Analysis of factors affecting U.S. emergency physician workforce projections. SAEM Workforce Task Force

OBJECTIVES: To use existing data sources to refine prior estimates of the U.S. emergency medicine (EM) workforce and to estimate effects of proposed changes in the U.S. health care system on the EM workforce. METHODS: Relevant data were extracted from the American College of Emergency Physicians (ACEP) 1995 Membership Activity Report, the American Medical Association (AMA) publication "1995/96 Physician Characteristics and Distribution in the U.S.," the American Hospital Association (AHA) 1994 hospital directory, a written survey of each state's medical licensing board and state medical society, and the American Board of Emergency Medicine (ABEM) annual activity report for 1995. These data were used to project workforce supply and demand estimates applicable to workforce models. RESULTS: None of the available information sources had complete data on the number and distribution of emergency physicians (EPs) currently practicing in the United States. Extrapolating the limited reliable statewide EP numbers to make nationwide projections reveals a shortage of EPs needed to fully staff the nation's existing EDs. At least 22 states had an average ratio of < 5 EPs per existing ED. Additional national projections incorporating a decreasing number of U.S. EDs indicate that the current annual number of EM residency graduates will not eliminate the deficit of EPs for at least several decades, given that projected numbers of retiring EPs annually will soon equal the total annual EM residency graduate production. CONCLUSIONS: Although the current data on EPs in practice in the United States are incomplete, the authors project a relative shortage of EPs. More accurate and complete information on the numbers and distribution of EPs in America is needed to improve workforce projections.     

Emergency medicine career change: associations with performances in medical school and in the first postgraduate year and with indebtedness

OBJECTIVE: Emergency medicine has been identified as the specialty that has gained the most young physicians who have changed their careers. To identify factors that may have contributed to such career changes, the authors compared the characteristics of three groups of physicians trained at their medical school: those who chose and stayed in emergency medicine, those who migrated into emergency medicine from other specialties, and those who moved out of emergency medicine. METHODS: A prospective longitudinal study was conducted. The sample consisted of physicians who chose emergency medicine as their careers at graduation and stayed in the specialty (n = 24), those who migrated from other specialties into emergency medicine (n = 51), and those who moved out of emergency medicine (n = 10). This sample was obtained from a total of 2,173 graduates of Jefferson Medical College between 1978 and 1987. The three groups of physicians were compared according to their academic performances both during medical school and after graduation. The dependent variables were freshmen and sophomore grade point averages (GPAs), written clinical examination scores, scores on National Board of Medical Examiners examination (Parts I, II, and III), and residency program directors' ratings. Age and indebtedness at medical school graduation and board certification status also were examined. RESULTS: Those physicians who stayed in emergency medicine and those who migrated from other specialties into emergency medicine had similar measures of academic performance, but both of these groups had higher academic performance measures and higher board certification rates than did the physicians who moved out of emergency medicine. Those who stayed in emergency medicine had the highest mean debt in the senior year of medical school. CONCLUSIONS: High academic performance and high indebtedness are factors associated with choosing or staying in the specialty of emergency medicine.     

"Reasons to leave shiftwork and psychological and psychosomatic complaints of former shiftworkers": Correction to Frese and Okonek.

Reports an error in "Reasons to leave shiftwork and psychological and psychosomatic complaints of former shiftworkers" by Michael Frese and Klaus Okonek (Journal of Applied Psychology, 1984[Aug], Vol 69[3], 509-514). On p. 510, first column, third line from the bottom of the page, the N for the OR group should be 96, not 36. (The following abstract of the original article appeared in record 1984-32942-001.) 191 male blue-collar workers who had previously worked nights and shifts were differentiated into 3 groups: a group that had left night- and shiftwork because of health reasons; another that left it for various other reasons; and a middle group that had a combination of health and other reasons for leaving. Ss completed measures of environmental and psychological stress, psychosomatic and other health complaints, and irritation and strain. Findings show that the 1st group had more health complaints than the one that left for other reasons. They were less skilled, had been unemployed less often, and were typically told by their physician to leave shiftwork. They had also stayed in shiftwork longer than the group that left shiftwork for other reasons. It is suggested that studies on former shiftworkers should differentiate between these groups so as not to underestimate the real problems of former shiftworkers who left for health reasons. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interests of engineers related to turnover, selection, and management.

