Closed and restricted practices

OBJECTIVE

To determine the proportion of recently certificated Ontario family physicians who have closed their practices to new patients or restricted their services.

DESIGN

Cross-sectional survey mailed between September 1993 and January 1994.

SETTING

Ontario family practices.

PARTICIPANTS

All family medicine residency-trained certificants of the College of Family Physicians of Canada from 1989 to 1991 currently practising in Ontario. Response rate was 70% (395 of 564 eligible physicians). Otherwise eligible physicians practising as locums, emergency room physicians, or military physicians were excluded.

MAIN OUTCOME MEASURES

Self-report of practices being closed to new patients and of various restrictions placed on practices.

RESULTS

Nearly one third of respondents had closed their practices to new patients. Although the decision to close a practice correlated with length of time in practice, physicians in metropolitan Toronto were significantly less likely to report closed practices than physicians practising in other regions of Ontario. Restrictions reported related to patients and problems, geographic area, and type of setting(s) serviced. About 45% of respondents did not provide one or more of a defined set of five services.

CONCLUSIONS

Results of this study suggest that family physicians restrict their practices in various ways within the first 5 years after certification.

Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario

This paper analyzes data from a 1993 survey of 395 newly established female and male family physicians in Ontario, Canada, to examine the relationship between practice organization and gender. Previous research suggests that younger physicians, particularly women, tend to enter group practice. Compared to solo practice, groups may offer more predictable incomes, more manageable workloads, peer collaboration and review, and economies of scale. Further, female physicians in groups may develop distinctive styles of collaborative medicine. The results show that a majority of physicians in our cohort are in private community-based group practice. However, while many groups share premises, staff and expenses, and many have common charts and practice guidelines, only a minority incorporate regular meetings to discuss business or patient care, have shared care of hospitalized patients, or audits of physicians' practices. Few gender differences are observed in private group practice: although women physicians attract larger proportions of female patients than do their male colleagues, women and men organize their groups in similar ways and have similarity strong patient-centered attitudes.

Interest in different types of patients. What factors influence new-to-practice family physicians?

OBJECTIVE

To identify factors that influence new-to-practice family physicians to be particularly interested in certain types of patients.

DESIGN

Qualitative study and cross-sectional survey.

SETTING

Ontario family practices.

PARTICIPANTS

Seven focus groups involved a volunteer sample of 34 physicians who completed family medicine residency training between 1984 and 1989. A convenience sample of 43 physicians who had completed their residencies between 1990 and 1992 were interviewed. All certificates of the College of Family Physicians of Canada currently practising in Ontario who received certification between 1989 and 1991 were surveyed.

MAIN OUTCOME MEASURES

Physician interest as determined by scores on two scales: one labeled "Chronic/Older Patient," designed to assess special interest in geriatric patients, chronic pain patients, palliative care patients, and chronically ill patients, and one labeled "Young Patient," designed to assess special interest in young families and adolescents.

RESULTS

In general, new-to-practice physicians had little interest in caring for older or chronic patients; older physicians and male physicians had greater interest in caring for chronic or older patients. Women physicians, physicians rating higher on the "empathy" and "interest in counseling" scale, and physicians receiving primarily fee-for-service remuneration showed greater interest in caring for young families and adolescents than other physicians.

CONCLUSIONS

Physicians' age, sex, attitudes to patient care, method of remuneration, undergraduate and postgraduate schools of medical training, and the age and sex composition of their practices all influenced their interest in caring for different types of patients.

Time spent on professional activities and unwaged domestic work. Is it different for male and female primary care physicians who have children at home?

OBJECTIVE

To examine how having children affects the hours spent by male and female family physicians on professional activities and on unwaged domestic work.

DESIGN

Survey fielded between September 1993 and February 1994.

SETTING

Ontario.

PARTICIPANTS

All Ontario-based physicians certificated by the College of Family Physicians of Canada between 1989 and 1991 after completing a family medicine residency.

MAIN OUTCOME MEASURES

Self-reported hours spent per week on professional activities and unwaged domestic work.

