Establishing a high-school-based training room clinic

Being a team physician can be a time-consuming commitment. The team physician is responsible for all aspects of the athlete's care and has the final say in all medical matters related to athletic participation. Primary care physicians are well suited to be team physicians. The training room is an outstanding way to increase physician availability to adolescents and underserved population. Setting up a training room must be planned in advance, including funding, supplies and liability. Most legal problems can be avoided with a contract and proper documentation. The school-based training room provides the physician with an excellent opportunity for community service and can be a very rewarding experience.     

Collaborative practice in primary care: Integrated training for psychologists and physicians.

Managed health care has forced psychologists and primary care physicians to expand their practices into areas for which they have traditionally lacked training or experience. This article describes a training program designed to foster collaboration and to bridge the gap between the 2 specialties by having psychology interns and medical residents comanage patients in a primary care setting under the joint preceptorship, of a psychologist and a physician. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Physician recommendations and patient autonomy: finding a balance between physician power and patient choice

Medical care in the United States has rapidly moved away from a paternalistic approach to patients and toward an emphasis on patient autonomy. At one extreme end of this spectrum is the "independent choice" model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician's exercise of power and influence inevitably diminishes the patient's ability to choose freely. It sacrifices competence for control, and it discourages active persuasion when differences of opinion exist between physician and patient. This paper proposes an "enhanced autonomy" model, which encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests. Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience.     

Integrating mental health services within primary care. A Canadian program

The increasingly prominent role of the family physician in delivering mental health care can be enhanced if productive and collaborative relationships can be established with local mental health services. This paper describes a Canadian program that has achieved this by bringing mental health counselors and psychiatrists into the offices of 87 family physicians in 35 practices in a community in Southern Ontario. The paper describes the program, the activities of counselors and psychiatrists within the practices, and the administrative structures set up to coordinate these activities. Data is presented from the evaluation of the first year of the program's operation (13 practices and 45 family physicians) during which time 3085 referrals were received. The program made mental health care more available and accessible, increased continuity of care, provided additional support for the family physician, offered new opportunities for continuing education, and led to a reduced and more efficient use of other mental health services. The components of the program can be adapted to most communities.     

Medical consultation for the elderly patient with hip fracture

BACKGROUND: This article describes a family physician geriatrician's perspective on the comprehensive management of hip fracture in frail elderly patients. Primary care physicians might be called upon to provide medical consultation for these patients. METHODS: Guidelines were developed by a combination of personal experience in consulting for several hundred elderly patients with hip fracture at a large community hospital, literature review using the key words "hip fractures," "aged," and "aged, 80 and over," and educational presentations for family practice residents. RESULTS AND CONCLUSIONS: Elderly patients with hip fracture offer a prime opportunity for comprehensive geriatric assessment. Intertrochanteric fractures are almost always treated with internal fixation, whereas femoral neck fractures can be treated by either fixation or by hemiarthroplasty. Hip fracture should be regarded as a surgical urgency, and generally operation should not be delayed, even if patients have serious comorbidity. The family physician can be instrumental in preparing the patient for surgery, preventing and treating complications, and assisting in the placement and rehabilitation of patients after hospital discharge.     

Factors determining the quality of physician performance in patient care

The study determined the separate and joint effects of 1) physician specialty, 2) type of medical school attended, 3) time in practice, 4) type of ambulatory care setting, and 5) type of hospital on the quality of physician performance in patient care. The sample consisted of 454 physicians in 18 specialty categories. Multiple Classification Analysis was used to determine the effects of these predictors on the quality of physician performance. The study found that the organization of hospital care had a large independent effect, but that the other four predictors had relatively small effects on the quality of physician performance. The findings imply that the organization of the setting in which care is provided has more influence than the education and training that physicians had attained. All five predictors together explained 20 per cent of the variance. Methodological suggestions were made to improve the explanatory power of the variables, and various pragmatic for medical care administrators were presented.     

