Personal, organizational, and market level influences on physicians' practice patterns: results of a national survey of primary care physicians

Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes

OBJECTIVES

To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions.

METHODS

Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression.

RESULTS

For CHD, physicians were least certain for Black patients (p=.003) and for younger female patients (p=.013). For depression, average certainty was higher than for the CHD presentation (74.0 vs. 57.9 on of scale of 0-100, p<.001) and there were no main effects of patient or provider characteristics. Increasing diagnostic certainty was a significant predictor of subsequent clinical actions, and these varied according to physician and patient characteristics across both conditions.

CONCLUSIONS

Physicians were least certain of their CHD diagnoses for Black patients and for younger women, but patient characteristics alone did not affect physician certainty of depression diagnoses. Physicians responded differentially to diagnostic certainty in terms of their clinical therapeutic actions such as test ordering and writing prescriptions. Physician responses to certainty may be as important as their responses to patient characteristics for understanding variation in clinical decision-making.

Connoisseurs of care? Unannounced standardized patients' ratings of physicians

BACKGROUND

Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior.

OBJECTIVES

We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients.

STUDY DESIGN

Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance rho), and SPs' overall satisfaction with specific dimensions of physician performance.

RESULTS

Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC) and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions.

CONCLUSIONS

These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.

A behavioral model of clinician responses to incentives to improve quality

The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.

Practice characteristics associated with patient-specific receipt of dental diagnostic radiographs

OBJECTIVE

To quantify the role of practice characteristics in patient-specific receipt of dental diagnostic radiographic services.

DATA SOURCE/STUDY SETTING

Florida Dental Care Study (FDCS). Study Design. The FDCS was a 48-month prospective observational cohort study of community-dwelling adults. Participants' dentists were asked to complete a questionnaire about their practice characteristics.

DATA COLLECTION/EXTRACTION METHODS

In-person interviews and clinical examinations were conducted at baseline, 24, and 48 months, with 6-monthly telephone interviews in between. A single multivariate (four radiographic service outcomes) multivariable (multiple explanatory covariates) logistic regression was used to model service receipts.

PRINCIPAL FINDINGS

These practice characteristics were significantly associated with patient-specific receipt of radiographic services: number of different practices attended during follow-up; dentist's rating of how busy the practice was; typical waiting time for a new patient examination; practice size; percentage of patients that the dentist reported as interested in details about the condition of their mouths; percentage of African American patients in the practice; percentage of patients in the practice who do not have dental insurance; and dentist's agreement with a statement regarding whether patients should be dismissed from the practice. Effects had differential magnitudes and directions of effect, depending upon radiograph type.

CONCLUSIONS

Practice characteristics were significantly associated with patient-specific receipt of services. These effects were independent of patient-specific disease level and patient-specific sociodemographic characteristics, suggesting that practitioners do influence receipt of these diagnostic services. These findings are consistent with the conclusion that practitioners act in response to a mix of patients' interests, economic self-interests, and their own treatment preferences.

Effect of dental practice characteristics on racial disparities in patient-specific tooth loss

OBJECTIVE

The objective of this study was to test the hypothesis that dental practice characteristics are associated with tooth loss incidence with both tooth-specific and patient-specific characteristics already taken into account.

RESEARCH DESIGN

A population-based prospective cohort study was conducted. In-person interviews and clinical examinations were done at baseline, 24, and 48 months, with telephone interviews every 6 months. Practices that coincidentally served participants in the study completed practice characteristics questionnaires. To increase inferential power when testing practice-level effects, detailed tooth-specific and patient-specific data were simultaneously taken into account in tests for association between practice-level effects and tooth loss.

SETTING

Data were from the Florida Dental Care Study. The key health outcome was tooth loss, a leading measure of a population's oral health.

PARTICIPANTS

Eight hundred seventy-three African-Americans and non-Hispanic whites who had at least 1 tooth.

RESULTS

Certain practice characteristics were associated with tooth loss, including the racial mix of the practice's patient population; persons who attended practices with higher percentages of African-Americans were more likely to receive a dental extraction regardless of the individual patient's race.