RESULTS

Response rate was 70%; men and women were equally likely to respond. About half (47.7%) had children at home. Women with children at home spent fewer hours on professional activities (P < 0.001) than men with children, whose hours of professional activity were similar to hours of men without children. Both women and men with children reported spending more time on household maintenance than did those without children. Among physicians with children, although men spent time on child care (mean time 11.4 hours; SD 11), women spent much more time on it (mean time 39.7 hours; SD 21; P < 0.001). The women worked an average of 90.5 hours per week in professional and unwaged activities; men averaged 68.6 hours. Childless physicians worked fewer hours: men 54.1, women 52.6.

CONCLUSIONS

Female physicians with children at home spend more time on child care and household maintenance than their male partners. These responsibilities reduce professional work time (at least until all children are at school full time) and might deter women from active involvement in professional organizations.

Clinical practice guidelines. New-to-practice family physicians' attitudes

OBJECTIVE

To examine the attitudes toward clinical practice guidelines of a group of family physicians who had recently entered practice in Ontario, and to compare them with the attitudes of a group of internists from the United States.

DESIGN

Mailed questionnaire survey of all members of a defined cohort.

SETTING

Ontario family practices.

PARTICIPANTS

Certificants of the College of Family Physicians of Canada who received certification in 1989, 1990, and 1991 and who were practising in Ontario. Of 564-cohort members, 395 (70%) responded. Men (184) and women (211) responded at the same rate.

MAIN OUTCOME MEASURES

Levels of agreement with 10 descriptive statements about practice guidelines and analyses of variance of these responses for several physician characteristics.

RESULTS

Of respondents in independent practice, 80% were in group practice. Women were more likely to have chosen group practice, in which they were more likely to use practice guidelines than men. Generally favourable attitudes toward guidelines were observed. Physician characteristics occasionally influenced agreement with the descriptors. The pattern of agreement was similar to that noted in the study of American internists, but, in general, Ontario physicians were more supportive.

CONCLUSIONS

This group of relatively new-to-practice Ontario family physicians shows little resistance to guidelines and appears to read less threat of external control in them than does the US group.

Medicine and the Canadian state: from the politics of conflict to the politics of accommodation?

This paper analyzes data from three large-scale surveys of Canadian physicians conducted over the past decade to examine the politics of a cohort of recently established family physicians in Ontario, and to assess the extent to which these politics represent a "softening" of professional resistance to government health insurance. Politically, this is an important cohort because the physicians in it have grown up without any firsthand knowledge of the pre-Medicare period, and because they are among the first to establish practices in the wake of the month-long 1986 Ontario physicians' strike, a high point of profession-government conflict. Factors which may have contributed to a moderation of medical politics include the progressive entry of women into medicine. Our data suggest that professional opposition to Medicare is declining and that fewer physicians support a return to voluntary and commercial control of the health system, a shift which could assist in breaking the historical cycle of profession-government conflict and moving to the politics of accommodation. In the conclusions we discuss implications for medical politics in Canada and other countries such as the United States.

Current health policy initiatives and options. New-to-practice family physicians' attitudes

OBJECTIVE

To obtain information about new-to-practice family physicians' attitudes toward current health policy options and initiatives.

DESIGN

Cross-sectional, mailed survey.

SETTING

Ontario family practices.

PARTICIPANTS

Residency-trained Ontario family physicians (395 of 564 eligible physicians replied) who were certified between 1989 and 1991.

MAIN OUTCOME MEASURES

Extent of approval or disapproval for 14 health policy options and initiatives.

RESULTS

A 70% response rate was achieved. More than half of surveyed physicians expressed approval for shifting resources from acute care into preventive care and health promotion (71.6% approved), stricter immigration requirements to limit licensing of foreign physicians in Canada (60.4%), offering physicians salaries as an alternative to fee-for-service (54.0%), and incentives to physicians who wish to practise in community health centres or other forms of salaried group practice (51.1%). Some diversity of opinion was associated with sex, type of practice, primary source of remuneration, and practice location.

CONCLUSIONS

These new-to-practice family physicians display diverse views and should not be seen as sharing a single opinion of health care policy options and initiatives. Many approve of changes to the health care system or are willing to consider policy alternatives.

Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians

OBJECTIVE

To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions.

DESIGN

Qualitative study and cross-sectional survey.

SETTING

Ontario.

PARTICIPANTS

Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992.

