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Smith SM, Parkash V. Normalized "medical inferiority bias" and cultural racism against international medical graduate physicians in academic medicine. Acad Pathol 2023; 10:100095. [PMID: 37767366 PMCID: PMC10520300 DOI: 10.1016/j.acpath.2023.100095] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/28/2023] [Accepted: 08/05/2023] [Indexed: 09/29/2023] Open
Abstract
Socio-historical barriers remain a concern in Academic Medicine. Regrettably, despite the modern cultural era defined by increased recognition and response to such issues, widespread covert barriers and misperceptions continue to limit the advancement of many, in particular, international medical graduate physicians (IMGs) who represent a significant proportion of the US physician workforce. Adversity is experienced in the form of cultural racism, affinity bias, and underrepresentation in distinct specialties as well as in leadership roles. Often, these unnecessary hardships exacerbate pre-existing discrimination in Academic Medicine, further marginalizing IMGs. In this article, we discuss the prevalence of "medical inferiority bias" and the resulting impact on US healthcare, specifying considerations to be made from a policy perspective.
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Affiliation(s)
- Stephen M. Smith
- Department of Laboratory Medicine & Pathobiology at Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Laboratory Medicine and Pathobiology at the University of Toronto, Toronto, Ontario, Canada
| | - Vinita Parkash
- Yale University School of Medicine, New Haven, CT, USA
- Yale New Haven Hospital, New Haven, CT, USA
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Finn CB, Tong JK, Alexander HE, Wirtalla C, Wachtel H, Guerra CE, Mehta SJ, Wender R, Kelz RR. How Referring Providers Choose Specialists for Their Patients: a Systematic Review. J Gen Intern Med 2022; 37:3444-3452. [PMID: 35441300 PMCID: PMC9550909 DOI: 10.1007/s11606-022-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.
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Affiliation(s)
- Caitlin B Finn
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jason K Tong
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah E Alexander
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Wirtalla
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Carmen E Guerra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Wender
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Separate but Equal? The Sorting of USMDs and Non-USMDs in Internal Medicine Residency Programs. J Gen Intern Med 2020; 35:1458-1464. [PMID: 31823308 PMCID: PMC7210370 DOI: 10.1007/s11606-019-05573-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/03/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The US internal medicine workforce relies on international and osteopathic medical graduates to fill gaps in residency. Little is known about the distribution and impact of IMGs, DOs, and USMDs concentrating in different types of IM programs. OBJECTIVE Determining the extent to which USMDs, DOs, and IMGs concentrate in different types of IM programs and comparing Board pass rates by program concentration. DESIGN, SETTINGS, AND PARTICIPANTS This survey study used data from the AMA's FREIDA database for 476 non-military IM programs in 2017-2018, and 2016-2018 ABIM exam pass rates for 388 accredited programs. MEASUREMENTS Outcomes were (1) program concentration based on percentage of residents who were USMDs, IMGs, and DOs in 2017-2018 and (2) 2016-2018 program ABIM pass rates as proxies for program quality. Key independent variables were hospital type (community-based, community-based university-affiliated, or university-based) when program concentration was the outcome, and program concentration when Board pass rates were the outcome. RESULTS Twenty-five percent of programs were "USMD-dominated," 17% were "DO-dominated," 42% were "IMG dominated," and 16% were "integrated." The chances that a university hospital was USMD-dominated were 32 percentage points higher than that for a community hospital (AME = 0.32, baseline probability = 0.11, 95% CI, 0.17-0.46, P < .001). USMD-dominated programs also had significantly higher pass rates by 4.0 percentage points (AME = 0.04, baseline proportion = 0.90, 95% CI, 0.02-0.06, P < .001) than integrated programs, while DO-dominated programs had significantly lower pass rates (AME = - 0.1, baseline proportion = 0.90, 95% CI, - 0.15 to - 0.04, P < .001). CONCLUSION USMDs and non-USMDs systematically cluster in certain types of residency programs and their training may not be equal, as measured by board pass rates.
