Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part II: A Survey

Twenty-six rural California clinics have employed nurse practitioners (NP''s) or physician''s assistants (PA''s) to meet the primary health care needs of local communities. Of the 24 NP''s and 5 PA''s involved, 11 were men and 18 were women. Their average age was 37, and all but five were trained in California. The clinics, with less than 50 percent on-site physician supervision, averaged 19 miles in distance from the nearest physician (ranging up to 63 miles). More than half the clinics were satellites of central, physician-staffed, nonprofit clinics, a third were community-administered and two were private. Half served a whole community, a quarter were established to serve Indians and a quarter to serve Chicanos. Each NP or PA saw an average of 13 patients a day. All nonprivate clinics received subsidies from a variety of local, state and federal funds. Four of the clinics had closed or had no medical staff at the time of our survey.NP/PA clinics are proving to be a feasible and valuable means of offering essential health care needs to remote communities.     

Urinary Tract Infection/Vaginitis Protocol: Use in a Walk-in Clinic

A process, outcome and salary-cost analysis was made of the use of a urinary tract infection/vaginitis protocol. Three nurse practitioners, in a university-based, walk-in clinic, cared for 128 women presenting with complaints of dysuria or vaginal discharge, or both. There were no significant differences among the nurse practitioners in data collection, diagnostic accuracy or patient outcome. The diagnoses were correct in 92 percent, incorrect in 6 percent and indeterminate in 2 percent of the patients. Incorrect diagnoses were due to presumption of urinary tract infection in patients with the urethral syndrome or vaginitis. Of the patients, 78 percent were actually sent home without seeing a physician. Concordance with the nurse practitioners'' physical examination was 100 percent in those patients examined by a physician. In 82 percent of the patients there was alleviation of symptoms. Patient satisfaction with this method of care was extraordinary, with 98 percent of the patients giving favorable reports. True physician extension was achieved with a reduction in physician time per patient from 20 minutes to 6 minutes. In contrast to previously reported data, only a modest reduction in salary cost savings (10 percent) could be shown. The author concludes that nurse practitioners working in an acute care clinic or emergency department can see the patients defined in the study and provide high-quality care at a reasonable cost.     

Plastic surgeon's life: marvelous for mind, exhausting for body

Surgery is accepted as one of the most demanding professions that create both physical and mental strain on the performers. Therefore, the authors aimed to elucidate the mental burden of surgeons, which is dedicated to operative stress. They also tested the hypotheses that participating in surgery creates mental stress on surgeons that leads to cardiovascular changes, and that this stress is more pronounced for actual operators than for first assistants. The method chosen for this purpose was an analysis of heart rate variability. Twelve surgeons (five plastic surgery staff and seven plastic surgery residents) were monitored by a digital ambulatory Holter recorder on at least two occasions. Half of the recordings were carried out on operating days and the other half on office days. Heart rate variability indices (low frequency, high frequency, high frequency/low frequency ratio, and heart rate) were analyzed from those recordings using computerized research tool software. The heart rate variability indices of the operators showed statistically significant differences between operating days and office hours in favor of an increased sympathetic and decreased parasympathetic activity for the former. For first assistants, three of the parameters, with the exception of heart rate, changed in favor of a sympathetic predominance over parasympathetic activity; these changes were also statistically significant. These results showed a sympathetic hyperactivity for both operators and first assistants during the operations. When the sympathovagal balance of the actual operators was compared with that of assistants, the former group showed a more pronounced sympathetic arousal. This difference is accepted as a proof for the mental stress of the surgery being the main factor responsible for the sympathetic hyperactivity that we detected during the operations. Surgeons continuously face a unique mental strain that other professions rarely bring forth, and these psychological stressors are associated with alterations in cardiac autonomic control that may contribute to the development of cardiac disease. Prolonged sympathetic hyperactivity could anticipate cardiac discomfort in more experienced surgeons with marginal cardiac reserve. Such cardiac diseases would be reconsidered as occupation-related illnesses, which might be reimbursed to the physician. In addition, the legal responsibility of surgeons concerning their unfavorable results might be assessed with more understanding with a realization of their undue working conditions.     