SURVEY

all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively.

OUTCOME MEASURES

Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions.

RESULTS

During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001).

CONCLUSIONS

Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.

The putative essential nutrient pyrroloquinoline quinone is neuroprotective in a rodent model of hypoxic/ischemic brain injury

Pyrroloquinoline quinone is a ubiquitous redox cofactor and putative essential nutrient in mammals. Pyrroloquinoline quinone has recently been demonstrated to depress N-methyl-D-asparate induced electrical responses and is neuroprotective in vitro. In addition, pyrroloquinoline quinone has been demonstrated to act as a free radical scavenger in mammalian tissues. In this study, we demonstrate a neuroprotective effect of pyrroloquinoline quinone in an in vivo cerebral hypoxia/ischemia model in the rodent. Significant reduction in infarct size resulted from pyrroloquinoline quinone pretreatment and also when pyrroloquinoline quinone was administered following induction of hypoxia/ischemia. The neuroprotective effect was not dependent on change in core or cranial temperatures, as there was no difference between temperature measurements in pyrroloquinoline quinone-treated and vehicle-treated controls. No changes in electroencephalographic activity were observed at neuroprotective doses. These findings suggest that pyrroloquinoline quinone may represent a novel class of quinoid reagents of potential use in the treatment of neurological disorders that involve excitotoxicity. This study demonstrates a protective effect of the novel essential nutrient pyrroloquinoline quinone on brain injury in a rodent model of cerebral hypoxia/ischemia. Pyrroloquinoline quinone was neuroprotective when administered before and even after the insult, and did not appear to have significant neurobehavioral side effects. Pyrroloquinoline quinone represents a new class of agents with potential use in the therapy of stroke.

Necrotising fasciitis. Appropriate skin flap may reduce deformity

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Evidence that alternate foldings of the hepatitis delta RNA confer varying rates of self-cleavage

The pentapurine sequence GGAGA, located between 80 and 84 nucleotides downstream of the cleavage site in the self-cleaving antigenomic RNA of hepatitis delta virus, is necessary for highly efficient cleavage and for stability in up to 20 M formamide. Yet much of the cleavage activity lost upon its removal from the 3' end of an 84-nucleotide RNA can be restored by elongation of the 5' end of the RNA with the polypyrimidine sequence found in the virus. We propose that this sequence alteration causes a refolding of the RNA, resulting in a "structural compensation" of the active core of the molecule. Restoration of the self-cleavage activity did not restore the ability to cleave in high concentrations of formamide. Deletion mutagenesis was carried out and supported the alternate RNA folding. The ability to assume more than one active conformation and for one RNA structure to compensate for another in supporting ribozyme activity may be unique to RNA enzymes and could be a useful adaptation in viruses or in prebiotic RNAs.

Women in medicine: toward a conceptual understanding of the potential for change

In 1959 only 6% of Canadian medical school graduates were women, but by 1989 44% of graduating classes were female. Recent data indicate that women are more likely than men to work as general practitioners, in groups, in urban settings, and on salary; to work fewer hours per week and to see fewer patients. In this paper we address the ongoing discussion of the impact of women's progressive entry into medicine. We suggest that a shortcoming of the discussion thus far has been its preoccupation with a descriptive examination of women physicians' professional characteristics and practices; sufficient attention has yet to be paid to the development of a clearer conceptual understanding of the nature of gender differences and the potential for change they imply. Using data from quantitative and qualitative phases of a national study of Canadian physicians, we address the relationship between gender differences in practice and underlying attitudes and values and identify alternative hypotheses about the potential for change created as more women enter medicine. We suggest that this potential goes beyond professional demographics and workloads to the doctor-patient relationship, but that the extent of change will be mediated by the socializing impact of medical school and the extent to which women physicians are included in or excluded from positions of power within the profession. We suggest also, that to meaningfully understand and document change, greater attention must be given to arguments that women and men view the world in qualitatively different ways.