CONCLUSIONS

This is the first longitudinal report of increased risk for tooth loss resulting from practice-level effects. Although a patient-level racial disparity remained evident, and even with detailed tooth-specific and patient-level characteristics taken into account, racial differences in characteristics of practices attended independently contributed to the patient-level racial disparity in health.

Transforming medical care: case study of an exemplary, small medical group

PURPOSE

Most published descriptions of organizations providing or improving quality of care concern large medical groups or systems; however, 90% of the medical care in the United States is provided by groups of no more than 20 physicians. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality.

METHODS

A 15-family physician medical group was identified from comparative public performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins.

RESULTS

This medical group ranked first in a composite measure of preventive services and fourth and sixth, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes of this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute for most of the others. Historical factors important to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group.

CONCLUSIONS

The identified 12 attributes of this medical group seem to be associated with its superior care quality, and most of them might be replicable by other small groups if they choose to work toward that end.

Patient treatment preferences in localized prostate carcinoma: The influence of emotion, misconception, and anecdote

BACKGROUND

Multiple therapeutic options exist for localized prostate carcinoma, without conclusive evidence to guide the choice of treatment. Thus, treatment should reflect trade-offs between the probability of curing disease and the desire to avoid treatment-associated side effects. Factors that actually influence patient treatment preferences are poorly understood.

METHODS

We reviewed medical records and carried out in-depth, semistructured interviews of 20 men with newly-diagnosed, clinically-localized prostate carcinoma in a Veterans Affairs Hospital following their first consultations with urologists and before treatments were initiated. Six to eight months after treatment, we carried out follow-up interviews. Interviews explored beliefs and attitudes about prostate cancer and treatment options, emotional reactions to the diagnosis, treatment preferences, information sources, and perceptions of interactions with urologists.

RESULTS

Patient treatment preferences were not based on careful assessments of numerical risks for various clinical outcomes. Instead, feelings of fear and uncertainty contributed to a desire for rapid treatment, and specific preferences were profoundly influenced by misconceptions, especially about prostatectomy, and by anecdotes about the experiences of others with cancer. Few patients wanted to seek second opinions. Most patients received treatments that matched their initial preferences. Afterwards, they justified their choices in terms of the same misconceptions and anecdotal influences invoked during treatment deliberation.

CONCLUSIONS

For men with localized prostate carcinoma, the treatment decision-making process would benefit from interventions that moderate feelings of fear and a desire for rapid treatment, dispel common and powerful misconceptions about prostate cancer and its therapies, and help patients avoid over-reliance on anecdotes.

Guideline attribute and implementation preferences among physicians in multiple health systems

OBJECTIVES

Although practice guidelines are effective in assisting providers with clinical decision making, ineffective implementation strategies often prevent their use in practice. This study aimed to understand physician preferences for guideline format, placement, content, evidence, and learning strategies in different clinical environments.

SUBJECTS AND METHODS

Semistructured telephone interviews were conducted with 500 randomly selected physicians from 4 major US health systems who were involved in the treatment of patients with acute myocardial infarction or pediatric asthma. Paired sample t tests and Tukey's method of comparisons determined the relative ranking of physicians' guideline implementation preferences.

RESULTS

Physicians preferred guidelines located on the front of the patient chart, in palm pilots, or in progress notes and presented as flow charts/flow diagrams, algorithms, or preprinted orders that contain strategies to minimize readmits/encourage self-management and immediate treatment flows. Discussions with colleagues and continuing medical education are the most effective strategies for encouraging guideline use, and randomized controlled trials remain the most persuasive medical evidence.

CONCLUSIONS

Health care organizations must align guideline implementation efforts with physician preferences to encourage utilization. The results of this study reveal systematic physician preferences for guideline implementation that can be applied to clinical settings to encourage guideline use by physicians.

