The INSURE project on lifecycle preventive health services.

The INSURE Project on Lifecycle Preventive Health Services is a 3-year study to determine the feasibility of implementing preventive services in primary medical care as a health insurance benefit and to assess the short-term impact of this implementation on providers and consumers. Initiated by the life and health insurance companies, the project has received additional support from private philanthropic foundations. Preventive services, which will be provided under a lifecycle approach according to the age and sex of the patient and include education of patients on health-related behavior, will range from prenatal care through geriatrics. A quasi-experimental design will be used in which three study (experimental) group practice sites are matched with three control group practice sites. At the study sites, the primary care physicians will participate in orientation sessions on recommended preventive services and patient education procedure; they will also examine and counsel the study patients. The study and control physicians and patients will be surveyed before and after the program of intervention is conducted at the study sites to assess their knowledge, attitudes, and behavior toward health behavior practices.     

Physicians' and patients' attitudes toward manual medicine: implications for continuing medical education

INTRODUCTION: Manual medicine (MM) is a physical modality infrequently used in primary care clinics. This study examines primary care physicians' experience with and attitudes toward the use of MM in the primary care setting, as well as patients' experience with and attitudes toward MM. METHODS: Surveys were distributed to a convenience sample of physicians (54.3% response rate) attending a 1-week primary care continuing medical education (CME) conference in Kentucky. Similar surveys were also mailed to a random sample of primary care patients (35.3% response rate) living in a service region in which most conference attendees practiced. RESULTS: Similar responses were obtained from physicians and patients. A majority (81% and 76%, respectively) of physicians and patients felt that MM was safe, and over half (56% of physicians and 59% of patients) felt that MM should be available in the primary care setting. Although less than half (40%) of the physicians reported any educational exposure to MM and less than one-quarter (20%) have administered MM in their practice, most (71%) respondents endorsed desiring more instruction in MM. The majority of those seeking additional educational exposure (56%) were willing to pay for MM training that included CME credit. DISCUSSION: This survey suggests that primary care physicians feel that there is currently insufficient education in MM. The majority of physicians and patients feel that MM is beneficial, safe, and appropriate for use in a primary care setting. Thus, there may be a rising demand for quality instruction in MM from physical medicine doctors and other licensed therapists who currently practice MM.     

An Assessment of Practice Support and Continuing Medical Education Needs of Rural Pennsylvania Family Physicians

Family physicians provide the greatest proportion of care in rural communities. Yet, the number of physicians choosing family practice and rural practice has continued to decline. Undesirable aspects of rural practice, such as professional isolation and a lack of or inadequate resources, are assumed to be associated with this decline. This article reports on the practice support and continuing medical education needs of rural family physicians. A mail survey was conducted in 1993 on a purposive sample of family physicians in 39 of 67 rural-designated or urban Pennsylvania counties with low population densities. The physicians identified needs that included patient education materials and programs, community health promotion, federal regulation updates, technical assistance with computers and business management, database software and a videotape lending library, a drug hotline, and mini-fellowships on clinical skill development. A majority of respondents were willing to participate in clinical educational experiences for students and residents. Some physicians indicated a lack of interest in access to information through telecommunications, e.g., video conference referrals and consultations. Overall, findings revealed that family physicians need and are receptive to a variety of practice support and continuing education programs. A practice support program coupled with policy coordination among public and private organizations is likely to lessen complaints by rural primary care physicians.     

Why Rural Residents Migrate for Family Physician Care

Several studies have examined why rural residents bypass local hospitals, but few have explored why they migrate for physician care. In this study, data from a random mail survey of households in rural Iowa counties were used to determine how consumers' attitudes about their local health system, health beliefs, health insurance coverage and other personal characteristics influenced their selection of local vs. nonlocal family physicians (family physician refers to the family practice, internal medicine or other medical specialist providing an individual's primary care). Migration for family physician care was positively associated with a perceived shortage of local family physicians and use of nonlocal specialty physician care. Migration was negatively associated with a highly positive rating of the overall local health care system, living in town, Lutheran religious affiliation and private health insurance coverage. By understanding why rural residents prefer to bypass local physicians, rural health system managers, physicians and policy-makers should be better prepared to design innovative health organizations and programs that meet the needs of rural consumers.     

