Factors influencing family physicians to continue providing obstetric care.

To determine the reasons some family physicians continue to practice obstetrics when most of their colleagues do not, we surveyed family physicians in 26 counties of northern California whose practices include obstetrics and those who have recently discontinued it. In all, 70% of family physicians practicing obstetrics cited enjoying it as a reason for continuing this practice. Over a third of family physicians practicing obstetrics thought that obstetric practice was a responsibility to the community. Only 1 in 6 reported obstetrics to be important in terms of financial implications. Despite this, family physicians practicing obstetrics had a mean gross income derived from obstetric practice of $30,000 above the cost of their total malpractice premium. In contrast, a comparison group of family physicians who had recently discontinued obstetrics cited malpractice insurance costs most frequently as the reason for discontinuing it. Nearly 40% of these physicians indicated that they would be willing to return to obstetrics if circumstances were to change substantially. The most frequently cited change necessary for these physicians to return to obstetrics was a reduction in malpractice insurance rates.     

Preventive attitudes,beliefs, and practices of physicians in fee-for-service and health maintenance organization settings.

To identify the self-reported differences in preventive practices, attitudes, and beliefs of physicians practicing in fee-for-service (FFS) and health maintenance organization (HMO) settings, we surveyed a 100% sample of primary care physicians practicing in a large, urban, closed-panel HMO and a random sample of physicians, in the same county, who were in an FFS practice. The FFS physicians were more likely to consider behavioral risk factors important than were HMO physicians, and they were more likely to ask their patients about behavioral risk factors. Fee-for-service physicians were more likely than HMO physicians to use continuing medical education courses to upgrade their skills in modifying behavioral risk factors. There was little difference in the self-reported proportion of patients with specific behavioral risks in the FFS and HMO practices. Also, both groups were comparable in their perception of their ability to do behavioral counseling and their perceived success in such counseling. We conclude that FFS physicians are more likely to have positive preventive beliefs, attitudes, and practices than are HMO physicians.     

Effect of incentives on the use of indicated services in managed care

In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services.     

The Ethical and Legal Framework for the Decision Not to Resuscitate

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.     

Managing low back pain--a comparison of the beliefs and behaviors of family physicians and chiropractors.

Random samples of 605 family physicians and 299 chiropractors in Washington were surveyed to determine their beliefs about back pain and how they would respond to three hypothetic patients with back pain. With 79% of the family physicians and 70% of the chiropractors responding, family physicians and chiropractors differed greatly not only in their technical approaches to back pain--such as drug therapy versus spinal manipulation--but also in their underlying beliefs and attitudes. Family physicians think that most back pain is caused by muscle strain, that lumbosacral radiographs are rarely useful, that appropriate therapy does not depend on a precise diagnosis, and that back pain will usually resolve within a few weeks without professional help. Family physicians were more likely than chiropractors to feel frustrated by patients with back pain, less likely to think they can help patients prevent future episodes of back pain, and less confident that their patients are satisfied with their care. Studies are needed to determine whether the different perspectives of family physicians and chiropractors are associated with differences in the costs and outcomes of care.     

An Ontario solution to medically underserviced areas: evaluation of an ongoing program.

In 1969 a program was established to place physicians in area of Ontario deemed to be medically underserviced. The main features of the program are area designation, physician subsidies, student bursaries, community participation and physician recruitment. From 1969 to March 1973, 162 communities were designated as underserviced and 196 physicians placed. As the program became active the rate of increase of numbers of physicians practising in northern rural areas (population, less than 15 000) increased sharply, exceeding that for the entire province. Fifty-three percent of bursaried students have honoured their commitment. Seventy-five communities have built modern medical centres that have been an important factor in attracting physicians. Still unanswered are whether the physicians will stay and whether the health of the population will be improved.     

公立医院临床医师对临床路径实施工作及效果的评价

目的 了解我国公立医院临床医师对临床路径实施工作及效果的评价。方法 对我国东、中、西3省（直辖市）1638名临床医师进行问卷调查。结果 我国公立医院临床医师对临床路径实施工作和实施效果的总体评价分别为3.16分和3.41分。并且,不同地区、等级公立医院临床医师的评价存在一定差异。结论 我国公立医院临床医师对临床路径实施工作的认可度不高;西部地区和二级医院的临床医师更偏好实施临床路径;临床医师对临床路径实施可提高医疗服务过程质量的认同度相对较高。     

Tort reform and the obstetric access crisis. The case of the WAMI states.