An empirical assessment of high-performing medical groups: results from a national study

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performing medical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

Clinical vignette-based surveys: a tool for assessing physician practice variation

Clinical vignette-based surveys have been used for more than 30 years to measure variation in physicians' approaches to the diagnosis and treatment of patients with similar health problems. Vignettes offer advantages over medical record reviews, analysis of claims data, and standardized patients. A vignette-based survey can be completed more quickly than a record review or standardized patient program. Research has shown that vignette-based surveys produce better measures of quality of care than medical record reviews when used to measure differential diagnosis, selection of tests, and treatment decisions. Although standardized patients are preferred when measuring communication and physical examination skills, vignettes are more cost-effective than standardized patients when assessing clinical physicians' decision making. Vignettes offer better opportunities to isolate physicians' decision making and to control case-mix variation than do analyses of claims data sets. Clinical vignette-based surveys are simple and economical tools that can be used to characterize physicians' practice variation.

Use of preventive services by Medicare fee-for-service beneficiaries: does spillover from managed care matter?

BACKGROUND

Health care delivery varies with the level of managed care activity (MCA) in an area, potentially affecting health care for those not participating in managed care programs. However, the extent to which MCA is associated with the use of cancer screening by fee-for-service beneficiaries (FFS) is unclear.

OBJECTIVE

We sought to study colorectal cancer screening among Medicare FFS beneficiaries in relation to levels of Medicare MCA.

RESEARCH DESIGN

This study linked 1999 Medicare denominator and Part B claims data with the 1998 Area Resource File. After categorizing MCA as low (<10%), moderate (10-29.99%), or high (> or =30%), we assessed the association between colorectal cancer screening among FFS beneficiaries and MCA, controlling for individual demographic variables and county-level attributes of socioeconomic status and physician resources.

SUBJECTS

We included Medicare FFS beneficiaries 65 years of age or older with both Part A and Part B coverage for the entire calendar year from large counties in the study.

MEASURES

We measured the likelihood of undergoing fecal occult blood testing (FOBT), flexible sigmoidoscopy (FLEX), or colonoscopy (COL).

RESULTS

Compared with Medicare FFS beneficiaries residing in counties with low MCA, those in high MCA counties were significantly more likely to undergo FOBT (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 1.04-1.16), FLEX (AOR 1.11, 95% CI 1.04-1.18), or colonoscopy, after receiving FOBT/FLEX (AOR 1.07, 95% CI 1.02-1.13).

CONCLUSIONS

From a public health perspective, an association between higher levels of MCA and colorectal cancer screening among those not enrolled in managed care may translate into modest increases in use of colorectal cancer screening and possibly earlier detection.

Translating evidence-based information into effective risk communication: Current challenges and opportunities

Recent medical advances and the easy availability of evidence-based information at the point of care are believed to provide physicians with improved tools for risk communication. However, evidence indicates that physicians still display marked variability in ordering tests. Factors that determine a physician's test-ordering tendencies vary by specialization, practice, geographical location, defensive practice, and tolerance of uncertainty and are also modified by patient requests. Understanding of statistical terms on the part of both physicians and patients remains limited. Physicians may display limited ability to assess pretest and posttest probabilities, especially in low- and intermediate-risk patients, even after attending short courses in epidemiology, or may find the process impractical. Presentation of diagnostic-test results in a natural-frequency format might improve understanding. Both physicians and patients have difficulty grasping the term "number needed to treat" compared with "relative risk reduction" when comparing therapeutic options. Other patient-related factors that limit understanding include low literacy, individual risk tolerance, and framing patterns of the problem (potential gains vs losses). Despite numerous available modalities (quantitative and qualitative) of risk communication, consensus over the advantage of any single modality in translating evidence into risk communication is limited. It is essential that physicians remain patient-centered, generate trust, and build a partnership with the patient to achieve consensus for medical decision-making. Future studies are indicated to assess the effectiveness of novel risk-communication modalities based on patients' and physicians' characteristics and identify appropriate modality of translating evidence (quantitative or qualitative information).

Penetrating the "black box": financial incentives for enhancing the quality of physician services

This article addresses the impact of financial incentives on physician behavior, focusing on quality of care. Changing market conditions, evolving social forces, and continuing organizational evolution in health services have raised societal awareness and expectations concerning quality. This article proceeds in four parts. First, the authors place financial incentives in the context of broader forces shaping the quality of physician services. Second, the article reviews the literature on financial incentive effects on physician behavior. Third, a simple net income maximization model of physician choices is presented, from which are derived formal hypotheses regarding the effect of financial incentives on physician choices of quality per unit of physician service and the quantity of services per patient. The model is extended qualitatively to offer further hypotheses and research directions. Finally, gaps and limitations of the model and of the extant empirical research are articulated, and additional researchable questions are posed.