Anticonvulsant teratogenesis 4: inter-rater agreement in assessing minor physical features related to anticonvulsant therapy

BACKGROUND: We report on inter-rater agreement in the assessment of newborn infants with respect to a range of minor physical features in a cohort study of the fetal effects of maternal anticonvulsant use during pregnancy. METHODS: Infants from three groups (exposed to anticonvulsants, seizure history but no medication exposure, and unexposed controls) were examined by both a pediatrician/teratologist, who was blinded with respect to the mother's exposure status, and an unblinded research assistant. Agreement on assessments for selected anomalies associated with anticonvulsant therapy was measured by kappa-statistics, as well as by more sensitive log-linear modeling techniques, which allow examination of possible covariate effects on the strength of agreement. Although the physician and research assistant agreed on a high proportion of cases (80-90%), kappa values were modest (0.2-0. 5), partly because of the low prevalence of the anomalies considered. To explore how agreement varies within subgroups, we used recently developed methods for studying agreement based on log-linear models. RESULTS: Log-linear modeling indicated that there was substantial variation in pattern of agreement between different individual research assistants but that other factors (e.g., exposure category, sex, and birthweight) did not appear to be related to agreement. Our results suggest that research assistants with more experience showed the highest degree of agreement with the physicians. CONCLUSIONS: Our results have implications for both clinical practice and epidemiologic research and underline the importance of thorough training of staff in the definitions to be used and also the need for multiple independent assessments of these subtle anomalies.     

The financial environment of aesthetic surgery: results of a survey of plastic surgeons

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.     

Transgender Care by Endocrinologists in the United States

Objective: Little is known about the attitudes and practice patterns of transgender care by endocrinologists. The objective of this study was to assess the knowledge, practice patterns, access, and competency among a representative sample of endocrinologists in the mid-Atlantic region of the United States.Methods: An anonymous 19-item paper survey was administered to 80 conference attendees that included 61 adult endocrinologists, 13 endocrinology fellows, 2 pediatric endocrinologists, and 4 nurse practitioners/physician assistants.Results: The participation rate was estimated to be ~80%. Sixty-three percent of endocrinology providers were willing to provide transgender care, but the majority of providers had no current transgender patients under their care. Half of providers had read the Endocrine Society's clinical practice guidelines, with a rate of 70% among those under age 40. Nonetheless, only 20% were “very” comfortable in discussing gender identity and/or sexual orientation, and 41% described themselves as “somewhat” or “very” competent to provider transgender care.Conclusion: Endocrinologists and other providers have received more education and training on transgender care within the past decade. Nevertheless, many participants have had little opportunity to care for transgender patients, and they rate their competency to do so as low. Research is needed on how to increase comfort levels regarding gender identity among those who provider care to transgender patients.     

Focus: Sex and Gender Health: Patient Preference for Physician Gender in the Emergency Department

Despite historical gender bias against female physicians, few studies have investigated patients’ physician gender preference in the emergency department (ED) setting. We sought to determine if there is an association between ED patient demographics and physician gender preference. We surveyed patients presenting to an ED to determine association between patient demographics and patient physician gender preference for five ED situations: 1) ‘routine’ visit, 2) emergency visit, 3) ‘sensitive’ medical visit, 4) minor surgical/‘procedural’ visit, and 5) ‘bad news’ delivery. A total of 200 ED patients were surveyed. The majority of ED patients reported no physician gender preference for ‘routine’ visits (89.5 percent), ‘emergent’ visits (89 percent), ‘sensitive’ medical visits (59 percent), ‘procedural’ visits (89 percent) or when receiving ‘bad news’ (82 percent). In the setting of ‘routine’ visits and ‘sensitive’ medical visits, there was a propensity for same-sex physician preference.     

Staff attitudes to oral health care. A comparative study of registered nurses,nursing assistants and home care aides

This study compares differences in attitude, of oral health care of nursing personnel working with dependent elderly and severely disabled patients. A questionnaire was administered to 398 personnel covering (1) personal oral health care habits. (2) experiences and attitudes in assisting oral care and (3) willingness to assist patients/residents with their daily oral hygiene. Three hundred and sixty - four persons answered the questionnaire, including 70 registered nurses, 148 nursing assistants and 146 home care aides. The study revealed that oral care assistance is viewed as more disagreeable than other nursing activities. Although registered nurses were found to have more positive attitudes toward oral care assistance than the other nursing groups, they were seldom invoked in the daily practice of oral hygiene care. The results indicate a gap between knowledge and practice in nursing personnel's attitudes toward oral health care of dependent elderly and severely disabled patients.     