How many physicians will be needed to provide medical care for older persons? Physician manpower needs for the twenty-first century

To estimate the number of full-time-equivalent (FTE) physicians and geriatricians needed to provide medical care in the years 2000 to 2030, we developed utilization-based models of need for non-surgical physicians and need for geriatricians. Based on projected utilization, the number of FTE physicians required to care for the elderly will increase two- or threefold over the next 40 years. Alternate economic scenarios have very little effect on estimates of FTE physicians needed but exert large effects on the projected number of FTE geriatricians needed. We conclude that during the years 2000 to 2030, population growth will be the major factor determining the number of physicians needed to provide medicare care; economic forces will have a greater influence on the number of geriatricians needed.

Assessing the continuing education needs of long-term care administrators in Ontario: results of a survey

This article reports the results of a 1989 survey of the professional characteristics and educational needs of 429 managers and supervisors in long-term care institutions and community-based service agencies in greater metropolitan Toronto. The data identify important gaps in the professional training of these administrators: while two-thirds report attainment of postsecondary education credentials, the remaining third, including a quarter of senior managers, have no formal college or university training. Moreover, of those with postsecondary credentials, only a minority are trained in health or human services and administration--skills and knowledge areas key to establishing and managing a client-centered continuum of long-term care. The data also demonstrate that there is widespread support in principle and practice among current administrators in the Toronto region for programs of education which address the particular challenges of long-term care administration, and that specific credentials in the field are seen as a future requirement for promotion to management positions. Preferred modes of education program delivery are short, intensive seminars and night classes.

A typology of medical practice organization in Canada. Data from a national survey of physicians

Different modes of practice organization may result in advantages for physicians and their patients. Compared with solo practice, group practice may produce economies of scale, efficiencies in health care delivery, and improvements in the quality of care. However, in Canada assessment of the implications of differences in practice organization have been impeded by a lack of relevant data and a tendency to treat practice type as a dichotomous variable. Conventional solo/group distinctions fail to address the significance of the growing number of medical practices that are neither solo nor group, but combinations of both, and they obscure the policy implications of the growing number of physicians in institutional as opposed to private practice. This paper develops and applies a theoretically based typology of practice organization to data collected as part of a national survey of 2,398 Canadian physicians conducted in late 1986 and early 1987. The analysis identifies six practice types, describes their distribution and operating characteristics, and identifies the characteristics of physicians working in them.

Modeling the effect of insurance on health expenditures in the People's Republic of China

A pilot study was undertaken in two rural counties in Sichuan Province to determine the feasibility of offering health insurance to peasant families. Models of per capital inpatient and outpatient health care expenditures were developed using self-reported utilization from a survey of 880 households, supplemented by cost and utilization data from the providers in the counties. Expenditures at a facility were modeled as a function of level of insurance in three parts: (1) as the product of the probability of any use, (2) the expected number of visits given any use, and (3) the cost per visit at the facility. Output from the model for representative insurance plans is presented.

Women in medicine: practice patterns and attitudes

Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada's health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.

The reproduction of physician autonomy in Ontario medical group practice

A belief exists about the advantages of group medical practice over solo practitioners. The paper through a survey of 105 group practices examines a number of organisational and operational factors. The results suggest that practices are not always organised in a way to maximise the benefits of group operation but are still characterised by an individualistic approach.

Characteristics of established group practices in Ontario

Established group practices in Ontario were surveyed to determine their structure, characteristics and attitudes toward government assistance in the development of group practice. The degree of organization of the groups surveyed was related to size and less than that reported in surveys of United States group practices. Group size and years of operation were strongly associated. Night, weekend and vacation coverage, the use of a unit patient record and the employment of non-physician administrators were reported frequently, and were more common in older and larger groups. As well, fringe benefits, except for professional organization dues, were not commonly provided.

Laser temperature-jump, spectroscopic, and thermodynamic study of salt effects on duplex formation by dGCATGC

Salt effects on duplex formation by dGCATGC have been studied with spectroscopic, thermodynamic, and kinetic methods. Circular dichroism spectra indicate different salt conditions have little effect on the structures of the duplex and single strand. NMR chemical shifts indicate the structure of the duplex in 1 M NaCl is similar to that of the B-form determined previously in 0.5 M KCl [Nilges, M., Clore, G. M., Gronenborn, A. M., Brunger, A. T., Karplus, M., & Nilsson, L. (1987) Biochemistry 26, 3718-3733]. Optical melting experiments indicate the effect of Na+ concentration on melting temperature is similar to that expected for a polynucleotide with the same GC content. Laser temperature-jump experiments indicate the effect of Na+ concentration on the rate of duplex formation is much less than is observed for polynucleotides. The observations are consistent with expectations based on a counterion condensation model. This is surprising for a duplex with only 10 phosphates.