Does Capitation Matter? Impacts on Access, Use, and Quality

Provider capitation may constrain costs, but it also may reduce access and quality of care. We examine the impacts of capitating the usual source of care of enrollees in health maintenance organizations (HMOs). We account for the endogeneity of capitation and other characteristics using generalized methods of moments (GMM) estimation on a sample from the Medical Expenditure Panel Survey for 1996 and 1997. Being organized as a group/staff HMO generally has stronger impact on access and quality than capitation. Capitation by itself may increase access to consumers' usual sources of care, improve primary preventive care, and reduce coordination, but estimates with GMM were not statistically significant.

Efficacy of Educational Interventions Targeting Primary Care Providers' Practice Behaviors: an Overview of Published Systematic Reviews

OBJECTIVES

Primary care providers (e.g., family physicians, pediatricians, registered nurses, physician assistants, and nurse practitioners) could play a pivotal role in the provision of preventive services, especially for very young children (younger than 3 years old) and population groups with limited access to dental care. Given the current problems with access to dental care among low-income Americans, we contend there is a need to involve nondental primary health care providers in screening for and preventing oral health problems. The objective of this overview is to present findings from systematic reviews on the efficacy of continuing medical education, printed educational material, academic outreach, reminders, and local opinion leaders on the adoption of new knowledge and practices by primary care providers.

METHODS

A search was conducted using the Cochrane Library and MEDLINE. The search aimed to locate systematic reviews published between January 1988 and March 2003. Two researchers independently extracted data and assessed study quality using a modified version of the QUOROM statement.

RESULTS

Eleven systematic reviews were included in this overview. The evidence from the included systematic reviews showed that formal continuing medical education (CME) and distributing educational materials did not effectively change primary care providers' behaviors. There are effective interventions available to increase knowledge and change behaviors of primary care providers, such as small group discussion, interactive workshops, educational outreach visits, and reminders.

CONCLUSION

There is a limited knowledge base on the efficacy of the selected interventions on oral health screening by primary care providers. Considering the potential role of primary care providers in improving oral health of underserved populations, this research area should receive more attention.

Radiologist uncertainty and the interpretation of screening

OBJECTIVE

To determine radiologists' reactions to uncertainty when interpreting mammography and the extent to which radiologist uncertainty explains variability in interpretive performance.

METHODS

The authors used a mailed survey to assess demographic and clinical characteristics of radiologists and reactions to uncertainty associated with practice. Responses were linked to radiologists' actual interpretive performance data obtained from 3 regionally located mammography registries.

RESULTS

More than 180 radiologists were eligible to participate, and 139 consented for a response rate of 76.8%. Radiologist gender, more years interpreting, and higher volume were associated with lower uncertainty scores. Positive predictive value, recall rates, and specificity were more affected by reactions to uncertainty than sensitivity or negative predictive value; however, none of these relationships was statistically significant.

CONCLUSION

Certain practice factors, such as gender and years of interpretive experience, affect uncertainty scores. Radiologists' reactions to uncertainty do not appear to affect interpretive performance.

Primary care physicians who treat blacks and whites

BACKGROUND

In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients.

METHODS

We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical "evaluation and management" who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000-2001 Community Tracking Study Physician Survey.

RESULTS

Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital.

CONCLUSIONS

Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.

Gender Differences in the Practice of Adult Primary Care Physicians

OBJECTIVE

This study investigates how physician gender affects reactions to six model patients.