"Using the Strong Vocational Interest Blank, four groups of interest items were found to distinguish engineers who left the service of a particular electrical utility within the first 2 years from engineers who stayed longer. Comparing the interests of engineers who had assumed senior responsibility in relatively short time confirmed the suspicion that some of the men who were leaving might be those who were similar in interest to the leaders. Thus, those likely to leave the organization could be separated into two identifiable groups. One group it is considered relatively safe to screen out at the time of application. The other group should be encouraged to stay by efforts to change conditions in the organization so as to provide better satisfaction for their interests. It is suggested that, as well as selecting suitable people, an organization may need to adapt itself so as to satisfy the needs of the kind of people it requires." From Psyc Abstracts 36:04:4LI43B. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reasons to leave shiftwork and psychological and psychosomatic complaints of former shiftworkers.

[Correction Notice: An erratum for this article was reported in Vol 70(2) of Journal of Applied Psychology (see record 2008-10966-001). On p. 510, first column, third line from the bottom of the page, the N for the OR group should be 96, not 36.] 191 male blue-collar workers who had previously worked nights and shifts were differentiated into 3 groups: a group that had left night- and shiftwork because of health reasons; another that left it for various other reasons; and a middle group that had a combination of health and other reasons for leaving. Ss completed measures of environmental and psychological stress, psychosomatic and other health complaints, and irritation and strain. Findings show that the 1st group had more health complaints than the one that left for other reasons. They were less skilled, had been unemployed less often, and were typically told by their physician to leave shiftwork. They had also stayed in shiftwork longer than the group that left shiftwork for other reasons. It is suggested that studies on former shiftworkers should differentiate between these groups so as not to underestimate the real problems of former shiftworkers who left for health reasons. (13 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Finite element analysis of trabecular bone structure: a comparison of image-based meshing techniques

OBJECTIVE: To report a qualitative evaluation of the Partnerships in Health Care/EMS Project between Poland and the United States. The goal of the partnership was to strengthen the emergency medical services (EMS) system in three Polish cities, Krakow, Bialystok, and Lodz. METHODS: The Polish participants were interviewed in Poland approximately eight months after a U.S.-based training program. They were asked to evaluate the effectiveness of the partnership project and discuss their experiences incorporating U.S. emergency medicine (EM) knowledge and technology in the Polish EMS system. RESULTS: The Polish physicians identified three major factors that had the greatest impact on the implementation of U.S. EM knowledge in Poland. These factors were the substantive differences between Polish and U.S. EM knowledge and technology, staffing differences in Polish and U.S. ambulances, and the differing role the EMS system plays in the delivery of primary care in the two countries. CONCLUSIONS: The Polish physicians succeeded in training EM providers in the three cities, thus strengthening clinical skills of EMS providers. They also were able to adapt the principles of U.S. EM that they had learned to fit the specific circumstances that characterize Polish emergency care. As in the United States, the health care system in Poland is inseparable from the social, political, and economic realities of the nation.     

Preferences of physicians and their patients for end-of-life care

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.     

Investigating behavioral antecedents of turnover at three job tenure levels.

A field study was conducted to investigate differences between hourly assembly operators who stayed and hourly assembly operators who voluntarily quit their jobs. A total of 80 stayers and 121 leavers were identified from personnel records and were classified into one of three job tenure groups, 2–5 months, 6–12 months, and more than 12 months. Job performance, attendance measures, and biographical variables were used to predict turnover for each job tenure group. Results indicated poorer performance by leavers with 6–22 months tenure compared with stayers. No differences in performance or attendance were obtained between stayers and leavers with between 2–5 months and those with more than 12-months job tenure. Leavers after 6 and before 12 months demonstrated more absenteeism compared with stayers. Implications for the role of absenteeism and constraints on the performance-retention relation are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

U. S. medical graduates versus foreign medical graduates. Are there performance differences in practice?

This study has attempted to determine the relationship between physicians' medical education and their performances (technical quality and utilization of medical care resources) in offices and hospitals. The sample consisted of 506 physicians of Hawaii, involving 18 specialty categories. The study finds little evidence of the influence of the type of medical schools on physicians' technical quality and utilization of medical resources in practice. The mean differences between the categories of medical schools were not statistically significant (except for the quality when specialists practiced within their own areas of specialization). There is no evidence that all categories of U.S. medical graduates provided a higher quality care and better utilization than all categories of foreign medical graduates. There was no consistent pattern of performances within the categories of U.S. medical schools and of foreign medical schools in these dimensions of performances.     

Job satisfaction: Environmental and genetic components.