The degradation of different protein supplements in the rumen of steers and the effects of these supplements on carbohydrate digestion

1. Four steers with simple rumen and abomasal cannulas were given diets consisting of ground and pelleted alkali-treated straw, rolled barley and tapioca supplemented with urea (diet U) or containing single-cell protein (diet SCP), maize-gluten meal (diet MGM) or rapeseed meal (diet RSM) in place of some of the tapioca. The isoenergetic diets were given in a 4 x 4 Latin square design in eight feeds/d at 3-h intervals and provided sufficient metabolizable energy to support a growth rate of approximately 0.5 kg/d. Chromic oxide and polyethylene glycol were given as markers and appropriate samples taken from the rumen and abomasum. Flows (g/d) at the abomasum of organic matter and nitrogenous and carbohydrate constituents were calculated. 2. Rumen ammonia levels were similar with all three protein supplements at about 9 mmol/l, which was significantly lower (P less than 0.05) than that in animals on diet U (16 mmol/l). Rumen liquid outflow rates (/h) were 0.099, 0.139, 0.125 and 0.160 for diets U, SCP, MGM and RSM respectively; the difference between diet U and diet RSM was significant (P less than 0.05). Corresponding values for Cr2O3 outflow rates were 0.027, 0.032, 0.027 and 0.030/h respectively, which did not differ significantly from each other. 3. RNA, 35S and diaminopimelic acid (DAP) were used as microbial markers. Efficiencies of microbial-N (MN) synthesis, expressed as g MN/kg apparently digestible organic matter, truly digestible organic matter or carbohydrate fermented, were generally not significantly affected by the diet and averaged 29, 22 and 29 respectively based on mean RNA and 35S markers. Corresponding values derived from DAP of 22, 16 and 21 g MN/kg respectively were all significantly (P less than 0.001) lower. Using 35S as microbial marker, MN flows at the abomasum as a proportion of non-ammonia-nitrogen flow were 0.78, 0.64, 0.51 and 0.78 for diets U, SCP, MGM and RSM respectively. Derived true rumen degradability values (g/g intake) of the total dietary N were 0.91, 0.79, 0.69 and 0.90 for diets U, SCP, MGM and RSM respectively. Protein supplement degradabilities for single-cell protein, maize-gluten meal and rapeseed meal were 0.73, 0.51 and 0.98 respectively. 4. Mouth-to-abomasum digestibility coefficients of the main neutral-sugar components of dietary polysaccharides were 0.68, 0.63 and 0.61 for arabinose, xylose and cellulose-glucose on diet U.(ABSTRACT TRUNCATED AT 400 WORDS)

Affirmative action in medical education and its effect on Howard and Meharry: a study of the class of 1975

During the decade of the 1970s, affirmative action programs were introduced in US medical schools for the purpose of increasing the number of black and other minority medical students and of improving the medical care resources for black and other minority communities. Having for many years served as the main sources of black physicians in the US, Howard University College of Medicine and Meharry Medical College School of Medicine were also affected by affirmative action. No previous studies have compared the black graduates from Howard and Meharry with black and other minority graduates from the other US medical schools.The purpose of this study was to compare these medical school graduates in terms of actual choice of specialty, patient characteristics, practice location, and specialty board certification, using the graduating class of 1975. A greater proportion of black graduates from Howard and Meharry chose primary care specialties than did black graduates from other schools, though this difference was not statistically significant. Black graduates from Howard and Meharry had significantly greater proportions of black patients compared with black graduates from other schools, but the same proportion of Medicaid patients.Though not statistically significant, black graduates from Howard and Meharry were less likely to be found practicing in federally designated underserved areas. Black graduates from Meharry were significantly less likely to have achieved specialty board certification, compared with graduates from Howard or the other medical schools. These results illustrate the experience of Howard and Meharry during the era of affirmative action and generally support their critically important role in producing black physicians and enhancing medical care resources in the black community.