METHODS

Telephone interviews with 3205 internists and family or general physicians were completed between 1996 and 1997 for the Community Tracking Study. Physicians responded to six vignettes describing model patients with presentations designed to have multiple appropriate treatment plans: a 50-year-old man with a 1-month history of exertional chest pain who may need a referral to a cardiologist, a 60-year-old man with a normal digital rectal examination (DRE) who may benefit from a prostate-specific antigen (PSA) test, a 40-year-old married woman with vaginal itching and discharge who may benefit from an office visit, a 60-year-old man with symptoms of benign prostatic hypertrophy (BPH) who may benefit from a urological consultation, a 35-year-old man with back pain and a new left footdrop who may benefit from an MRI, and a 50-year-old man with elevated cholesterol and no other cardiac risk factors who may benefit from cholesterol-lowering agents.

RESULTS

Female physicians are significantly more likely than males to refer a patient with BPH to a urologist (37.5% vs. 24.9%, p < 0.001). Male physicians are significantly more likely to recommend that a woman with vaginal itching and discharge have an office visit (52.7% vs. 40.6%, p < 0.001). Male physicians recommend cholesterol-lowering agents slightly more often than women physicians (39.4% vs. 36.4%, p < 0.03) and recommend a PSA test more often than female physicians (73.1% vs. 64.4%, p < 0.001). Neither physician attributes, practice characteristics, referral patterns, nor geographical traits account for the disparity between male and female physicians in the treatment of BPH. Approximately 40% of the gender gap in treatment of vaginal itching and discharge can be attributed to physician attributes. The association between provider gender and the decision to prescribe cholesterol-lowering agents and the association between provider gender and recommending a PSA test are explained by physician attributes.

CONCLUSIONS

Gender differences in treatment seem to appear most strongly for genital-specific conditions. The results may suggest that physicians use fewer resources to treat the genital-specific conditions of patients who share their sex.

Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians

This analysis addresses the relationship between perceived access to high-quality specialty mental health and medical services and 2 aspects of managed care organizational complexity at the practice level: 1) gatekeeper requirements for specialty services, and 2) managing multiple contracts. Cross-sectional analysis of a national telephone survey of 7,197 primary care physicians (PCPs) was performed. Access was defined as high-quality specialty services being always or almost always available to the PCP's patients when medically necessary. PCPs rated access to high-quality outpatient specialty mental health services as much lower than that of specialty medical services (28%; 95% confidence interval [CI], 27-29 versus 81%; 95% CI, 80-82). After adjustment for physician, practice, and managed care factors (multiple logistic regression analysis), perceived access to high-quality outpatient mental health services was lowest for practices with the largest number of managed care contracts and when a physician's practice was a "mixed model" with regard to the gatekeeper function. Perceived access to high-quality specialty medical services was not as strongly associated with these practice characteristics. PCPs who interact with a large number of managed care plans and different administrative models may have the most difficulty in obtaining high-quality mental health services for their patients.

A research agenda for bridging the 'quality chasm.'

Realizing the vision of the IOM's landmark report, Crossing the Quality Chasm, will require new knowledge to support new policy and management. This paper lays out a research agenda that must be pursued if the health care system is to bridge the quality chasm. Based on a consensus process involving leading health care researchers and authorities, the paper highlights knowledge gaps and research directions in five areas identified by the Quality Chasm report as critical to its goals of building organizational supports for change; applying evidence to health care delivery; developing information technology; aligning payment policies with quality improvement; and preparing the workforce.

Changes in career satisfaction among primary care and specialist physicians, 1997-2001

CONTEXT

A number of forces have changed the practice of medicine in the past decade. Evidence suggests that physicians are becoming less satisfied in this environment.

OBJECTIVES

To describe changes in career satisfaction in a large, nationally representative sample of physicians and to examine market and practice factors associated with changes in physician satisfaction.

DESIGN AND SETTING

Data were collected from the first 3 rounds of the Community Tracking Study (CTS) Physician Survey, a series of nationally representative telephone surveys of physicians in 60 US sites conducted in 1996-1997 (round 1: 12 385 respondents; 65% response rate), 1998-1999 (round 2: 12 280 respondents; 61% response rate), and 2000-2001 (round 3: 12 389 respondents; 59% response rate) for the Center for Studying Health System Change. The second and third rounds of the survey included physicians sampled in the previous round, as well as new physicians.

PARTICIPANTS

Primary care and specialist physicians who spent at least 20 hours per week in direct patient care activities.