Practice Location Choice by New Physicians: The Importance of Malpractice Premiums, Damage Caps, and Health Professional Shortage Area Designation

Objective. To understand the factors affecting the choice of initial practice location by new physicians.
Data Sources/Study Setting. A unique survey of exiting medical residents in New York State from 1998 to 2003.
Study Design. We estimate conditional logit models to examine the factors affecting the choice of initial practice location by new physicians.
Data Collection/Extraction Methods. We identify all physicians completing their training in obstetrics/gynecology or surgery and primary care physicians (PCPs) (general internal medicine, pediatrics, and family medicine) who had accepted a job in patient care and who provided the location (zip code) of their job. This resulted in 3,758 physicians in our sample.
Principal Findings. Our results indicate that malpractice insurance premiums are a significant deterrent for surgeons, but they do not appear to deter OB/GYNs or PCPs from locating in particular areas. In addition, caps on malpractice damage awards attract surgeons to areas. Shortage area designations attract PCPs without education debt yet deter PCPs with debt, suggesting that subsidies do not outweigh the perceived costs of locating in underserved areas.
Conclusions. In general our results highlight that new physicians are sensitive to the characteristics of the locations in which they could potentially locate when beginning their careers in patient care.     

Evolution of physicians' attitudes towards practice guidelines

OBJECTIVES: To assess changes in physicians' attitudes towards practice guidelines and towards the role of empirical evidence in their development. METHODS: The findings from two surveys carried out in 1993 and 1997 on the same random sample from two Italian medical specialty societies were compared. In both studies, physicians were mailed a questionnaire asking their views on the goals and role of practice guidelines in influencing clinical decision-making, and the role of empirical evidence versus subjective clinical experience in their development. RESULTS: One hundred and seventy physicians participated in both surveys. An increasing proportion of physicians accepted that cost containment could be a legitimate goal of practice guidelines (from 26% in 1993 to 40% in 1997; P = 0.010). More clinicians (43% in 1993 and 57% in 1997; P < 0.01) supported the use of empirical evidence, as opposed to subjective clinical experience, as the primary basis for practice guidelines. Although only a tiny minority of physicians (6% in 1993 and 1997) supported the view that practice guidelines should reflect patient preferences, an increased proportion of physicians supported the participation of representatives from outside the medical profession in their development. The level of support increased from 6% in 1993 to 26% in 1997 (P < 0.001) in the case of consumers, from 24% to 38% (P = 0.015) for patient involvement and from 16% to 33% (P = 0.003) in the case of health care administrators. CONCLUSIONS: The documented changes suggest that more clinicians acknowledge the role of empirical evidence and the need for a dialogue with other professionals and patient groups in the development of practice guidelines than was the case in the recent past.     

A survey of primary care physicians' perceptions and needs regarding the precepting of medical students in their offices

OBJECTIVE: To assess the interest, perceptions, and needs of primary care physicians with regard to office-based precepting of medical students. DESIGN: Random survey. SETTING: The New England region of the United States (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut). PARTICIPANTS: Family physicians, general internists and paediatricians. MAIN OUTCOME MEASURES: These included: (1) practice and preceptor demographics; (2) Likert scale agreement or disagreement with various positive and negative perceptions about precepting students; rating (from unimportant to necessary) of potential benefits from medical schools associated with the support of precepting in the office setting, and (3) comparisons among physician groups to determine differences in perceptions and needs. RESULTS: There is a high level of interest in precepting regardless of primary care specialty, practice structure, payment mechanism, or precepting experience. Negative impacts included decreased productivity and increased length of the day by a median of 60 minutes. Positive impacts included keeping one's own knowledge up-to-date and enhanced enjoyment of practice. Benefits such as academic appointments, continuing medical education credits, faculty development, computer linkages for clinical information and medical library access are rated highly. Monetary payment, whether as a modest honorarium or as compensation for lost time/income, was felt to be important by half of our sample. CONCLUSION: A significant interest in precepting medical students on a regular basis is expressed by primary care physicians in the ambulatory medicine setting. The results of this survey can be used by medical schools to address negative perceptions and to develop appropriate benefits packages to recruit and retain these primary care preceptors.     