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Wong H, Karaca Z, Gibson TB. A Quantitative Observational Study of Physician Influence on Hospital Costs. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018800906. [PMID: 30264626 PMCID: PMC6166308 DOI: 10.1177/0046958018800906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physicians serve as the nexus of treatment decision-making in hospitalized
patients; however, little empirical evidence describes the influence of
individual physicians on hospital costs. In this study, we examine the extent to
which hospital costs vary across physicians and physician characteristics. We
used all-payer data from 2 states representing 15 237 physicians and 2.5 million
hospital visits. Regression analysis and propensity score matching were used to
understand the role of observable provider characteristics on hospital costs
controlling for patient demographics, socioeconomic characteristics, clinical
risk, and hospital characteristics. We used hierarchical models to estimate the
amount of variation attributable to physicians. We found that the average cost
of hospital inpatient stays registered to female physicians was consistently
lower across all empirical specifications when compared with male physicians. We
also found a negative association between physicians’ years of experience and
the average costs. The average cost of hospital inpatient stays registered to
foreign-trained physicians was lower than US-trained physicians. We observed
sizable variation in average costs of hospital inpatient stays across medical
specialties. In addition, we used hierarchical methods and estimated the amount
of remaining variation attributable to physicians and found that it was
nonnegligible (intraclass correlation coefficient [ICC]: 0.33 in the full
sample). Historically, most physicians have been reimbursed separately from
hospitals, and our study shows that physicians play a role in influencing
hospital costs. Future policies and practices should acknowledge these important
dependencies. This study lends further support for alignment of physician and
hospital incentives to control costs and improve outcomes.
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Affiliation(s)
- Herbert Wong
- 1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Zeynal Karaca
- 1 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD, USA
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Abstract
BACKGROUND Access to physicians is a major concern for Medicaid programs. However, little is known about relationships between physician participation in Medicaid and the individual-level and practice-level characteristics of physicians. METHODS We used the 2011 Massachusetts All Payer Claims Database, containing all commercial and Medicaid claims; we linked with data on physician characteristics. We measured Medicaid participation intensity (fraction of the physician's patient panel with Medicaid) for primary care physicians (PCPs) and medical specialists. We measured influence of physicians within a patient referral network using eigenvector centrality. We used regression models to associate Medicaid intensity with physician individual-level and practice-level characteristics. FINDINGS About 92.6% of physicians treated at least 1 Medicaid patient, but the median physician's panel contained only 5.7% Medicaid patients. Medicaid intensity was associated with physician training and influence for PCPs and specialists. For medical specialists, a 1 percentage point increase in Medicaid intensity was associated with a lower probability of being board certified (-0.22 percentage points; 95% CI, -0.30, -0.14), lower probability of attending a domestic medical school (-0.14 percentage points; 95% CI, -0.22, -0.05), having attended a less well-ranked domestic medical school (0.23 ranks; 95% CI, 0.15, 0.30), and having slightly less influence in the referral network. PCPs displayed similar results but high Medicaid intensity physicians had substantially less influence in the referral network. CONCLUSIONS Medicaid participation intensity shows substantial variation across physicians, indicating limits of binary participation measures. Physicians with more Medicaid patients had characteristics often perceived by patients to be of lower quality.
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Campbell KH, Smith SG, Hemmerich J, Stankus N, Fox C, Mold JW, O'Hare AM, Chin MH, Dale W. Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making. BMC Nephrol 2011; 12:47. [PMID: 21943241 PMCID: PMC3192737 DOI: 10.1186/1471-2369-12-47] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 09/26/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD. METHODS We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision. RESULTS More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24). CONCLUSIONS In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.
