Is "involuntary childlessness" within the realm of family medicine responsibility of the general practitioner?

The aim of the study was to assess whether or not management of infertility is within the domain of the general practitioner in his capacity as a family physician. All accredited family physicians in the wider area of Goettingen were invited to take part in our survey. A total of 57 doctors (84%) participated. In personal interviews the family physicians were encouraged to frankly discuss the following main topics: the frequency of infertility in their own practice as well as their care for and attitudes towards infertile patients. Many family physicians interviewed were reluctant to address involuntary childlessness and underestimated its frequency. According to their patients' needs and demands, however, family doctors--above all in rural practices--have been participating in the screening and counseling of, and providing emotional support for, involuntarily childless patients. A qualitative analysis of the interview data revealed that many family physicians regarded infertility as the patients' private matter and placed it within the domain of specialists. About one-third of the physicians expressed negative attitudes towards infertile patients. Moreover, assisted reproduction techniques were sometimes rejected as "unnatural" methods. If a family-oriented approach should be amplified in family practice by offering supportive counseling for infertile patients, continuing medical education will have to take these attitudes into account.     

Influence of salt concentration on the cellular fatty acid composition of the moderately halophilic bacterium Halomonas salina

CONTEXT: Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory. OBJECTIVE: To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care. DESIGN: Cross-sectional mail survey of a probability sample of primary care physicians. SETTING: A total of 13 large urban counties in California. PARTICIPANTS: Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice. MAIN OUTCOME MEASURES: Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts. RESULTS: Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice. CONCLUSIONS: Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.     

5-Hydroxytryptamine, angiotensin and bradykinin transiently increase intracellular calcium concentrations and PKC-alpha activity, but do not induce mitogenesis in human vascular smooth muscle cells

Primary care physicians have an important role in coronary heart disease prevention. This paper discusses the results of a qualitative study conducted with Nova Scotian physicians to explore the following: physicians' expectations about their role in prevention; obstacles to providing preventive care; and, mechanisms by which preventive care occurs. The second part of the paper presents a practice model which is intended as a framework by which physicians may more effectively educate and counsel their patients about health issues, such as coronary heart disease.     

Guidelines as a strategy for preserving professional autonomy

Practice guidelines are often perceived as a threat to physician autonomy. However, the true challenge to physician autonomy is the rising costs of health care, which in turn is the result of continued progress in medical research. Since, inevitably, choices must be made about how our limited resources are expended, an increasing number of physicians are concluding that health care providers should assume financial risk for providing care--so that providers can make the decisions about which interventions are used for which patients. In this context, groups of physicians are adopting practice guidelines as an important strategy for providing high quality and efficient care under capitation. At least in some areas, practice guidelines are emerging as a critical tool for physicians to assume financial risk, and thereby protect professional autonomy.     

A method of estimating physician requirements

This article describes and applies a method of estimating physician requirements for the United States based on physician utilization rates of members of two comprehensive prepaid plans of medical care providing first-dollar coverage for practically all physician services. The plan members' physician utilization rates by age and sex and by field of specialty of the physician were extrapolated to the entire population of the United States. On the basis of data for 1966, it was found that 34 percent more physicians than were available would have been required to give the entire population the amount and type of care received by the plan members. The "shortage" of primary care physicians (general practice, internal medicine, and pediatrics combined) was found to be considerably greater than of physicians in the surgical specialties taken together (41 percent as compared to 21 percent). The paper discusses in detail the various assumptions underlying this method and stresses the need for careful evaluation of all methods of estimating physician requirements.     

Managed care liability update

As the volume of litigation involving managed care grows, the liability issues become clearer. For example, recent decisions demonstrate that failure to provide access to qualified physicians, failure to process claims appropriately, denial of claims and undue delay of treatment can and do lead to liability. Moreover, the federal Employment Retirement Income Security Act of 1974 (ERISA) won't protect the managed care providers, and physicians may sue the managed care organization if its policies or agents open them to liability.     

Physician management preferences and barriers to care for rural patients with depression

OBJECTIVE: To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition. DESIGN: Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas. SETTING: Primary care practices in nonmetropolitan counties. PARTICIPANTS: Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%. MAIN OUTCOME MEASURES: Physician preferences for and barriers to the effective management of depression. RESULTS: An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up. CONCLUSIONS: The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.     

The early case for caring for the insane in general hospitals

The early argument for caring for the insane in general hospitals arose in the late 1800s in the context of criticisms of the asylum made by neurologists and some psychiatrists. The movement in support of general hospital psychiatry gained ground within psychiatry as the modernization of the general hospital made it a more attractive work site for physicians. By the second decade of this century, a newly independent discipline of hospital administration was providing an audience for psychiatrists who wanted to make the medical and financial case for the value of psychiatric care in the general hospital. Although in the 1930s only a fraction of general hospitals included a "department for mental patients," general hospital psychiatric treatment had ceased to be only a rhetorical or experimental concept and was fast becoming a practical program of treatment.     