Information-seeking behaviors and reflective practice

INTRODUCTION: As they care for patients, physicians raise questions, but they pursue only a portion of them. Without the best information and evidence, care and patient safety may be compromised. Understanding when and why problems prompt physicians to look for information and integrate results into their knowledge base is critical and shapes one part of reflection about care. This study explores the role of the Internet in gathering medical information as one step in that reflective practice, the barriers to its use, and changes in utilization over time. METHODS: A questionnaire with 18 items adapted from previous studies was sent by facsimile to a randomly selected sample of U.S. physicians in all specialties and active in practice. RESULTS: Specific patient problems and latest research in a specific topic most often prompt physicians to search on the Internet. Younger physicians and female physicians were most likely to seek information on a specific patient problem. Only 9% of all respondents (n = 2,500) searched for information during a patient encounter. When unsure about diagnostic and management issues for a complex case, 41.3% chose to consult with a colleague or read from a text (22.8%). Searching most often occurred at home after work (38.2%) or during breaks in the day (35.7%). Most (68.7%) found the information they were looking for more than 51% of the time. Searching was facilitated by knowing preferred sites and access in the clinical setting. The greatest barriers to answering clinical questions included a lack of specific information and too much information to scan. DISCUSSION: Although physicians are increasingly successful and confident in their Internet searching to answer questions raised in patient care, few choose to seek medical information during a patient encounter. Internet information access may facilitate overall reflection on practice; physicians do not yet use this access in a just-in-time manner for immediately solving difficult patient problems but instead continue to rely on consultation with colleagues. Professional association Web sites and point-of-care databases are helpful. From physicians' use of the Internet, professionals in continuing medical education must learn which search engines and sites are trusted and preferred.     

The Physician Pipeline to Rural and Underserved Areas in Pennsylvania

ABSTRACT: Context: An implicit objective of a state's investments in medical education is to promote in‐state practice of state educated physicians. Purpose: To present a tool for evaluating this objective by analyzing the “pipeline” from medical education to patient care, primary care, rural areas, and underserved areas in Pennsylvania. Methods: AMA Masterfile data (2004) including all physicians with a Pennsylvania address or who received medical education in Pennsylvania were analyzed. These data were combined with local physician supply data. Results: About 36% of Pennsylvania medical school graduates provide patient care in the Commonwealth, 16% primary care, 7% rural care, 4% rural primary care, and 0.5% primary care in a rural underserved area. Fifty‐four percent of physicians who received both undergraduate and graduate medical education in‐state are retained. Conclusions: These retention rates have developed within the context of a middle‐of‐the‐road educational pipeline policy. If Pennsylvania policy makers consider that further pipeline development is advisable, there is room to amend current policy to that end. Conditions are favorable for other states to consider similar policy amendments.     

A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States

PURPOSE

We undertook a study to reexamine the relationship between educational debt and primary care practice, accounting for the potentially confounding effect of medical student socioeconomic status.

METHODS

We performed retrospective multivariate analyses of data from 136,232 physicians who graduated from allopathic US medical schools between 1988 and 2000, obtained from the American Association of Medical Colleges Graduate Questionnaire, the American Medical Association Physician Masterfile, and other sources. Need-based loans were used as markers for socioeconomic status of physicians’ families of origin. We examined 2 outcomes: primary care practice and family medicine practice in 2010.

RESULTS

Physicians who graduated from public schools were most likely to practice primary care and family medicine at graduating educational debt levels of $50,000 to $100,000 (2010 dollars; P <.01). This relationship between debt and primary care practice persisted when physicians from different socioeconomic status groups, as approximated by loan type, were examined separately. At higher debt, graduates’ odds of practicing primary care or family medicine declined. In contrast, private school graduates were not less likely to practice primary care or family medicine as debt levels increased.

CONCLUSIONS

High educational debt deters graduates of public medical schools from choosing primary care, but does not appear to influence private school graduates in the same way. Students from relatively lower income families are more strongly influenced by debt. Reducing debt of selected medical students may be effective in promoting a larger primary care physician workforce.     

Medical education and the retention of rural physicians.

OBJECTIVE. This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN. Design is a prospective cohort study. PARTICIPANTS. Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION. In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS. Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS. These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.     