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Affiliation(s)
- Kellie H Campbell
- University of Chicago, Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, Illinois 60637, USA
| | - Sandy G Smith
- University of Chicago, Pritzker School of Medicine, 924 East 57 th Street, BSLC 013A, Chicago, Illinois 60637, USA
| | - Joshua Hemmerich
- University of Chicago, Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, Illinois 60637, USA
| | - Nicole Stankus
- University of Chicago, Section of Nephrology, 5841 South Maryland Avenue, MC 5000, Chicago, Illinois 60637, USA
| | - Chester Fox
- University of New York at Buffalo, Department of Family Medicine, 462 Grider Street, Buffalo, New York, 14215, USA
| | - James W Mold
- University of Oklahoma, Department of Family Medicine, 900 North East 10 th Street, Oklahoma City, Oklahoma, 73104, USA
| | - Ann M O'Hare
- VA/Puget Sound Medical Center, 1660 South Columbian Way, Seattle, Washington, 98108, USA
| | - Marshall H Chin
- University of Chicago, Section of General Internal Medicine, 5841 South Maryland Avenue, MC 2007, Chicago, Illinois, 60637, USA
| | - William Dale
- University of Chicago, Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, Illinois 60637, USA
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Campbell KH, Dale W, Stankus N, Sachs GA. Older adults and chronic kidney disease decision making by primary care physicians: a scholarly review and research agenda. J Gen Intern Med 2008; 23:329-36. [PMID: 18175190 PMCID: PMC2359471 DOI: 10.1007/s11606-007-0492-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Revised: 11/06/2007] [Accepted: 11/20/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults. OBJECTIVE This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD. RESULTS While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD. CONCLUSIONS More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.
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Copeland KA, Harris EN, Wang NY, Cheng TL. Compliance with American Academy of Pediatrics and American Public Health Association illness exclusion guidelines for child care centers in Maryland: who follows them and when? Pediatrics 2006; 118:e1369-80. [PMID: 17079538 DOI: 10.1542/peds.2005-2345] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 1992, the American Academy of Pediatrics and the American Public Health Association jointly published guidelines for temporary exclusion of sick children from child care. However, little is known about key stakeholders' compliance with these guidelines. OBJECTIVES The purpose of this work was to compare pediatricians', parents', and child care providers' compliance with American Academy of Pediatrics guidelines and determine predictors for higher rates of compliance. METHODS We conducted a cross-sectional survey of 215 randomly selected Maryland pediatricians, 223 parents, and 192 child care providers from 22 Baltimore, Maryland, child care centers from January to July 2004. Questionnaires contained the following 6 case vignettes depicting common child care illnesses: upper respiratory infection, conjunctivitis, gastroenteritis, mild febrile illness, tinea capitis, and atopic dermatitis. The instrument measured the correctness of exclusion and inclusion decisions (using American Academy of Pediatrics/American Public Health Association guidelines as gold standard) according to varying levels of fever, disease severity (eg, clear versus yellow eye discharge), familiarity with the child, and parent work schedule flexibility. RESULTS Response rates were 71% for pediatricians, 56% for parents, and 85% for child care providers. Guideline compliance was higher for pediatricians (74%) than for child care providers (60%) and parents (61%). Only 23% of pediatricians and parents and 29% of child care providers reported familiarity with American Academy of Pediatrics/American Public Health Association guidelines by name. In general, child care providers and parents had lower false-negative rates (allowed fewer children to attend who met criteria for exclusion) than pediatricians, suggesting that pediatricians may underexclude. Child care providers and parents correctly excluded in 65%-98% of cases requiring exclusion, whereas pediatricians correctly excluded 31%-86% of cases requiring exclusion, depending on the vignette. Yet pediatricians were much more specific about which children met criteria (pediatricians correctly included 61%-93% of cases requiring inclusion versus child care providers and parents who correctly included 20%-75% of such cases), suggesting that child care providers and parents may overexclude. Compliance rates varied significantly by stakeholder, vignette (disease), level of fever, and disease severity but did not vary with the stakeholder's familiarity with the child or the flexibility of the parent's work schedule. CONCLUSIONS Pediatricians, parents, and child care providers were unfamiliar with American Academy of Pediatrics/American Public Health Association illness exclusion guidelines by name but moderately compliant with them. When noncompliant, child care providers and parents generally overexcluded, and pediatricians underexcluded. Stakeholder- and disease-specific predictors for noncompliance gleaned from this study suggest how educational interventions aiming to increase guideline compliance could be individually tailored to child care providers, parents, and pediatricians.