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians'' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.     

Liberal rationalism and medical decision-making

I contrast Robert Veatch's recent liberal vision of medical decision-making with a more rationalist liberal model. According to Veatch, physicians are biased in their determination of what is in their patient's overall interests in favour of their medical interests. Because of the extent of this bias, we should abandon the practice of physicians offering what they guess to be the best treatment option. Patients should buddy up with physicians who share the same values —'deep value pairing'. The goal of choice is maximal promotion of patient values. I argue that if subjectivism about value and valuing is true, this move is plausible. However, if objectivism about value is true — that there really are states which are good for people regardless of whether they desire to be in them — then we should accept a more rationalist liberal alternative. According to this alternative, what is required to decide which course is best is rational dialogue between physicians and patients, both about the patient's circumstances and her values, and not the seeking out of people, physicians or others, who share the same values. Rational discussion requires that physicians be reasonable and empathic. I describe one possible account of a reasonable physician.     

Physician resource databank: numbers,distribution and activities of Canada's physicians

The physician resource databank, compiled and maintained by the Canadian Medical Association (CMA), contains functional information from 41 599 of Canada''s licensed physicians. The information was gathered from a 20-item questionnaire sent to 47 162 physicians. Of the total, 38 653 responses came from physicians who had completed their training and these were included in the analysis to produce a profile of the supply of physicians in Canada. The data from physicians younger than 35 years indicate some changes in the structure of the supply: 27% are women (compared with only about 9% of physicians older than 45 years).The implications of these statistics are not yet clear, but within the next decade the numbers in some specialties—surgery, anesthesia, obstetrics and gynecology, and radiology—may be too few to meet the demand as more than 20% of the current practitioners reach retirement age. Other findings are that [List: see text]     

"Natural cause of death or not?" How do nursing home physicians act when in doubt of natural cause of death?

The objective of the study was to explore if nursing home physicians act by law, when they doubt the natural cause of death. In May 1999, a questionnaire was sent to 153 nursing home physicians in the region of Utrecht and Nijmegen. They were asked if they consult the coroner when they have doubts about the natural cause of death. Eighty-six percent (104) returned the questionnaire. Thirty-two percent of the nursing home physicians always consult the coroner and 52% does so most of the time. Only 12% does not consult the coroner most of the time and 2% never does. The main reasons for not consulting the coroner were that nursing home physicians judge a death after a fall as an incident that fits in the descending lifeline of patients and that some nursing home physicians had bad experiences consulting the coroner. We conclude that this policy may lead to underregistration of unnatural deaths. Changing the definition or changing the law may reduce this problem. Education and information can also contribute to change in physician's attitudes.     

Attitudes of Washington State physicians toward health care reform.

Attitudes of Washington State physicians about health care reform and about specific elements of managed competition and single-payer proposals were evaluated. Opinions about President Clinton''s reform plan were also assessed. Washington physicians (n = 1,000) were surveyed from October to November 1993, and responses were collected through January 1994; responses were anonymous. The response rate was 80%. Practice characteristics of respondents did not differ from other physicians in the state. Of physicians responding, 80% favored substantial change in the current system, 43% favored managed competition, and 40% preferred a single-payer system. Of physicians responding, 64% thought President Clinton''s proposal would not adequately address current problems. Reduced administrative burden, a central element of single-payer plans, was identified by 89% of respondents as likely to improve the current system. Other elements of reform plans enjoyed less support. More procedure-oriented specialists than primary care physicians favored leaving the current system unchanged (28% versus 8%, P < .001). While physicians favor health care reform, there is no consensus on any single plan. It seems unlikely that physicians will be able to speak with a single voice during the current debates on health care reform.     

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

Medical women of the West.

The presence in the West of women physicians with degrees from regular medical schools spans a period of approximately 130 years. Women''s Medical College of Pennsylvania graduated many of these early women physicians. The first woman medical graduate of a western school was Lucy M. Field Wanzer, who finished in 1876 at the Department of Medicine, University of California in San Francisco. Soon thereafter, schools that would become Stanford University and the Oregon Health Sciences University schools of medicine, as well as the newly founded University of Southern California, were contributing to the pool of women physicians. The University of Michigan Medical School, the first coeducational state medical school, also educated some of the western women physicians, who by 1910 numbered about 155. This regional account of the progress of women physicians as they strove to become an integral part of the profession emphasizes the familiar themes of altruism, ingenuity, and perseverance that characterized their efforts.     