Factors influencing physicians' preventive practices

We used data on a stratified random sample of 809 Quebec physicians to determine the extent to which the integration of prevention into medical practice was related to physicians' sociodemographic background, area of specialization, medical practice characteristics, and professional attitudes. Among factors positively associated with physicians' preventive practices were favorable attitudes toward prevention, patient education and patient-oriented activities, being in primary care medicine or in a medical specialty such as cardiology, gastroenterology, or pneumology, practicing in a public community health center on a salary basis, working in a group practice, having an office-based practice, devoting time to research activities, being older, and being a woman. Specialization in neurology, hematology, dermatology, nephrology, obstetrics-gynecology, and most notably surgery was negatively associated with preventive practices, as was working in an emergency room. Overall, the study variables explained 33% of the variance in physicians' preventive practices. The study underlines the prevailing role of attitudes in predicting physicians' preventive practices.     

Information mastery: integrating continuing medical education with the information needs of clinicians

Traditional continuing medical education (CME) has been disconnected from the actual practice of medicine and has not focused on providing the most useful information in the most efficient way. Physicians have different information needs at different times. When asked at the end of a day of patient care, physicians will typically report having had one question for every four or five patients. However, direct observation during patient care reveals many more questions. In the outpatient primary care setting, most studies have found, on average, that about two clinical questions are generated during every three patient encounters, with even higher numbers reported in the inpatient teaching setting. Thus, a physician seeing 25 patients in a typical day of outpatient care may have 15 clinical questions. Because clinical questions are the result of critical reflection by a clinician on his or her practice, they are central, to physician learning. This connection between "need" and learning is consistent with generally accepted theories of adult learning. When applied to continuing education, this connection suggests that physicians will learn best when learning is in the context of patient care, answers their questions, does not take too much time, and is directly applicable to their work. Pursuing answers to these questions and answering them with the best available evidence, at the time the answer is needed, may well change the physician's general approach to patient care.     

Practice settings and prescribing profiles: the simulation of tension headaches to general practitioners working in different practice settings in the Montreal area

The purpose of this study was to determine whether physicians practicing in one type of setting manage a medical problem differently than those practicing in another type of setting. The investigation took the form of presenting physicians with a simulated case of tension headache with a history going back three years, for which diazepam had been taken daily for the past year. Four simulated patients (aged 20-23) visited a stratified random sample of 111 general practitioners practicing in health centers funded by government (CLSCs) and in private group practice clinics in the Montreal area. Fifty-one per cent of group practice physicians recommended therapy rated as "inadequate" compared to 25 per cent in CLSCs; in addition, the data show significant differences between CLSC and group practice physicians in performing various aspects of the clinical examination. Alternative explanations for the observed differences are discussed.     

Use of clinic versus private family planning care by low-income women: access, cost, and patient satisfaction.

Use of private physicians versus public family planning facilities by poverty level and near poverty level women was examined by means of a sample survey conducted in low-income areas of Los Angeles County. Utilization differed by race/ethnicity, with Hispanics more likely to go to federally subsidized family planning clinics (primarily county-run), Whites and Blacks to private physicians. Private family planning offers easier access, greater convenience, and higher satisfaction, albeit at almost double the cost. Clinic usage is influenced by lack of a regular source of medical care and lack of insurance coverage more than poverty level per se. Clinic patients report greater patient education regarding contraceptive methods, but less general medical care during clinic visits. They are more likely than private patients to express a desire for a different source of family planning care.     

Differences in the obstetric practices of obstetricians and family physicians in Washington State

In response to the obstetric malpractice crisis, both obstetrician-gynecologists and family physicians have raised their fees and preferentially selected lower risk patients. In addition, large numbers of general and family physicians have left obstetric practice altogether. The impact of these responses was explored by examining the differences in the demographic and clinical profile of patients served by these two disciplines in the State of Washington. Eighty-five percent (45,540) of all complete records from 1983 births attended by physicians in the State of Washington were matched to physician specialty information. These births represent 67% of the total deliveries in Washington State in 1983. Although twice as many general and family physicians as obstetricians were practicing obstetrics, obstetricians delivered 2.5 times as many infants as did general and family physicians. Obstetricians served an older patient population with more low-birthweight infants, multiple births, and complications of pregnancy than family physicians. General and family physicians were more likely to care for minorities, teenagers, and unmarried and rural mothers. Obstetricians cared for patients with higher medical risks, whereas general and family physicians provided care to more socially vulnerable and geographically isolated populations. To the extent that general and family physicians are differentially abandoning obstetric practice because of the current malpractice crisis, access to care for rural and socially vulnerable groups may deteriorate rapidly.     

