Importance of and satisfaction with work and professional interpersonal issues: a survey of physicians practicing general internal medicine in Ontario.

OBJECTIVES: To explore the importance of and satisfaction with clinical responsibilities, teaching, research and interpersonal issues among general internists; to understand the barriers to satisfaction in these domains and the usefulness of potential solutions to these problems. DESIGN: Cross-sectional survey conducted from November 1992 to June 1994. SETTING: Ontario. PARTICIPANTS: General internists who were fellows of the Royal College of Physicians and Surgeons of Canada and members of the Ontario Medical Association. Of 1192 physicians, 1007 (84.5%) returned a completed questionnaire; only the 199 who devoted at least 50% of their time to the practice of general internal medicine were included in this analysis. RESULTS: The respondents were satisfied with their primary role as clinicians dealing with complex, undifferentiated problems caring for the total patient and providing consultation. Guidelines for the referral of patients to general internists, computerization of test results, recruitment of general internal medicine fellows and more confidence in the future of general internal medicine were some of the solutions considered likely to increase professional satisfaction. The respondents involved in teaching suggested additional solutions, such as an opportunity to improve their teaching and evidence-based medicine skills and a greater recognition for their teaching efforts. Few of the general internists conducted research, barriers included lack of personal and project funding, and pressure to generate clinical earnings. In the domain of professional interpersonal issues, women were significantly more likely than men to rate having a mentor, peer support groups, ongoing career counselling, promotion and tenure guidelines for parental leave, availability of on-site day care, addressing gender discrimination and adoption of gender-neutral language as likely to improve the work environment. CONCLUSIONS: The primary role of general internists is that of patient-centred clinician. Our findings suggest that general internists want to take responsibility for revitalizing this discipline. The potential solutions generated in this survey may help to promote action that will improve professional satisfaction in the area of clinical responsibilities, teaching, research and interpersonal issues.     

Adolescent health care in a large multispecialty prepaid group practice. Who provides it and how well are they doing?

Adolescents are at risk for pregnancy, sexually transmitted diseases, suicide, homicide, accidents, and substance abuse. Adolescent medicine involves an overlap of many skills needed to provide routine medical care, as well as care for those conditions that require psychosocial assessment. We report the results of a mail survey covering care of this age group by practitioners of pediatrics, internal medicine, obstetrics and gynecology, family practice, and adolescent medicine in a large, multispecialty, prepaid group practice. The mail survey covered 10 areas of adolescent care. Adolescent medicine physicians expressed the highest level of perceived knowledge and competence in these areas, with family practitioners ranked second. More than 50% of internists and pediatricians felt only fair to poor competence for a variety of adolescent conditions, whereas a third of internists and pediatricians reported that they liked to care for adolescents. Physicians in all 4 of the primary care specialties reported a need for a teen health center for both consultation and education. These results are similar to those reported for pediatricians and primary care physicians in private practice and for residents in internal medicine.     

Patterns of primary care of patients infected with human immunodeficiency virus.

To determine the patterns of care of patients infected with the human immunodeficiency virus (HIV), data from 2 sources were analyzed. Initial data obtained from the Washington State HIV/Acquired Immunodeficiency Syndrome (AIDS) Epidemiology Unit indicate that 46% of patients with class IV AIDS were seen by physicians who reported fewer than 5 patients with AIDS, and 68% of all Washington physicians who reported treating patients with AIDS have reported only 1 patient. Subsequent data obtained from a questionnaire distributed in 4 Northwest states suggest that 74% of primary care internists and 73% of family practitioners have some experience in caring for patients with HIV infection, but most of these physicians report fewer than 6 patients in the past 2 years. Although most providers seeing large numbers of HIV-infected patients in their practices were based in the region''s major metropolitan area, 59% of the internists and 55% of the family practitioners surveyed outside of the metropolitan area had seen at least 1 HIV-infected patient in their practices. These results suggest that primary care physicians with relatively little experience treating HIV infection are providing care for a large number of HIV-infected persons. Further study is needed to determine the extent and quality of care provided.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Prevalence of myofascial pain in general internal medicine practice.

