The impact of greed on academic medicine and patient care

To what extent is the increasing emphasis on profit generation at US academic institutions shackling intellectual freedom and compromising healthcare?     

The impact of hissy fits in primary care

BACKGROUND: Hissy fits are experienced by physicians and patients alike, yet their full impact has never been studied before. METHODS: Specially trained researchers observed hissy fits at a clinic over 12 months. They interviewed perpetrators, victims and witnesses and recorded their comments because they had to. RESULTS: Hissy fits were common at the clinic and sometimes escalated to riots. Seasonal variations were endured. INTERPRETATION: Nobody likes this behaviour. Efforts should be made to counsel hissy fitters in channeling their angst in other, more positive ways.     

Greater weight loss and hormonal changes after 6 months diet with carbohydrates eaten mostly at dinner

This study was designed to investigate the effect of a low-calorie diet with carbohydrates eaten mostly at dinner on anthropometric, hunger/satiety, biochemical, and inflammatory parameters. Hormonal secretions were also evaluated. Seventy-eight police officers (BMI >30) were randomly assigned to experimental (carbohydrates eaten mostly at dinner) or control weight loss diets for 6 months. On day 0, 7, 90, and 180 blood samples and hunger scores were collected every 4 h from 0800 to 2000 hours. Anthropometric measurements were collected throughout the study. Greater weight loss, abdominal circumference, and body fat mass reductions were observed in the experimental diet in comparison to controls. Hunger scores were lower and greater improvements in fasting glucose, average daily insulin concentrations, and homeostasis model assessment for insulin resistance (HOMA(IR)), T-cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) levels were observed in comparison to controls. The experimental diet modified daily leptin and adiponectin concentrations compared to those observed at baseline and to a control diet. A simple dietary manipulation of carbohydrate distribution appears to have additional benefits when compared to a conventional weight loss diet in individuals suffering from obesity. It might also be beneficial for individuals suffering from insulin resistance and the metabolic syndrome. Further research is required to confirm and clarify the mechanisms by which this relatively simple diet approach enhances satiety, leads to better anthropometric outcomes, and achieves improved metabolic response, compared to a more conventional dietary approach.     

Methodological problems of training epidemiologists at institutes for physician advanced training

The system of raising the qualification of epidemiologists at the chair of epidemiology of the Kiev Institute for Advanced Medical training is described.     

The role of the primary care physician in the management of bladder dysfunction

Urinary incontinence is a major health challenge for primary care physicians. Unfortunately, the majority of incontinent patients remain untreated. Primary care physicians are ideally positioned to screen for and manage urinary incontinence. A knowledge of basic micturition physiology is important for the physician to accurately identify the cause of incontinence and arrive at the correct treatment course. To this end, this article reviews the physiology of the lower urinary tract, describes the clinical types of urinary incontinence, and outlines a stepwise approach for the primary care physician to the basic evaluation and management of patients with this condition.     

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians'' management of patients'' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians'' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians'' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients'' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.     

The legal assault on physician—patient privilege

Can there be appropriate and just disclosure of medical and therapeutic records, given that such records are defined and acted upon quite differently in the arenas of law and health? Medical and therapeutic records are kept for healing purposes, not as findings of fact for a court. However, Canadian courts increasingly are being asked to disregard privilege between doctor and patient when that patient has reported a sexual assault. The Supreme Court will soon rule in two cases that may change policies and laws and affect Canadian physicians, other health care professionals and hospitals.     

Implications of the human genome initiative for the primary care physician

... Despite the need for physicians to be knowledgeable about and open to advances in genetic technology, little is known about the level of preparedness of primary care physicians to offer new genetic tests. Evidence suggests that several barriers exist to physicians adopting genetic tests. These include lack of knowledge, inability to interpret probabilistic information, low tolerance for uncertainty, negative attitudes about their responsibility for genetic counseling and testing, lack of confidence in their clinical skills, and unfamiliarity with ethical issues raised by testing. This paper will explore some of these barriers in further depth, discuss the ethical impact of physician unpreparedness on both patient care and the diffusion of genetic tests, and describe a study that is currently underway to investigate some of these issues.     

The effect of training in reduced energy density eating and food self-monitoring accuracy on weight loss maintenance

Background: Failure to maintain weight losses in lifestyle change programs continues to be a major problem and warrants investigation of innovative approaches to weight control. Objective: The goal of this study was to compare two novel group interventions, both aimed at improving weight loss maintenance, with a control group. Methods and Procedures: A total of 103 women lost weight on a meal replacement‐supplemented diet and were then randomized to one of three conditions for the 14‐week maintenance phase: cognitive‐behavioral treatment (CBT); CBT with an enhanced food monitoring accuracy (EFMA) program; or these two interventions plus a reduced energy density eating (REDE) program. Assessments were conducted periodically through an 18‐month postintervention. Outcome measures included weight and self‐reported dietary intake. Data were analyzed using completers only as well as baseline‐carried‐forward imputation. Results: Participants lost an average of 7.6 ± 2.6 kg during the weight loss phase and 1.8 ± 2.3 kg during the maintenance phase. Results do not suggest that the EFMA intervention was successful in improving food monitoring accuracy. The REDE group decreased the energy density (ED) of their diets more so than the other two groups. However, neither the REDE nor the EFMA condition showed any advantage in weight loss maintenance. All groups regained weight between 6‐ and 18‐month follow‐ups. Discussion: Although no incremental weight maintenance benefit was observed in the EFMA or EFMA + REDE groups, the improvement in the ED of the REDE group's diet, if shown to be sustainable in future studies, could have weight maintenance benefits.     

