to assist physicians in integrating external feedback.     

"What's in, what's out": stakeholders' views about the boundaries of Medicare

The Canada Health Act requires that provincial insurance plans provide universal coverage without co-payments for all "medically necessary" services delivered by hospitals and doctors, but allows care delivered by other providers in other locations to fall outside of the boundaries of Medicare. Discussion about the sustainability of medicare at both the national and provincial levels has called for the revisiting of these boundaries. The M-THAC (Medicare to Home and Community) Research Unit attempted to clarify the areas of consensus and controversy as to what key stakeholders thought should be "in" or "out" of Medicare. Using a non-experimental, cross-sectional design, a self-administered survey (in both English and French, constructed in consultation with our partners) was distributed between January and April 2002 to policy elites of key stakeholder groups. The results are based on 2,523 responses. Much of the current "debate" is mired in discussing issues where consensus already exists. We found strong support for in-hospital care. However, there is considerable resistance, across all groups, to full funding for similar services in private clinics or in the home, and almost no support for full funding for non-medical home-based services. The vision of many policy elites remains heavily linked to the current system of guaranteed public funding only for acute care in hospitals or by physicians. Successful reform will need to address, rather than assume, a broader view of healthcare.     

HMOs and physician recruiting: a survey of problems and methods among group practice plans.

A mail survey was conducted among 69 group practice health maintenance organizations (HMOs) to collect information on the recruiting of primary care physicians and specialists. In reporting on difficulties in recruiting physicians for primary care, the medical directors of HMOs indicated that the greatest problem was locating obstetrician-gynecologists. Among specialists, recruiting for orthopedists was reported as being most difficult, although plans that employ neurologists and anesthesiologists generally reported great difficulty in recruiting these specialists. The most important source of new physicians is the pool of the those completing residencies, describe by nearly three out of four plans as a very important resource. The next most important source was faculty or staff of medical schools or teaching hospitals. The recruiting methods reported by most plans as the most useful are direct personal contacts and advertisements in newspapers and journals. About one-fourth of the HMOs found unsolicited inquiries from physicians a useful method of recruiting. The problem most frequently reported in recruiting new physicians was that of matching fee-for-services incomes and second, but far less frequently mentioned, was physician prejudice against group practice. About one in four plans report that residents trained in their own HMOs were a useful recruiting source.     

"What's in, what's out": stakeholders' views about the boundaries of Medicare

The Canada Health Act requires that provincial insurance plans provide universal coverage without co-payments for all "medically necessary" services delivered by hospitals and doctors, but allows care delivered by other providers in other locations to fall outside of the boundaries of Medicare. Discussion about the sustainability of medicare at both the national and provincial levels has called for the revisiting of these boundaries. The M-THAC (Medicare to Home and Community) Research Unit attempted to clarify the areas of consensus and controversy as to what key stakeholders thought should be "in" or "out" of Medicare. Using a non-experimental, cross-sectional design, a self-administered survey (in both English and French, constructed in consultation with our partners) was distributed between January and April 2002 to policy elites of key stakeholder groups. The results are based on 2,523 responses. Much of the current "debate" is mired in discussing issues where consensus already exists. We found strong support for in-hospital care. However, there is considerable resistance, across all groups, to full funding for similar services in private clinics or in the home, and almost no support for full funding for non-medical home-based services. The vision of many policy elites remains heavily linked to the current system of guaranteed public funding only for acute care in hospitals or by physicians. Successful reform will need to address, rather than assume, a broader view of healthcare.     

Restructuring hospital-physician relationships for future success

Integrating physicians into the Healthfirst administration through employment sowed seeds of mutual understanding among these two groups that would benefit the system immeasurably over the next several years. The immediate future, however, saw only cultural upheaval between our hospitals and newly employed physicians, hospitals and nonemployed physicians, employed and nonemployed physicians, as well as specialists and primary care providers. Traditional physician-relationship-building efforts became difficult, if not impossible, to maintain. Essentially, administration was forced to scrap ten years of physician-development plans in order to reconfigure a relations effort that would maintain hospital support from all sides while restructuring the employed medical group. This article describes the evolution of Healthfirst's approach to maintaining effective physician relationships within our healthcare system and its affiliated entities over the past decade. Specifically, the article details the manner in which our system has evolved physician-relations activity to maintain an effective strategy during times of significant change in the healthcare industry.     

Transmission of financial incentives to physicians by intermediary organizations in California

Many U.S. physicians participate in provider-sponsored organizations that act as their intermediaries in contracting with managed care plans, particularly where capitation contracts are used. Examining a survey of 153 intermediary entities in California, we trace the cascade of financial incentives from health plans through physician organizations to primary care physicians. Although the physician organizations received the vast majority (84 percent) of their revenues through capitation contracts, most of the financial risk related to utilization and costs was retained at the group level. Capitation of primary care physicians was common in independent practice associations (IPAs), but payments typically were restricted to primary care services. Thirteen percent of medical groups and 19 percent of IPAs provided bonuses or withholds based on utilization or cost performance, which averaged 10 percent of base compensation.     

The Lake Wobegon Effect: Are All Cancer Patients above Average?

Context

When elderly patients face a terminal illness such as lung cancer, most are unaware that what we term in this article “the Lake Wobegon effect” taints the treatment advice imparted to them by their oncologists. In framing treatment plans, cancer specialists tend to intimate that elderly patients are like the children living in Garrison Keillor''s mythical Lake Wobegon: above average and thus likely to exceed expectations. In this article, we use the story of our mother''s death from lung cancer to investigate the consequences of elderly people''s inability to reconcile the grave reality of their illness with the overly optimistic predictions of their physicians.

Methods

In this narrative analysis, we examine the routine treatment of elderly, terminally ill cancer patients through alternating lenses: the lens of a historian of medicine who also teaches ethics to medical students and the lens of an actuary who is able to assess physicians’ claims for the outcome of medical treatments.

Findings

We recognize that a desire to instill hope in patients shapes physicians’ messages. We argue, however, that the automatic optimism conveyed to elderly, dying patients by cancer specialists prompts those patients to choose treatment that is ineffective and debilitating. Rather than primarily prolong life, treatments most notably diminish patients’ quality of life, weaken the ability of patients and their families to prepare for their deaths, and contribute significantly to the unsustainable costs of the U.S. health care system.

Conclusions

The case described in this article suggests how physicians can better help elderly, terminally ill patients make medical decisions that are less damaging to them and less costly to the health care system.     

Creating clinical and economic "wins" through integrated case management: lessons for physicians and health system administrators

OBJECTIVE: This article describes an innovative integrated approach to case management using a standardized complexity assessment grid and communication tool, which is designed to identify barriers to improvement in 4 domains: biological, psychological, social, and health system; to create and implement holistic care plans based on "anchored barriers; and to document ongoing targeted outcomes. PRACTICE SETTINGS: Adult and pediatric case and disease managers working for hospitals or clinics, health care delivery systems, general medical health plans, care management vendors, government agencies, and employers can effectively employ integrated case management procedures. INTEGRATED CASE MANAGEMENT: Integrated case management augments traditional care coordination by allowing trained medical or mental health managers to assist with cross-disciplinary barriers without handoffs; to connect multidomain barriers to mutually agreed-upon care plan goals and activities; and to measure clinical, functional, fiscal, quality of life, and satisfaction outcomes as a part of the management process, especially in high-cost, complex patients. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Integrated case management provides a step-by-step interdisciplinary approach for helping complex patients that has the potential to maximize clinical and functional value, while reducing total health-related costs.