Internal medicine in the current health care environment: a need for reaffirmation

Managed care has substantially changed the environment of health care delivery for general internists and internist-subspecialists. In the current system, one may wonder whether detailed and thoughtful workups still have a role when the direction of medical practice increasingly prizes a high volume of brief encounters. However, the very forces that drive managed care make the role of internist in the care of adults even more central. The internist's unique training and clinical approach should lead to both medically effective and cost-effective health care for adults. This type of health care will be increasingly important as the U.S. population ages and an increasing number of Americans have chronic, multisystem disease. Over the past century, internal medicine has evolved from a consultative model to a discipline that encompasses total adult care, from prevention to diagnosis and treatment of acute and chronic illness and from outpatient care in the office to inpatient care in the intensive care unit. However, the leadership role of internists in the medical care of adults is now being threatened by family medicine and by fragmentation within internal medicine itself. Managed care organizations and the general public must be shown why internists are better able than family physicians to meet the health care needs of adults. Furthermore, as the marketplace becomes more competitive, the issue of when care given by a subspecialist is superior to that given by an internist has become more prominent. The rapidly developing "hospitalist" movement also threatens the traditional role of the internist as the caregiver for adults in health and disease. Given the historic flexibility of internal medicine and the assumption that appropriate roles can be defined for family physicians, subspecialists, and hospitalists, internists will continue to play a central role in providing the best care for adults in the new world of health care delivery.     

Deciphering the physician-older patient interaction

OBJECTIVE: The purpose of this article is to provide a commentary on non-verbal communication in the physician-older patient interaction. METHOD: A literature review of physician-older patient communication yielded several published studies on this topic. Nonverbal behaviors were rarely examined in this body of literature even though the need to adopt a more "biopsychosocial" model of care was mentioned in several of the articles. The nonverbal communication literature was also reviewed to determine whether aging had been a variable of interest with regard to encoding (sending) and decoding communication (receiving) skills. RESULTS: To date there have been very few studies that have investigated the role of nonverbal communication in the physician-older patient interaction. Selected encoding and decoding characteristics for both physicians and patients are discussed with the context of the aging process. In lieu of direct evidence linking nonverbal behavior and physician-older patient communication, possible implications are offered for the following characteristics: expression of emotion, pain expression, gestures, gaze, touch, hearing, and vocal affect. Three relevant outcomes (satisfaction with care, quality of life, and health status) are also discussed within the nonverbal behavior-aging framework. CONCLUSION: The connection between nonverbal behavior and how physicians and older patients interact with one another has not been rigorously examined. Identifying and improving nonverbal communication will likely enhance the verbal exchange in the medical encounter and may improve the older patient's quality of care.     

Untreated anxiety among adult primary care patients in a Health Maintenance Organization

BACKGROUND: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. METHOD: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. RESULTS: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. CONCLUSION: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.     

Postoperative nausea and vomiting. A retrospective analysis in patients undergoing elective craniotomy

CONTEXT: Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. OBJECTIVE: To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. DESIGN: Cross-sectional questionnaire. SETTING: A total of 89 California physician groups with capitated contracts. PARTICIPANTS: A total of 910 primary care physicians (80% response rate). MAIN OUTCOME MEASURE: Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. RESULTS: Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). CONCLUSION: These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.     

Managed care and the survival of neurology referral centers. A commitment to centers of excellence

Since the collapse of federal health system reform legislation in 1994, there has been a growing concern with the quality of care provided within managed care systems. Just as physicians practicing under a traditional fee-for-service payment base have financial incentives to do as much as possible for each patient (doing well by doing good), physicians working for managed care plans are sometimes given perverse incentives to do as little as possible. A major quality-related concern among patients and payers (often referred to jointly and ambiguously as consumers of care) is the much larger role assigned to primary care physicians in managed care plans than is usually the case with traditional indemnity insurance.     

The development of international emergency medicine: a role for U.S. emergency physicians and organizations. SAEM International Interest Group

There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.     

Psychiatry and the primary care physician

Psychiatry makes an important contribution to the training and practice of primary care physicians by emphasizing a holistic approach to patient care, by teaching psychiatric skills and by providing knowledge that enables primary care physicians to give basic psychological care to the large numbers of their patients who need it. Consultation-liaison psychiatry and psychiatry education programs for medical students, both of which are given high priority for support by the Psychiatry Education Branch of National Institute of Mental Health (NIMH), are model settings in which to teach the psychiatric aspects of primary care.     

Selective serotonin reuptake inhibitors and atypical antidepressants: A review and update for psychologists.

Psychologists are increasingly being required to care for patients who are concurrently undergoing pharmacological treatment, particularly when patients suffer from mood disorders, such as major depression. In addition, nonpsychiatric physicians are prescribing antidepressant medications with greater frequency, thereby increasing the likelihood that the physician with which the psychologist must collaborate will have a limited understanding of psychiatric illnesses. As independent mental health professionals, psychologists have a right and a responsibility to be actively engaged in all aspects of their patients' treatment, including pharmacotherapy. A prerequisite for providing this level of professional care is a solid grounding in the principles and actions of pharmacological agents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Considering nursing resource as "caring time'

The present constrained economic climate faced by health care agencies underscores the need for nurse administrators to have an in-depth appreciation of how nursing services are being used. The purpose of this investigation was to increase the understanding of nursing as a resource. Using phenomenological research methodology, the investigator purposefully selected six patients and a chain sample of 14 professionals responsible for their care, including nurses, nurse managers and physicians. Data collection methods included in-depth interviews, document reviews, and participant observation. The inductive interpretation depicts the nature of nursing resource to be "caring time'. Caring was understood primarily in terms of time and was experienced by all participants as "spending time'. Caring time was spent through "being with' and "doing to/doing for' the patient. Study participants experienced tension with regard to how best to spend precious "caring time'. Nursing resource was inextricably linked to both quantitative and qualitative expressions of nursing, and "being with' patients was a highly valued, under-allocated, and unintentionally provided component of nursing resource. The researcher concluded that nursing administrators, nurse managers and practitioners all have leadership roles to play in achieving recognition, allocation and promotion of caring time within their agencies.     

The primary care network--a new type of HMO for private practice physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year. Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah. This plan represents an attempt by physicians to control costs without government regulation.