Myofascial pain is a regional pain syndrome characterized in part by a trigger point in a taut band of skeletal muscle and its associated referred pain. We examined a series of 172 patients presenting to a university primary care general internal medicine practice. Of 54 patients whose reason for a visit included pain, 16 (30%) satisfied criteria for a clinical diagnosis of myofascial pain. These patients were similar in age and sex to other patients with pain, and the frequency of pain as a primary complaint was similar for myofascial pain as compared with other reasons for pain. The usual intensity of myofascial pain as assessed by a visual analog scale was high, comparable to or possibly greater than pain due to other causes. Patients with upper body pain were more likely to have myofascial pain than patients with pain located elsewhere. Physicians rarely recognized the myofascial pain syndrome. Commonly applied therapies for myofascial pain provided substantial abrupt reduction in pain intensity. The prevalence and severity of myofascial pain in this university internal medicine setting suggest that regional myofascial pain may be an important cause of pain complaints in the practice of general internal medicine.     

Absence of race- or gender-specific income disparities among full-time white and Asian general internists working for the Veterans Administration

Background: Gender-based, but not race-based, income disparities exist among general internists who practice medicine in the private sector.Objective: The aim of this study was to assess whether race- or gender-based income disparities existed among full-time white and Asian general internists who worked for the Veterans Health Administration of the US Department of Veterans Affairs (VA) between fiscal years 2004 and 2007, and whether any disparities changed after the VA enacted physician pay reform in early 2006.Methods: A retrospective study was conducted of all nonsupervisory, board-certified, full-time white or Asian VA general internists who did not change their location of practice between fiscal years 2004 and 2007. A longitudinal cohort design and linear regression modeling, adjusted for physician characteristics, were used to compare race- and gender-specific incomes in fiscal years 2004–2007.Results: A total of 176 physicians were included in the study: 82 white males, 33 Asian males, 30 white females, and 31 Asian females. In all fiscal years examined, white males had the highest mean annual incomes, though not statistically significantly so. Regression analyses for fiscal years 2004 through 2006 revealed that physician age and years of service were predictive of total income. After physician pay reform was enacted, Asian male VA primary care physicians had higher annual incomes than did physicians in all other race or gender categories, after adjustment for age and years of VA service, though these differences were not statistically significant.Conclusions: No significant gender-based income disparities were noted among these white and Asian VA physicians. Our findings for white and Asian general internists suggest that the VA' s goal of maintaining a racially diverse workforce may have been effected, in part, through use of market pay among primary care general internists.     

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.     

Effect of medicolegal liability on patterns of general and family practice in Canada.

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians'' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years.     

Educating Internists in Emergency Medicine

The education of internists in emergency medicine needs to be thoughtfully planned by those involved in their education. Objectives for their emergency medicine rotation include the recognition and initial treatment of true medical and surgical emergencies, clinical experience with and knowledge of common acute primary care problems, the ability to handle several patients with problems having different degrees of urgency, effective use of consultants in the follow-up and management of difficult patients and a knowledge of and clinical experience with the prehospital care system. A curriculum should be designed to give the resident a core of didactic material in addition to supervised clinical experience. The rotation should be evaluated by both residents and faculty from internal medicine and emergency medicine to determine if it is accomplishing the objectives set forth.     

Facilitating prevention in primary care.

We believe that many general practitioners would practice preventive medicine if they had the opportunity to organise their practice to do this. We therefore provided a "facilitator," who understands the work of a general practice, to help practices that were interested in prevention to set up programmes. She, for example, helped the primary care team to set up objectives, trained practice nurses to measure blood pressure, and set up a system to measure the progress of the programme.     

Canadian departments of pediatrics and family medicine: in need of family therapy?