Monozygotic twins reared apart from an early age were used to test the hypothesis that there is a significant genetic component to job satisfaction. 34 monozygotic twin pairs who had been reared apart completed the Minnesota Job Satisfaction Questionnaire as part of a comprehensive work-history assessment. Three subscales were formed from the job satisfaction items to reflect intrinsic, extrinsic, and general satisfaction with the current (or major) job. Intraclass correlations were computed to estimate the proportion of observed variability resulting from genetic factors for all job satisfaction items and for the 3 subscales. Resulting values indicated that approximately 30% of the observed variance in general job satisfaction was due to genetic factors. Additional analysis indicated that these results obtained even when job characteristics such as complexity, motor skill requirements, and the physical demands were held constant via partialing methods. Finally, the data indicated significant heritabilities for several of these job characteristics, which is consistent with the hypothesis of a genetic disposition to seek and remain in similar environments (jobs). Implications of these findings for theories of job satisfaction, selection, and job enrichment are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A longitudinal test of the investment model: The impact on job satisfaction, job commitment, and turnover of variations in rewards, costs, alternatives, and investments.

A 12-mo longitudinal study of 88 newly hired nurses and junior accountants (mean age of all Ss 24 yrs) tested a series of assumptions from the authors' (see record 1981-31481-001) investment model concerning the determinants of job satisfaction, job commitment, and turnover. In general, greater job satisfaction resulted from high job rewards and low job costs; whereas strong job commitment was produced by high rewards, low costs, poor alternative quality, and large investment size. Whereas the impact of job rewards on satisfaction and commitment remained relatively constant, job costs seemed to exert an increasingly powerful influence over time. Investment size also exerted greater impact on job commitment with the passage of time. Just prior to their leaving, the job commitment of Ss who left was best predicted by a combination of rewards, costs, and alternatives. Ss who stayed and those who left differed from one another with regard to changes over time in each investment model factor—those who left experienced greater decline in rewards, increase in costs, increase in alternative quality, and decrease in investment size than those who stayed. Turnover appeared to be mediated by a decline over time in degree of job commitment. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Job performance and turnover.

The literature on job performance and turnover generally indicates that employees who leave their organization are better performers. This hypothesized relationship was tested for 162 female registered nurses who were evaluated by their supervisors using the Slater Nursing Competence Rating Scale. Nurses who left their jobs did not perform significantly better than those who stayed. Four issues related to performance–withdrawal research are discussed: (a) The combined use of objective measures and rater methods would improve performance measurement validity. (b) More than just professional employees in service organizations must be studied. (c) Different types of people who leave must be investigated. (d) Withdrawal research must move beyond studying its determinants to studying its impact on a wide range of organizational properties. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Drug-induced acute interstitial nephritis

This paper reports the findings of a five-year, three-stage study of the occupational status persistence of 333 physicians who immigrated to Israel from the former Soviet Union in 1990. The first data collection, by way of a structured questionnaire in Russian, was undertaken in 1991, during their participation in preparatory courses for the medical licensure examination. The second and third stages of data collection were undertaken by mail in 1993 and 1995. Data are presented regarding the influence of gender and age on employment status and on the relationship between employment status and psycho-social well-being, including work and general satisfaction, self-esteem, mood, health and overall adaptation, at both stages. The dynamics of occupational integration are investigated by looking at the effects of occupational stability vs occupational change between stage 2 and stage 3 on the psycho social outcome variables. After three years in Israel, men were more likely to be working as physicians than women, and women were more likely to be unemployed. However, after five years, women were equally likely to have found work in their profession, albeit in lower status positions. Younger respondents were more successful than older respondents in passing the licensure examination, finding work in their profession, and entering residency programs. The gap between them did not close between stage 2 and stage 3. At both stage 2 and stage 3, those working as physicians had significantly more positive well-being scores than those not working as physicians. All occupational groups had more positive scores at stage 3 than at stage 2, except for those who were working in non-medically related jobs. The greatest improvement in psycho-social well-being was among those who became physicians between stage 2 and stage 3, compared to those who were not physicians at either stage and those who were physicians at both stages.     