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Affiliation(s)
- Kristen A Copeland
- General and Community Pediatrics Division, Cincinnati Children's Hospital Medical Center, MLC 7035, 3333 Burnet Ave, Cincinnati, OH 45229, USA.
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Mukamel DB, Weimer DL, Mushlin AI. Referrals to high-quality cardiac surgeons: patients' race and characteristics of their physicians. Health Serv Res 2006; 41:1276-95. [PMID: 16899007 PMCID: PMC1797085 DOI: 10.1111/j.1475-6773.2006.00535.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the referral process to cardiac surgeons in order to explain racial disparities in access to high-quality cardiac surgeons. DATA SOURCES/STUDY SETTINGS All white and black Medicare fee-for-service patients undergoing coronary artery bypass graft (CABG) surgery in New York State during 1997-1999. STUDY DESIGN A retrospective analysis of referral patterns for white and black patients in relation to the quality of the cardiac surgeon, measured by the surgeon's risk-adjusted mortality rate (RAMR), and in relation to characteristics of the physician providing the majority of cardiac care before the surgery. The average RAMRs of the surgeons to whom different physicians referred patients were compared using t-tests and paired t-tests. A hierarchical multivariate regression model was estimated to test hypotheses about the effect of physicians' characteristics on referrals of blacks to low-quality surgeons. DATA EXTRACTION METHOD Variables were constructed from Medicare claims. PRINCIPAL FINDINGS The differential in surgeons' quality for white and black patients is partially due to the physician providing the majority of cardiac care before the surgery. There is both across- and within-physician variation in referrals. Of the physician characteristics investigated, only the number of black patients referred to CABG and the percent of all cardiac referrals to the same hospital decrease the difference in surgeons' quality between whites and blacks. CONCLUSIONS Several different pathways lead blacks to cardiac surgeons of lower quality. Further research is needed to understand the causes and inform policies designed to minimize disparities in access to high-quality providers.
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Affiliation(s)
- Dana B Mukamel
- Center for Health Policy Research, University of California, 111 Academy Suite 220, Irvine, CA 92697-5800, USA
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Martin DR. Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2006; 81:189-92. [PMID: 16436585 DOI: 10.1097/00001888-200602000-00016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
International visitors who travel to the United States for the express purpose of receiving medical care constitute a small, but unique and important, subset of patients in this country. These visitors have traditionally sought care at what are widely regarded as the premier U.S. academic medical centers. Their care may prove challenging due to logistical, medical, language, and cross-cultural issues, and has the potential to distract from the educational and research missions of these medical centers. The author reflects on how one academic medical center, the Johns Hopkins Medical Institutions, has experienced and responded to these challenges. Specific issues include scheduling and evaluation challenges, language and cultural differences, and arranging continuity care. The author concludes that when an institution invests the resources necessary to address these issues, and enlists physicians stimulated by this challenging group of patients, the arrangement is mutually beneficial to the international patients and the institution. Scholarly evaluation of this phenomenon has been virtually nonexistent, due to both the unique niche occupied by these programs and institutional competition for this group of patients. However, collaborative evaluation of international patient programs will provide the opportunity to assess similarities, differences, and effectiveness, benefiting both those providing and those receiving care by improving the appropriateness and quality of care.
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Affiliation(s)
- Don R Martin
- Johns Hopkins Outpatient Center, Room 7143, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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