Whether and how much the departments of pediatrics in Canadian medical schools collaborate with the family medicine departments in training for child care were the focus of a survey conducted in 1983-84. Responses to a questionnaire sent to department heads indicated that in general the most supportive relationships existed in the western provinces, with progressively more problems uncovered from west to east. The responses concerning the roles of pediatricians and family physicians paralleled this trend, with the western view being that pediatricians are consultants and not competitors for primary care. Many respondents supported the expansion of family medicine, particularly into ambulatory and behavioural areas. The data provide some cause for concern about the future health care of children, as the forecasted oversupply of physicians is likely to encourage competition rather than consultation between the two groups. Also, many Canadian pediatricians accept the US model of pediatrics, which includes primary care, although in Canada the ratio of family physicians to pediatricians is six times that in the United States, and Canadian specialists are concentrated in urban centres. This means that family physicians will continue to provide most of the child care in Canada and need adequate training. They also need to develop cooperative, supportive relationships with specialists in child health care to enhance appropriate referral patterns.     

The safety of obstetric services in small communities in northern Ontario.

The safety of the obstetric care system in the small hospitals of northern Ontario was assessed by analysing the outcomes of all obstetric cases over a 2-year period. Information was retrieved by place of residence rather than hospital of delivery so that the overall perinatal system, including the referral patterns, would be assessed. There was little difference in perinatal loss rate (stillbirths and neonatal deaths up to 28 days per 1000 births) for residents of areas served by different levels of obstetric care. Areas served by units where cesarean sections are done regularly but which do not have specialists in obstetrics or pediatrics had a perinatal loss rate of 10.43, whereas areas served by units staffed with two or more specialists in both obstetrics and pediatrics and handling more than 1000 deliveries per year had a perinatal loss rate of 12.13. Although many of the smaller hospitals did not have the minimum capabilities suggested for obstetric units relatively safe care was being provided. These results do not support the need for further centralization of obstetric services in northern Ontario.     

Extent and determinants of error in physicians' prognoses in terminally ill patients: prospective cohort study

Objectives To describe physicians' prognostic accuracy in terminally ill patients and to evaluate the determinants of that accuracy. Design Prospective cohort study. Setting Five outpatient hospice programs in Chicago. Participants A total of 343 physicians provided survival estimates for 468 terminally ill patients at the time of hospice referral. Main outcome measures Patients' estimated and actual survival. Results Median survival was 24 days. Of 468 predictions, only 92 (20%) were accurate (within 33% of actual survival); 295 (63%) were overoptimistic, and 81 (17%) were overpessimistic. Overall, physicians overestimated survival by a factor of 5.3. Few patient or physician characteristics were associated with prognostic accuracy. Male patients were 58% less likely to have overpessimistic predictions. Medical specialists excluding oncologists were 326% more likely than general internists to make overpessimistic predictions. Physicians in the upper quartile of practice experience were the most accurate. As the duration of the doctor-patient relationship increased and time since last contact decreased, prognostic accuracy decreased. Conclusions Physicians are inaccurate in their prognoses for terminally ill patients, and the error is systematically optimistic. The inaccuracy is, in general, not restricted to certain kinds of physicians or patients. These phenomena may be adversely affecting the quality of care given to patients near the end of life.     

Area variations in the process of care in urban general practice.

One hundred and eighty three practitioners collected data on 110 000 consultations. Case mix and pattern of care are compared for doctors practising in different urban areas. Inner city areas are compared with outer areas and the most deprived with the most affluent. Case mix varies slightly between areas, but there are no systematic differences in the pattern of care, which is equally variable in different areas. The stereotype of inner city general practice is not confirmed.     

Continuing Medical Education—A Survey Among Physicians Practicing in San Diego and Imperial Counties

Patterns of continuing education of 244 physicians practicing in San Diego and Imperial Counties were studied by means of an interview questionnaire. An additional 20 internists and general practitioners were observed for one week in order to check the validity of the questionnaire findings.All physicians reported that they engaged in one or more means of continuing education and about three quarters had attended at least one formal course during the preceding three years. Almost all (99 percent) had attended some hospital-based teaching conference, tumor board or professional society meeting during the year preceding interview and 88 percent had attended at least once each month. Physicians in group practice participated more regularly in continuing education than those in solo practice, but no differences in participation were observed between those practicing in the metropolitan area of San Diego and those practicing in the other areas of the two counties. Different patterns of continuing education by specialty are also reported and the attitudes of physicians toward continuing education are described.     