MAIN OUTCOME MEASURES

Changes in physicians' overall satisfaction with their career and the proportion of dissatisfied physicians in particular sites.

RESULTS

Physician satisfaction levels declined marginally between 1997 and 2001, with most of the decline occurring between 1997 and 1999. Among primary care physicians, 42.4% were very satisfied in 1997, as were 43.3% of specialists, compared with 38.5% and 41.4%, respectively, in 2001. There were nearly equal increases in those who reported that they were somewhat satisfied. Overall means mask significant differences across the 60 sites. Among 12 sites randomly selected for more intensive study, the proportion of respondents who were somewhat or very dissatisfied ranged from 8.8% of physicians in Lansing, Mich (1999), to 34.2% in Miami, Fla (1997). Between 1997 and 1999, 25.6% of primary care physicians reported decreased satisfaction and 18.1% reported improved satisfaction, while approximately equal percentages reported increased (19.8%) and decreased (20.4%) satisfaction between 1999-2001. Findings were similar for specialist physicians. In multivariable models, the strongest and most consistent predictors of change in satisfaction were changes in measures of clinical autonomy, including increases in hours worked and physicians' ability to obtain services for their patients. Changes in exposure to managed care were weakly related to changes in satisfaction.

CONCLUSIONS

Our findings demonstrate that overall physician satisfaction levels over this time period did not change dramatically. In addition, satisfaction and changes in satisfaction vary greatly among sites. Rather than declining income, threats to physicians' autonomy, to their ability to manage their day-to-day patient interactions and their time, and to their ability to provide high-quality care are most strongly associated with changes in satisfaction.

How surgeon age affects surveillance strategies for extremity soft tissue sarcoma patients after potentially curative treatment

BACKGROUND

The optimal strategy for follow-up of extremity soft tissue sarcoma patients after potentially curative treatment remains unknown. We investigated whether the date of completion of formal surgical training affects choice of surveillance strategy.

MATERIALS AND METHODS

The 1,592 members of the Society of Surgical Oncology were asked how often they use 12 separate surveillance modalities during years 1-5 and 10 postsurgery. The motivation underlying follow-up was assessed separately. Repeated-measures analysis of variance was used to compare practice patterns by the year in which the surgeon's formal surgery training was completed, controlling for tumor grade, tumor size, and year postsurgery.

RESULTS

Of the 716 respondents, 318 performed surgery and also provided long-term postoperative surveillance for their patients. These respondents were considered evaluable. Erythrocyte sedimentation rate, extremity X ray, and bone scan were the follow-up tests which differed significantly among physician age groups. Surgeons who completed training more than 30 years ago ordered erythrocyte sedimentation rate more frequently (P < 0.001). Surgeons in the 21-30 year category ordered extremity X ray and bone scan more frequently (P < 0.05), but the absolute differences among age groups were quite small. Older surgeons were also significantly more likely to believe that follow-up is clinically worthwhile.

CONCLUSIONS

The posttreatment surveillance practice patterns of the members of the Society of Surgical Oncology caring for extremity soft tissue sarcoma patients vary only marginally with the length of time since completion of training. Postgraduate education may be one factor homogenizing surgeon behavior in this important aspect of cancer patient care.

Obstetrical textbooks: recommendations about drinking during pregnancy

BACKGROUND

For the past 2 decades, public health authorities have recommended that pregnant women abstain from alcohol. We reviewed obstetrical textbooks published over the last 4 decades to identify trends in recommendations for drinking during pregnancy. The study was begun in 2000 and completed in 2001.

DESIGN

Eighty-one texts were identified from a national listing service (n =51) and local library shelves (n =30).

RESULTS

Only 14 (17%) of the texts contained a consistent recommendation that pregnant women should not drink alcohol. Although there was a slight upward trend toward recommendations for abstinence in more recent texts, only 24% of the 29 texts published after 1990 were in this category. Fifty-three percent of all texts and 52% of texts published after 1990 contained a sentence condoning drinking at some level. The remaining texts (30%) contained no recommendations.

CONCLUSIONS

Many texts, even those published recently, have not embraced public health recommendations and, in some instances, contradict them.