A survey of physician attitudes and practices concerning cost-effectiveness in patient care

Objective To identify physicians'' views regarding cost-containment and cost-effectiveness and their attitudes and experience using cost-effectiveness in clinical decision making. Design A close-ended 30-item written survey. Subjects 1,000 randomly selected physicians whose practices currently encompass direct patient care and who work in the California counties of Sacramento, Yolo, Placer, Nevada, and El Dorado. Outcome measures Physician attitudes about the role of cost and cost-effectiveness in treatment decisions, perceived barriers to cost-effective medical practice, and response of physicians and patients if there are conflicts about treatment that physicians consider either not indicated or not cost-effective. Results Most physicians regard cost-effectiveness as an appropriate component of clinical decisions and think that only the treating physician and patient should decide what is cost-worthy. However, physicians are divided on whether they have a duty to offer medical interventions with remote chances of benefit regardless of cost, and they vary considerably in their interactions with patients when cost-effectiveness is an issue. Conclusion Although physicians in the Sacramento region accept cost-effectiveness as important and appropriate in clinical practice, there is little uniformity in how cost-effectiveness decisions are implemented.The rising cost and the equitable distribution of health care resources are important social and political issues. A major contributor to cost inflation is the enormous capacity of biomedical science to create new and costly medical interventions.^1,2 Whereas purchasers—primarily employers and government—resist increases in health care premiums and reimbursements, physicians, medical groups, and health plans face legal, regulatory, and social pressures to provide all care that is “medically necessary.”^3,4Reconciling the tension between finite resources and ever-increasing demands is not easy. One approach is for physicians to use cost-effectiveness as an explicit criterion when developing clinical policies applicable to broad populations or when considering treatment alternatives for individual patients.^5,6 Although using cost-effectiveness criteria to develop clinical policies (eg, drug formularies or practice guidelines) has long been considered an appropriate physician role,^7,8 limiting marginally beneficial and costly interventions for individual patients is controversial.^{9,10,11,12,13} The literature on the cost-effectiveness of medical interventions is growing, but little is known about how physicians incorporate cost-effectiveness decisions at the bedside.To explore the acceptability of explicitly incorporating cost-effectiveness into clinical and coverage decisions, a regional 15-member consortium (listed at the end of article) created the Visible Fairness project. Its goal is to develop recommendations that reflect consumer and provider values, interests, and concerns regarding cost-effectiveness. The first component of Visible Fairness was a written survey of local physicians seeking their views on 3 principal issues: cost containment and the role of physicians in providing cost-effective care, barriers to practicing cost-effective medicine, and experience with patients who insist on treatment that is viewed as not cost-effective.     

The impact of health care advice given in primary care on cardiovascular risk. CELL Study Group.

OBJECTIVE--To evaluate the additional benefit of "intensive" health care advice through six group sessions, compared with the advice usually offered to subjects with multiple risk factors for cardiovascular disease. DESIGN--Prospective, randomised controlled clinical study lasting 18 months. SETTING--681 subjects aged 30-59 years, with at least two cardiovascular risk factors in addition to moderately high lipid concentrations: total cholesterol > or = 6.5 mmol/l on three occasions, triglycerides < 4.0 mmol/l, and ratio of low density lipoprotein cholesterol to high density lipoprotein cholesterol > 4.0. Most (577) of the subjects were men. MAIN OUTCOME MEASURE--Percentage reduction in total cholesterol concentration (target 15%); quantification of the differences between the two types of health care advice (intensive v usual) for the Framingham cardiovascular risk and for individual risk factors. RESULTS--In the group receiving intensive health care advice total cholesterol concentration decreased by 0.15 mmol/l more (95% confidence interval 0.04 to 0.26) than in the group receiving usual advice. The overall Framingham risk dropped by 0.068 more (0.014 to 0.095) in the group receiving intensive advice, and most of the risk factors showed a greater change in a favourable direction in this group than in the group receiving usual advice, but the differences were seldom significant. The results from questionnaires completed at the group sessions showed that the subjects improved their lifestyle and diet. CONCLUSION--Limited additional benefit was gained from being in the group receiving the intensive health care advice. It is difficult to make an important impact on cardiovascular risk in primary care by using only the practice staff. Better methods of communicating the messages need to be devised.     

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.