The future supply of physicians

Many health services researchers point to a growing surplus of physicians by the end of the century. The author discusses in detail a variety of policy positions, from the Flexner Report onward, that have affected the present and projected supplies of U.S. physicians. These include the American Medical Association's decades of efforts to control the numbers and types of U.S. medical students; effects of Medicare and Medicaid; changes in immigration and naturalization laws that increased the number of international medical graduates (IMGs); the medical community's non-response to the 1981 GMENAC Report's forecasts on physician oversupply; growth in the numbers of specialists; the fall and subsequent rise in the numbers of applicants to medical schools; the changing composition of the physician workforce; the refusal of the medical profession to consider a shorter training period for physicians; and other events from the past that can inform today's policymakers. The author then evaluates four policy recommendations that have evolved to deal with the problem of physician oversupply, and concludes that (1) reliance on the market to contain physician supply is unwarranted; (2) there is little prospect that Congress will soon reduce the inflow of IMGs, and even if it did, such action would have a marginal effect; (3) there is no prospect that 20-25% of U.S. medical schools will be closed by 2005, since the forces militating against such action are overwhelming; and (4) it remains to be seen whether the new health care environment will have more than a marginal effect in altering the current ratio of primary care to specialist physicians in the years ahead. In fact, if future outlays for health care increase as predicted, there should be sufficient funds for physician supply to continue to grow and for specialists to continue to make good incomes.     

The local community as a life environment for the elderly--on the future role of the community in supporting the elderly

Current and recent internal medicine residents were surveyed on their level of confidence in practicing operational medicine, satisfaction with graduate medical education, the impact of TRICARE, the military managed care plan, on their patients and education, and intentions on remaining in uniformed service. Their sentiments were recorded on a five-point Likert scale (1 = strongly agree, 3 = neutral, 5 = strongly disagree). Two hundred twenty-one of the 294 surveys were returned (75.2%). Most physicians felt unprepared to perform duties in a nuclear, biological, or chemical warfare environment, or handle administrative aspects of operational medicine (mean scores, 3.2-3.7). A majority of respondents felt satisfied with the quality of their residency experience (mean score, 1.9). Although more than half of those surveyed (53.6%) listed the opportunity to teach residents as a top factor influencing their retention decision, most felt skeptical that graduate medical education would remain important in the future (mean score, 3.6). Most physicians agreed that restriction of TRICARE to patients less than 65 years old may degrade the quality of military internal medicine residencies (mean score, 1.6). Previous service, Reserve Officer Training Corps experience, and graduation from the Uniformed Services University of the Health Sciences were factors associated with increased physician intention to remain beyond their obligated service. The most common factors inducing physicians to leave the military included frequent deployments, relocations, and financial compensation. Factors cited most frequently as influencing physicians to stay on active duty included high-quality colleagues, opportunities for teaching residents, and freedom from malpractice and office management details.     

Evaluation of undergraduate medical education - why and how?

The education of physicians both at the undergraduate and graduate level is no longer a matter for an individual professor or department in a medical faculty. The curriculum has to be developed and carried out according to the needs of the society in which the physician is going to function. Evaluation of the educational programme by external reviewers should therefore be seen as a normal part of the quality control process of all medical faculties. The most important part of such an evaluation is the self-assessment performed by the faculty and the students; self-assessment, together with advice from the external reviewers, will constitute the basis for necessary curriculum changes.     

Congenital toxoplasmosis and seroconversion at the end of pregnancy: clinical observations

OBJECTIVE: To determine the knowledge of HIV-disease management and the adherence to contemporary guidelines among British Columbia physicians whose practices focused on HIV/AIDS. DESIGN: Self-administered mail survey. PARTICIPANTS: All 659 physicians registered in a province-wide HIV/AIDS drug treatment program. OUTCOME MEASURES: Data on demographic and personal characteristics of respondents, level of HIV-related experience, use of preventive vaccinations and tests, and preferred approaches to the prophylaxis and treatment of common opportunistic infections. Knowledge scores in 4 areas of patient care, as well as an overall score, were computed by comparing respondents' answers with the therapeutic strategies recommended at the time of the survey. Associations between physician characteristics and knowledge scores were identified by linear regression analysis. RESULTS: Of the 659 physicians surveyed, 65% returned responses: only 38% returned completed surveys while a further 27% returned a follow-up survey that asked nonrespondents about their demographic characteristics and HIV-related experience. Scores for specific areas of patient management ranged from 29% for the treatment of opportunistic infections to 62% for preventive measures, with a mean overall score of 47%. Physician knowledge in all areas of patient care was associated with the number of HIV-positive patients in the practice (p = 0.003 to p < 0.001). Physicians who were younger were more knowledgeable regarding preventive measures (p = 0.001); those whose practice location was in Vancouver had a greater knowledge of prophylaxis (p = 0.047); and those who had medical specialty training were more knowledgeable about the treatment of opportunistic infections (p = 0.009). CONCLUSIONS: There is substantial disparity in how physicians approach the management of HIV and related conditions. Deviations from therapeutic guidelines are common and may be associated with physician characteristics, particularly lack of experience in managing HIV.     