The impact of provider flexibility and capacity allocation on the performance of primary care practices

The two important but often conflicting metrics for any primary care practice are: (1) Timely Access and (2) Patient-physician Continuity. Timely access focuses on the ability of a patient to get access to a physician (or provider, in general) as soon as possible. Patient–physician continuity refers to building a strong or permanent relationship between a patient and a specific physician by maximizing patient visits to that physician. In the past decade, a new paradigm called advanced access or open access has been adopted by practices nationwide to encourage physicians to “do today’s work today.” However, most clinics still reserve pre-scheduled slots for long lead-time appointments due to patient preference and clinical necessities. Therefore, an important problem for clinics is how to optimally manage and allocate limited physician capacities as much as possible to meet the two types of demand—pre-scheduled (non-urgent) and open access (urgent, as perceived by the patient)—while simultaneously maximizing timely access and patient–physician continuity. In this study we adapt ideas of manufacturing process flexibility to capacity management in a primary care practice. Flexibility refers to the ability of a primary care physician to see patients of other physicians. We develop generalizable analytical algorithms for capacity allocation for an individual physician and a two physician practice. For multi-physician practices, we use a two-stage stochastic integer programming approach to investigate the value of flexibility. We find that flexibility has the greatest benefit when system workload is balanced, when the physicians have unequal workloads, and when the number of physicians in the practice increases. We also find that partial flexibility, which restricts the number of physicians a patient sees and thereby promotes continuity, simultaneously succeeds in providing high levels of timely access.     

Expert Roundtable on Continuous Glucose Monitoring

ObjectiveThe objective of this study was to define an expert opinion on continuous glucose monitoring (CGM) in persons with type 2 diabetes mellitus, including its advantages, barriers, and best clinical practices for initiation, patient-clinician communication, and data management.MethodsA series of virtual discussions was held to recommend improvements to clinical practice and design clinical tools for primary care clinicians. Participants included endocrinologists, primary care physicians, physician assistants, advanced practice nurses, and diabetes care and education specialists.ResultsThe expert panels recommended CGM as a supplement to blood glucose monitoring and hemoglobin A1c for managing diabetes in persons with diabetes (PWDs). CGM can help predict potential pitfalls in glycemic management, including hypo and hyperglycemic excursions, which directly influence lifestyle changes, medication initiation, and dosing decisions. A toolkit was designed with practical guidance on the integration of CGM into clinical practice, interpretation of results, clinical guidelines, a patient action plan, and other useful management tools.ConclusionThis review summarizes the findings from a roundtable discussion with endocrinology and primary care clinicians, a discussion of the advantages and challenges of CGM, and clinical approaches to improving the care of PWDs. CGM offers more detailed tracking of glucose levels than blood glucose monitoring or hemoglobin A1c, and it can detect asymptomatic hypoglycemia. Specialized education of providers, the cost to patients and providers, and data management are barriers to the widespread adoption of CGM for PWDs.     

Prevalence of HBsAg and anti HBs in hospital personnel

Of the 473 employees of a Prague hospital, examined for the presence of hepatitis B surface antigen (HBsAg) and the antibody to it (anti HBs), 23 (4.9%) were shown to have the antigen and 88 (18.6%) to have the antibody. No differences were found in the prevalence of HBsAg and anti HB according to sex and age, but the percentage of persons with antibodies increased with increasing length of occupation. Significantly higher levels of antibodies were found in persons having direct contact with the patients or their excretions (nurses, laboratory assistants). Positive serological findings were more frequent in employees with a history of falling ill with hepatitis after entering employment in the health services than in persons without this history. In the serological evidence of hepatitis B according to work place, those working in biochemical and haematological laboratories and in the blood transfusion department took first place, followed by persons employed in medical and surgical departments.     