Effect of managed care and financing on practice constraints and career satisfaction in primary care

BACKGROUND: The shift away from third party insurers to risk-sharing arrangements affecting care management and clinicians could be the most fundamental change in the health care system. Analysis was undertaken to study how managed care, practice setting, and financial arrangements affect physicians' perceived impact on their practice. METHODS: Data were taken from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1996 and August 1997. Survey instruments were completed by 7,146 primary care physicians in internal medicine (2,355), family practice (3,168), and pediatrics (1,623). The dependent variables are career satisfaction and perceived limitations and pressures on time spent with patients, clinical freedom, income, and continuity. To study the unique effect of financing and gatekeeping arrangements and practice setting, the dependent variables were regressed on gatekeeping, practice revenue, individual physician compensation, practice setting, specialty, age-group, sex, international medical graduate, board certification, and recent change in practice ownership. RESULTS: Total managed care revenue, or individual physician incentives, have no effect on career satisfaction and relatively limited effects on time pressure, income pressure, or patient continuity. In contrast, primary care gatekeeping has a highly significant adverse effect on the same outcome measures. After controlling for financial factors, demographic characteristics, and training differences, physicians in solo and 2-physician practices are significantly more likely to be dissatisfied with their medical career, more likely to report no clinical freedom, and more likely to feel income pressure than physicians in group practices, staff model HMOs, medical schools, or other settings. CONCLUSION: Physicians in solo and 2-physician practices were least satisfied with their careers and reported more constraints on their clinical freedom and income than physicians in other settings. Physicians in group practices or staff model HMOs are more likely to report time pressure than physicians in solo or 2-physician practices. Family practice falls between internal medicine (less satisfied, more practice constraints) and pediatrics (more satisfied, fewer practice constraints).     

Stress management in primary care: physicians' beliefs and patterns of practice

We examined attitudes and practices related to stress management in a random sample of Texas primary care physicians. Two fifths of the physicians indicated that avoiding undue stress was very important, and more than one third reported that they gathered information about stress on a routine basis. Over two thirds of the physicians said that they had counseled their patients regarding stress and 13 percent had referred patients with high stress to outside programs. The physicians' confidence that they had the skills to help patients with high stress, their belief in the benefits of avoiding undue stress, and their estimate of patient follow-through on recommendations were positively associated with history-taking and counseling regarding stress. Recommendations for medical education include incorporating information about stress and health into medical school curriculums, building skills in stress management, and increasing feedback from patients who have coped successfully with high stress.     

Newly implemented health system reform in Israel: physicians' attitudes

OBJECTIVE: To explore the attitudes of Israeli physicians towards the feasibility and potential consequences of the newly implemented health care reform. DESIGN: Physicians' attitudes were examined soon after the enactment of a National Health Insurance Law, the first element of the reform to be implemented. SETTING: A nationwide mail survey. SUBJECTS: A random sample of 2000 practicing physicians. MAIN OUTCOME MEASURES: Attitudes towards the health care system prior to the reform; predicted effects of the reform on health care and medical practice. RESULTS: Most of the respondents think that the system requires a change. Quality of community-based care is expected to increase, in contrast to hospital care. The reform is believed to exert an adverse effect on medical practice. Attitude is significantly influenced by practice setting and speciality: community setting and general practice correlate with less desire for a major change. Specialists believe that reform elements which will shift the balance towards the hospitals will have the greatest benefit on the health system. GPs, compared to specialists, are more optimistic regarding quality and accessibility of services (P<0.01). CONCLUSIONS: Our survey suggested that Israeli physicians favor a change in the health care system, despite a perceived adverse effect of the reform on medical practice. Since the reform is believed to shift the balance from the hospitals to the community, respondents support changes that will compensate for the imbalance.