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.     

Apoptosis detection: an overview

As with women in general, the vicissitudes of the female physician who suffers from a substance use disorder have been understudied, and such persons remain underrepresented in treatment. The purpose of the present study is to describe the similarities and differences between female and male physicians presenting for assessment; 108 physicians in total were included in the study, 10 of whom were female. Demographically, we found that the female physicians were more likely to be single and younger than their male counterparts. On clinical indices, females showed less impairment on legal and medical functioning, and better capability in sustaining abstinence and eliminating environmental cues to relapse. Of the women with substance use disorders, higher rates of comorbidity were found than with males. Although there were no significant differences in overall severity, males were more likely to be recommended to more intensive levels of care for either substance use or psychiatric disorders. The female physicians were recommended to a level of care of a lower intensity, but more often to a treatment with a dual-diagnosis focus. These findings are discussed in terms of the vulnerabilities of the female physician, barriers to treatment, tailoring treatment to female needs, and opportunities for prevention and further research.     

The principal physician in emergency medicine

The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. Within the administration of the EMS system, he is responsible for the medical aspects of strategic planning for the MCI response. During the MCI the MCO is responsible for the overall assessment of the situation, triage, and supervision of medical treatment by physician and non-physician providers. Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.     

Medical records audit in primary care clinics of the Israel Navy

The primary care clinics of the Israeli Defense Forces are similar to those of the civilian health system, yet some characteristics are unique: Soldiers are a young, healthy population; their physicians are either serving in the reserves for short periods, or are primary care physicians of the regular army; and during military service the soldier is usually treated in several different primary care clinics. A detailed medical record facilitates communication between the various primary care physicians. As part of a 2-year quality assurance project all naval clinics in Israel were surveyed at 6-month intervals. From the clinic records, 685 encounters involving the 7 most common problems were randomly chosen. We evaluated the quality of the medical records of these encounters scoring them according to subjective, objective assessment and therapeutic and evaluative plan (SOAP) Each record was evaluated by 2 physicians and scored from 0 to 100, using fixed criteria. The score for the therapeutic and evaluative plan was significantly higher than that of the other parts of the medical record (80% vs. 55-59%, p < 0.001). The score of the primary care physicians was significantly higher than that of physicians of the reserves (73% vs. 63%, p < 0.001). Encounters involving upper respiratory tract infections and abdominal pain scored higher than those involving other common problems. The medical recording process has a fundamental role in medical care. Our findings suggest that the subjective, objective and assessment parts of naval medical records need improvement. Further studies might help improve the quality of primary medical care.     

Nutrient Intake Report: a coordination of patient dietary assessment between physicians and registered dietitians

The Nutrient Intake Report (NIR) is based on a 7-day dietary recall questionnaire used previously in research for dietary assessment and adapted for clinical use. Used to provide information and counseling as part of total patient care, the NIR acts as a cornerstone for dietary education and interaction between physician, registered dietitian, and patient. The NIR is ordered by physicians or registered dietitians, scanned and assessed by a registered dietitian, and incorporated into the laboratory section of the medical record. It documents the patient's dietary intake in the context of his or her diagnosis and general health status. The NIR also opens a dialogue between physicians and registered dietitians. Incorporation of the NIR into the medical record makes the work of the registered dietitian available to other health practitioners, which is welcome in an era when licensing and reimbursement are contingent on systematic documentation of dietary assessment and its role in patient care.     