Lipoplasty claims experience of U.S. insurance companies

An analysis of medical liability claims for lipoplasty (liposuction) from January of 1985 through June of 1998 compared the insurance industry experience of plastic surgeons with that of other physicians. The Data Sharing Project database of the Physician Insurers Association of America, a trade association of professional liability companies owned and operated by medical professionals that collectively insure approximately 60 percent of America's private practice physicians, was queried. Of the nearly 45,000 total entries in the database, 292 were claims for adverse events related to lipoplasty or liposuction. These raw data were stratified by physician specialty, severity of complication, practice location, patient gender, indemnity payment, and other insurance industry-relevant variables.To simplify interspecialty comparisons, we normalized the claims rate to incidents per 100 insured physicians. The indexed lipoplasty claims rate was 3.0 per 100 insured plastic surgeons and 4.1 for other surgeons; the indexed lipoplasty claims rate for nonsurgical specialists was 2.5 per 100 insured dermatologists and 2.3 for other nonsurgeons. The higher claims rate for surgeons most likely reflects the wider scope of full-service aesthetic surgery performed by surgical specialists. Nearly two-thirds of claims (65.4 percent) during the 13-year survey period were the result of hospital-based lipoplasty; 20.9 percent were office-based claims. The prevalence of hospital-based claims may be a consequence of both historical bias introduced by hospital-based specialty surgery in the early years and prudent patient safety considerations during performance of complex or prolonged procedures in more recent years.Two-thirds of the claims (67 percent) arose from informed-consent or breach-of-contract issues, far higher than the 26 percent aggregate claims norm. The mean indemnity payment was $94,534 per lipoplasty claim; claims paid against board-certified specialists averaged $83,350. Consistent with national lipoplasty demographics, 87 percent of claims were brought by women and 13 percent were brought by men. Seven fatalities (three women and four men) were noted; cause of death is not recorded in this type of database.     

Realities of diagnosing Helicobacter pylori infection in clinical practice: a case for non-invasive indirect methodologies.

BACKGROUND: The current, arbitrarily defined gold standard for the diagnosis of H. pylori infection requires histologic examination of two specially stained antral biopsy specimens. However, routine histology is potentially limited in general clinical practice by both sampling and observer error. The current study was designed to examine the diagnostic performance of invasive and non-invasive H. pylori detection methods that would likely be available in general clinical practice. METHODS: The diagnostic performance of rotating clinical pathology faculty using thiazine staining was compared with that of an expert gastrointestinal pathologist in 38 patients. In situ hybridization stains of adjacent biopsy cuts were also examined by the expert pathologist for further comparison. Receiver operator characteristic (ROC) analysis was performed to evaluate whether the diagnostic performance of the expert pathologist differed depending upon the histologic method employed. A similar analysis was made to evaluate the diagnostic performance of pathology trainees relative to the expert. In the absence of an established invasive gold standard, non-invasive testing methods (rapid serum antibodies, formal Elisa antibodies and carbon-14 urea breath testing) were evaluated in 74 patients by comparison with a gold standard defined using a combination of diagnostic tests. RESULTS: Using either rapid urease testing of biopsy specimens or urea breath testing as the gold standard for comparison, the diagnostic performance of the rotating clinical pathology faculty was inferior to that of the expert gastrointestinal pathologist especially with regard to specificity (e.g., 69 percent for the former versus 88 percent, with the latter relative to rapid urease testing). Although interpretation of in situ hybridization staining by the expert appeared to have an even higher specificity, ROC analysis failed to show a difference. The mean ROC areas for thiazine and in situ hybridization staining for trainee pathologists relative to the expert were 0.88 and 0.94, respectively. In untreated patients, urea breath testing had a sensitivity and specificity of 100 percent as compared with thiazine staining with a sensitivity of 83 percent and a specificity of 97 percent. Post-therapy, breath testing had a sensitivity of 100 percent but a specificity of only 86 percent as compared with invasive testing with a sensitivity and specificity of 100 percent. Rapid serum antibody testing and formal Elisa antibody testing agreed in 93 percent of cases (Kappa 0.78) with the rapid test being correct in three of the four disagreements. CONCLUSIONS: The current study illustrates a number of realities regarding H. pylori diagnosis. There is no diagnostic gold standard in general clinical practice. Accurate interpretation of specially stained slides is a learned activity with a tendency towards overdiagnosis early on. Urea breath testing is likely to be the diagnostic method of choice for untreated patients in general clinical practice although antibody testing is almost as accurate. Rapid antibody tests are at least as accurate as formal Elisa antibody tests. Urea breath testing is useful for confirming cure after therapy, but false-positive results may occur in some patients.     

Assessment of physician performance in Alberta: the Physician Achievement Review

The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years.     