Willingness to perform euthanasia. A survey of physician attitudes

BACKGROUND: In the United States, few studies have examined important variables in physician attitudes toward the practice of euthanasia, such as the patient's underlying disease, mental capacity, and age, and the physician's specialty and religion. We administered a case-based survey to analyze the impact of such specific variables on physician attitudes toward the practice. METHODS: A four-section survey solicited (1) physician responses to three hypothetical cases in which patients requested euthanasia; (2) physicians' general opinions about euthanasia and how its legalization might affect them personally and professionally; and (3) demographic information. Analysis focused on physicians' characteristics as they related to their responses to the various aspects of euthanasia elicited in the survey. Univariate and multivariate analyses, using logistic regression, were performed. RESULTS: Completed and analyzable surveys were returned by 740 physicians. We found that physicians felt more comfortable with euthanasia requests from nondecisional, nonterminal patients who had left advance directives than they did with requests from decisional patients suffering from grave illnesses or injuries, or from decisional patients who had early signs of a progressive but nonlethal neurologic disease. We also found that physicians' specialties and religions correlated with their responses to the hypothetical cases and with their generalized attitudes toward euthanasia. CONCLUSIONS: Given the disparity in responding physicians' attitudes toward euthanasia, along with the fact that values based on religious affiliation or profession may underlie many physicians' opposition to the practice, we conclude that if euthanasia is to be legalized, safeguards protective of patients and physicians must be incorporated.     

Letter: Random thoughts on abortion attitudes

Comments on a paper of physicians' attitudes toward abortion are presented. The reasons for approval of abortion which show about 80% citing medical or psychiatric and only 60% citing social reasons or a woman's right to do with her body what she wants support the belief in the sexist attitudes of physicians. Disbelief is voiced toward the 1 physician who feels a woman cannot become pregnant from incest or rape, and towards the physician who believes a woman's mental health is unthreatened by an unwanted pregnancy. The author wonders if there were differences between male and female physicians sampled.     

Predictive value of letters of recommendation vs questionnaires for emergency medicine resident performance

OBJECTIVE: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program. METHODS: A retrospective association of LORs and PPQs with in-training residents performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the specialty of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings. RESULTS: Statistically, no differences were found between the LORs and PPQs in predicting resident performance. CONCLUSIONS: PPQs may substitute for LORs in the evaluation of resident applicants.     

The caring imperative

Healing depends on a caring, involved physician. In his story "Ward Number Six," Anton Chekhov illustrated how patients suffer when physicians become apathetic. Reading this story may inspire physicians to resist apathy and assume greater responsibility for the social conditions that impact on their patients' well-being. It may also stimulate physicians' imagination in such a way as to improve their ability to empathize with their patients. Finally, the act of reading itself--particularly reading great literature such as "Ward Number Six," can help rejuvenate those physicians who struggle with their own apathy.     

Primary care physicians' medical decision making for late-life depression

OBJECTIVE: To describe primary care physicians' clinical decision making regarding late-life depression. DESIGN: Longitudinal collection of data regarding physicians' clinical assessments and the volume and content of patients' ambulatory visits as part of a randomized clinical trial of a physician-targeted intervention to improve the treatment of late-life depression. SETTING: Academic primary care group practice. PATIENTS/PARTICIPANTS: One-hundred and eleven primary care physicians who completed a structured questionnaire to describe their clinical assessments immediately following their evaluations of 222 elderly patients who had reported symptoms of depression on screening questionnaires. INTERVENTIONS: Intervention physicians were provided with their patient's score on the Hamilton Depression rating scale (HAM-D) and patient-specific treatment recommendations prior to completing the questionnaire regarding their clinical assessment. MAIN RESULTS: Those physicians not provided HAM-D scores were just as likely to rate their patients as depressed, as determined by specific query of these physicians regarding their clinical assessments. A physician's clinical rating of likely depression did not consistently result in the formulation of treatment intentions or actions. Treatment intentions and actions were facilitated by provision of treatment algorithms, but treatment was received by fewer than half of the patients whom physicians intended to treat. Barriers to treatment appear to include both physician and patient doubts about treatment benefits. CONCLUSIONS: Lack of recognition of depressive symptoms did not appear to be the primary barrier to treatment. Recognition of symptoms and access to treatment algorithms did not consistently result in progression to subsequent stages in treatment decision making. More research is needed to determine how patients and physicians weigh the potential risks and benefits of treatment and how accurately they make these judgments.     

Effect of flexible working hours on employee satisfaction and performance: A field experiment.

64 federal workers were randomly assigned to flexible or fixed working hours, and after 6 mo they completed the Index of Job Satisfaction. In addition, their supervisors rated their 6-mo performance on a 9-point scale. Results indicate that flexitime caused a significant increase in worker satisfaction but had negligible effects on performance, whether assessed by output or ratings. Research should aim at uncovering the reasons for the positive effect of flexitime. (6 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)