The political agenda of health care for African Americans

Health care reform presents both challenges and opportunities for African Americans. On the one hand, reform could result in the closure of black medical institutions and fewer black physicians. On the other hand, reform gives African Americans an opportunity to bargain for available resources to gain equality in health care services. To this end, the Volunteer State Medical Association has been involved in state health care reform. Its goals are to resolve the current financial crisis at black medical institutions; to assist in the survival and development of local black managed care organizations; to assure that all licensed black physicians have continued access to patients; and to develop black-owned health-related businesses. The association has formed the Tennessee Coalition for Quality Health Care, a group of African American politicians, physicians, educators, and health care administrators who can negotiate with state and federal officials in the issue of health care reform.     

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.     

The aesthetes of chitons. III. Shell surface observations

The federal legislation mandating Professional Standards Review Organizations to monitor the decision making of physicians regarding their patients is a method unique to the United States to control medical care costs according to prevailing professional criteria. Other countries, so far, depend largely on health service structures, reimbursement methods, and arbitrary government budget limitations. Our dislike of highly structured delivery systems has pragmatically moved us in the direction of monitoring diagnostic and therapeutic decision making. PSRO is mandated at a time when there is no systematic methodology with validated criteria for monitoring medical practice. This will likely lead to subtle sabotage of PSRO by the medical profession justified by quality standards which are the professions' prerogative. It is conceivable that quality standards will rise and, therefore, costs. The drive for monitoring physician decision making is understandable even when there is no methodology. It then behooves medical schools to conduct research on methodologies of monitoring services, a possible favorable side-effect of the legislation. An unfavorable side-effect may likely be that the criteria will be based exclusively on technical medical considerations and ignore the personal and social attributes of patients which should affect the decision making of physicians. Medicine will then become even more technocratic than it is now. All countries are converging at various degrees of intensity in establishing planned limits to expansion, examining possibilities of monitoring physician decision making and capping this off with arbitrary budget ceilings. The state of the art of health services management appears to permit no other recourse.     

The role for regional autopsy centers in the evaluation of covered deaths. Survey of opinions of US and Canadian chairs of pathology and major health insurers in the United States

OBJECTIVE: To evaluate the advantages and disadvantages of, as well as the attitudes of health care professionals and insurers toward, the development of regional autopsy services. DESIGN: Survey of 150 medical school departments of pathology in the United States and Canada and 12 representative major health insurers in the United States. RESULTS: Of the 25 respondents from the pathology departments, most were in favor of regionalization of autopsy services, if properly underwritten. Of the five respondents from the health insurers, most were disinterested in the autopsy as a measure of outcome and unwilling to provide support. CONCLUSIONS: Health care is being regionalized around networks of insurers rather than hospitals. The networks are defined by a mixture of hospitals, physician groups, and other health care professionals. Within networks, the goal is to subscribe groups of patients, covered lives, for all medical needs from primary to complex care. As the economic risk of caring for patients is shifted to physicians, the incentive to provide service at the lowest possible cost grows, as does the need to assure that medical mismanagement does not occur. To provide quality care at affordable costs, it is necessary that outcomes, including deaths, be professionally evaluated. The present system of death investigation involves hospital colleagues and is potentially biased. Regional autopsy centers that provide timely expert information should be part of the health care system. Medical schools are potential sites for regional autopsy programs because they have the personnel needed to conduct appropriate death-related studies. Most schools are affiliated programmatically and economically with surrounding hospitals and physicians in a manner in which outcomes, costs, and quality of clinical service are of common interest.     

Signal-averaged electrocardiography in elderly subjects with and without heart disease

Despite a high level of support for the importance of clinical prevention, physician delivery of preventive services falls well below recommended levels. Competing demands faced by physicians during the medical encounter present a major barrier to the provision of specific preventive services to patients. These demands include acute care, patient requests, chronic illnesses, psychosocial problems, screening for asymptomatic disease, counseling for behavior change, other preventive services, and administration and management of care. This paper outlines how competing demands affect physician delivery of clinical preventive services and provides a model designed to help practicing physicians improve the delivery of preventive services. This model can be helpful in the planning of preventive interventions in primary care settings and can facilitate a better understanding of physician behavior.