Fatal hyperthermia associated with cocaine use.

Health insurance in the United States is failing patients and physicians alike. In this country 37 million uninsured face economic barriers to care, and the health of many suffers as a result. The "corporatization" of medical care threatens professional values with an unprecedented administrative and commercial intrusion into the daily practice of medicine. Competitive strategies have also failed their most ostensible goal--cost control. In contrast, Canada offers a model of a national health insurance plan that provides universal and comprehensive coverage, succeeds at restraining health care inflation, and does little to abrogate the clinical autonomy of physicians in private practice. I propose that American physicians relent in their historical opposition to national health insurance and participate in the development of a universal, public insurance plan responsive to the needs of both patients and physicians.     

Poem: the prophet in his own country

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians'' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians'' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians'' financial and nonfinancial concerns about providing care for poor patients.     

Diagnosis and management of hypertension: the stated practices of family physicians.

Hypertension is an important and common problem in family practice, but there is no general agreement on the systolic and diastolic pressures at which it should be diagnosed and treated. Responses from 273 family physicians surveyed by mail in Metropolitan Toronto showed a wide variation in the pressures used as cut-off points. The probability that in a given patient hypertension would be diagnosed or treated at different systolic and diastolic pressures varied considerably among the physicians, the variation increasing with the age of the patient. There was also wide variation in opinion among the surveyed physicians about how often patients should be screened for hypertension; depending on the patient''s age, up to 35% of the physicians stated that the blood pressure should be measured at every visit. Only one third reported using any one or more methods to ensure that patients with hypertension were not lost to follow-up. The family physicians with an academic appointment used higher cut-off points for diagnosis and treatment, and they screened and scheduled follow-up visits less frequently than those without an academic appointment.     

Physician attitudes towards pharmacological cognitive enhancement: safety concerns are paramount

The ethical dimensions of pharmacological cognitive enhancement have been widely discussed in academic circles and the popular media, but missing from the conversation have been the perspectives of physicians - key decision makers in the adoption of new technologies into medical practice. We queried primary care physicians in major urban centers in Canada and the United States with the aim of understanding their attitudes towards cognitive enhancement. Our primary hypothesis was that physicians would be more comfortable prescribing cognitive enhancers to older patients than to young adults. Physicians were presented with a hypothetical pharmaceutical cognitive enhancer that had been approved by the regulatory authorities for use in healthy adults, and was characterized as being safe, effective, and without significant adverse side effects. Respondents overwhelmingly reported increasing comfort with prescribing cognitive enhancers as the patient age increased from 25 to 65. When asked about their comfort with prescribing extant drugs that might be considered enhancements (sildenafil, modafinil, and methylphenidate) or our hypothetical cognitive enhancer to a normal, healthy 40 year old, physicians were more comfortable prescribing sildenafil than any of the other three agents. When queried as to the reasons they answered as they did, the most prominent concerns physicians expressed were issues of safety that were not offset by the benefit afforded the individual, even in the face of explicit safety claims. Moreover, many physicians indicated that they viewed safety claims with considerable skepticism. It has become routine for safety to be raised and summarily dismissed as an issue in the debate over pharmacological cognitive enhancement; the observation that physicians were so skeptical in the face of explicit safety claims suggests that such a conclusion may be premature. Thus, physician attitudes suggest that greater weight be placed upon the balance between safety and benefit in consideration of pharmacological cognitive enhancement.     

Non‐verbal interaction of Anglo‐Canadian,Jewish‐Canadian,and French‐Canadian physicians with their young,middle‐aged,and elderly patients

This study investigates the role that non‐verbal communication plays in establishing and maintaining rapport among physicians and their young, middle‐aged, and elderly patients.

Eleven physicians with a variety of patients were studied in the project in Montreal. Five physicians were Anglo‐Canadian, three were respectively Jewish‐Canadian and French‐Canadian. Three additional physicians were part of a pilot project.

Patient‐doctor interviews were videotaped by means of a stationary camera fitted with a wide‐angle lens placed in the doctors’ offices. Physical examinations were not videotaped. After each session, patients filled out a questionnaire elucidating the success of the interview.