Routine HIV Testing among Providers of HIV Care in the United States, 2009

In 2006, CDC recommended HIV screening as part of routine medical care for all persons aged 13–64 years. We examined adherence to the recommendations among a sample of HIV care providers in the US to determine if known providers of HIV care are offering routine HIV testing in outpatient settings.Data were from the CDC''s Medical Monitoring Project Provider Survey, administered to physicians, nurse practitioners and physician assistants from June-September 2009. We assessed bivariate associations between testing behaviors and provider and practice characteristics and used multivariate regression to determine factors associated with offering HIV screening to all patients aged 13–64 years.Sixty percent of providers reported offering HIV screening to all patients 13 to 64 years of age. Being a nurse practitioner (aOR = 5.6, 95% CI = 2.6–11.9) compared to physician, age<39 (aOR = 1.9, 95% CI = 1.0–3.5) or 39–49 (aOR = 2.1, 95% CI = 1.4–3.3) compared with ≥50 years, and black race (aOR = 2.6, 95% CI = 1.2–6.0) compared with white race was associated with offering testing to all patients. Providers with low (aOR = 0.2, 95% CI = 0.1–0.3) or medium (aOR = 0.4, 95% CI = 0.2–0.6) HIV-infected patient loads were less likely to offer HIV testing to all patients compared with providers with high patient loads.Many providers of HIV care are still conducting risk-based rather than routine testing. We found that provider profession, age, race, and HIV-infected patient load were associated with offering HIV testing. Health care providers should use patient encounters as an opportunity to offer routine HIV testing to patients as outlined in CDC''s revised recommendations for HIV testing in health care settings.     

Midlevel Personnel in Obstetrics and Gynecology Practices: Cost-Effectiveness and Consumer Benefits

Two private obstetrics-gynecology practices, in adjacent Northwest cities, which employ midlevel nurse practitioners for routine obstetric and gynecologic care were the subject of this study. At site A fees charged by the practitioner were 44 percent less than those for identical services provided by the physician. This was an attempt to pass cost savings directly to patients. At site B, fees were the same for both physician and practitioner, yielding a significant net income to the practice. At this latter site a proportion of the income was passed to patients by not increasing office fees for the years 1975 (when the practitioner was hired) through 1977, during which time the average fees of ten other physicians increased. The study shows that the use of midlevel personnel in private offices is highly cost-effective and profitable. Ideally, this profit can be passed on to patients by reduced overall office fees.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Early detection of ovarian cancer: preliminary results of the Yale Early Detection Program.

Eighty-four women at high risk for ovarian cancer by having first-degree relatives with epithelial ovarian cancer participated in a newly established, early ovarian cancer detection program at Yale University. Participants were to be evaluated with physical examinations and circulating tumor markers at entry and every six months thereafter. Endovaginal ultrasound and color Doppler flow studies were to be performed at three and nine months following entry into the program. In addition, women were encouraged to follow American Cancer Society guidelines for mammography. Stool was checked for occult blood. Endometrial sampling was offered to post-menopausal women. No participant has developed an ovarian cancer since entering the program. One woman has been diagnosed to have breast cancer. False-positive levels of circulating tumor markers (CA 125, 4/84 [4.8 percent]; lipid-associated sialic acid in plasma, 13/84 [15.5 percent]; NB/70K, 4/84 [4.8 percent]; and urinary gonadotropin fragment, 1/65 [1.5 percent]) were observed on entry into the program. Low resistive indices (less than 0.5) were documented in 8/91 (8.8 percent) ovaries studied by the color Doppler flow technique. One participant underwent a laparotomy based on a false-positive endovaginal ultrasound examination. Tests now being employed in community practice have a high likelihood of being associated with false-positive results. Therapeutic interventions based on isolated abnormal tumor markers or ultrasound studies obtained from women with family histories of ovarian cancer may lead to inappropriate surgery. It is necessary for cancer centers to develop expertise in ovarian cancer detection techniques to advise physicians in their geographic areas appropriately about the significance of the abnormal screening test.     

Physician time-saving by employment of expanded-role nurses in family practice

Registered nurses working in five family practices in Kingston, Ontario, were given a period of in-service training and supplementary formal instruction at Queen''s University to expand their skills and enable them to undertake prescribed procedures in the physicians'' offices. Operational data collected from the five practices before and after training was analysed to assess the saving of physician time effected by the expansion of the nurses'' activities in providing primary medical care. Physician time was saved in all cases but the amount varied. The results are presented and discussed in relation to staff, physical premises and patterns of practice of the participating physicians. Under the most advantageous practice circumstances in this study, a 33.7% saving in original physician time was obtained. The mean time-saving for the five practices was 18.2%.