The Canadian general internist: education and future role.

Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.     

Making a difference--women, medicine, and the twenty-first century

Women can and should make a difference in how medical care is given in the future. The increased number of women physicians presents an opportunity to make a significant impact on the quality of medical care. Data is provided on the number of women applicants to medical school, matriculants and graduates, specialty choices, the status of women in academic medicine, and the income of women physicians. Four aspects of the environment that portend important changes for medicine in the future are identified: scientific developments, alternative delivery systems and the corporate practice of medicine, the aging population and other demographic changes, and the expanding number of physicians. Some of these changes suggest opportunities for making a difference in the traditional specialties of medicine, in providing care to underserved populations, in research careers, in the shortage areas of preventive medicine and public health, occupational medicine, child psychiatry, and physical medicine and rehabilitation, and in new areas such as community pediatrics, behavioral pediatrics, and adolescent medicine. There are many choices and many decisions to be made, and each individual can choose to make a difference.     

Regional variation in nonmedical factors affecting family physicians' decisions about referral for consultation

OBJECTIVE: To determine whether there is regional variation in environmental (non-medical) factors affecting referral decisions of family physicians (FPs). DESIGN: Cross-sectional interview survey. SETTING: Nova Scotia. PARTICIPANTS: A random sample of 125 FPs grouped into 1 of 5 functionally defined geographic regions of Nova Scotia (25 in each group). Groupings were based on access to general hospital beds through active staff hospital appointments or to specialist consultants in the community, or both. Participants were personally interviewed on site. No physician refused an interview. In 9 cases the physician indicated that he or she did not fit the profile of the assigned group; the physician was excluded from the study and the next doctor on the list was substituted. OUTCOME MEASURES: The questionnaire was designed to test several hypotheses about factors known to potentially influence decisions about referral. Geographic differences in factors affecting referral and in decisions about 5 hypothetical cases were assessed with the use of significance tests for proportions that were sensitive to specific orders across groups. RESULTS: Three factors affecting referral showed unequivocal variation across the 5 groups. Access to hospital facilities and remoteness from specialist care, leading to local styles of practice or treatment policies, and the FP''s relationship with specialist consultants appeared to be important nonmedical factors affecting referral decisions. For similar case scenarios the physicians living in rural areas would refer only half as often overall as those living in urban areas with tertiary care hospitals; for some cases, such as a severe asthma attack, the difference was more than 7-fold. CONCLUSIONS: Significant differences in nonmedical factors affecting referral, and in referral decisions about hypothetical cases, were found between the groups of FPs. Differences in access to resources, creating local styles of practice, appeared to explain most of the variation. The results may account for previously observed differences in actual rates of referral for these particular groups.     

Guidelines for medical practice: 2. A possible strategy.

The recognition that much current medical practice is based on incomplete scientific evidence has led to calls for the generation of guidelines for optimal patterns of practice. These guidelines must be developed from a synthesis of existing scientific data ideally obtained from randomized clinical trials. However, at present we may have to rely on less satisfactory data and the views of experts in the field. The primary purpose of these initiatives must be to improve patient care. The Ontario Medical Association has made recommendations on how such guidelines should be produced, and in a recent survey a substantial majority of family physicians supported them. There is general agreement that the coordinating body should be independent of government and other interested parties. In addition, the medical profession must have the primary role, and a number of medical organizations should also be represented. We propose a possible structure for a group charged with developing guidelines for medical practice at a provincial level and on an experimental basis. Recommendations are made on its membership, function and relationship with other organizations. The identification and diffusion of justifiable, scientific practice patterns will help reduce waste of scarce resources, maintain the role of the profession as guardian of the quality of care and ultimately benefit the patient.