Career satisfaction and clinician-educators. The rewards and challenges of teaching. The Society of General Internal Medicine Career Satisfaction Study Group.
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Clinical Medicine↗
Biomedical subjects
D E Pathman
Publications and source records attributed to D E Pathman.
Maintaining the new practice networks.
Unless acquired physicians are managed carefully, many will flee the acquiring networks in anger and frustration. Because older networks relied on a self-selected population of physicians, the newer networks will have to develop alternative strategies to motivate those physicians who did not self-select for employment. This article makes recommendations about how to build a corporate practice culture under these new conditions.
Attitude of Health Personnel↗
Variation in patient charges for vaccines and well-child care.
BACKGROUND: Several state and federal programs have attempted to boost immunization rates by reducing or eliminating provider vaccine costs. The relation between patient vaccine and well-child visit charges and vaccine financing systems is unknown. OBJECTIVES: To determine patient charges for vaccines and well-child visits in three states with varying vaccine financing systems and to examine the effects of a short-term reduction in provider vaccine costs. DESIGN: Cross-sectional survey study of a random sample of physicians in three states. PARTICIPANTS: A total of 2797 pediatricians and family physicians in North Carolina, Texas, and Massachusetts were surveyed. MAIN OUTCOME MEASURES: Current charges to patients for diphtheria-tetanus-pertussis vaccine (DTP), measles-mumps-rubella vaccine, Haemophilus influenzae type b vaccine (Hib), and combined DPT-Hib vaccine for well-child visits; changes in charges over the previous 8 months. RESULTS: Response rate was 62%. Vaccine and well-child visit charges were comparable in North Carolina and Texas. Massachusetts' average charges for well-child visits were higher than in the other states, although vaccine charges were lower; with the use of combined DPT-Hib vaccine, total simulated charges for vaccines and well-child care during the first 6 months of life averaged only 10% less in Massachusetts vs Texas and North Carolina. Neither regional variation in cost of living nor Medicaid reimbursement rates explained this difference. CONCLUSIONS: The average cost and composition of charges for well-child care in Massachusetts, a state with universal purchase of vaccines, compared with the other states, warrant further study to explore whether physicians shift costs to other preventive services to compensate for lower allowable immunization charges. If such cost shifting occurs, current federal immunization initiatives that lower or eliminate provider cost may not provide increased access to preventive services.
Child↗
Medical education and physicians' career choices: are we taking credit beyond our due?
There is great enthusiasm for curricula that place students and residents in community-based primary care practices and in rural and underserved areas. Interest in these primary care training experiences is based, in part, on studies that report that they can prompt learners to pursue careers in primary care specialties and underserved areas. Given that these programs attract learners with prior career interests in primary care and underserved area medicine, however, it might be that the favored career choices of their graduates are better explained by programs' selection than by their curricula. In studies where learners are randomly assigned to various training programs, no curriculum effect is found, at least for the typical one- or two-month primary care and rural rotation. Only in studies of longitudinal, multidimensional programs have career effects been demonstrated when learners are randomized. The need for a balanced physician workforce, and therefore the need for curricula to create it, demands ongoing, rigorous assessments of the efficacies of the various primary care training programs. Critical reevaluation will probably show that most schools and residencies need extensive curriculum changes if learners' careers are to be affected, and that admission committees can play a pivotal role in creating a balanced physician workforce. These discussions challenge educators to be as thoughtful and as empirically grounded as possible when changing the content and process of medical training.
Career Choice↗
Minority physicians serving in rural National Health Service Corps sites.
Providing National Health Service Corps (NHSC) scholarships to under-represented minorities has been an important federal mechanism to bolster the numbers of minority physicians. Little is known about how minorities fare during their NHSC commitment periods. In 1991, questionnaires were mailed to all primary care physicians placed in rural communities from 1987 through 1990 in the NHSC scholarship program, in a retrospective cohort study. One hundred and twenty-two of the 398 eligible NHSC physician respondents (31%) indicated they were minorities. National Health Service Corps physicians were found to be well matched by race to the sites where they served, and minority NHSC physicians worked in counties and practices with greater proportions of minority inhabitants and patients. Minorities among rural NHSC physicians were less likely to have been raised in rural areas and were less interested in rural practice during medical school and when placed in their rural NHSC sites. The relative urban preferences of minority physicians in large part explains why this group was more dissatisfied with their work and personal lives while serving their obligations. Minority physicians also reported lower satisfaction for their families. Minority and nonminority NHSC physicians reported comparable acceptance by their communities, and demonstrated similarly low retention rates. The NHSC plays a significant role in the careers of many young minority physicians and in promoting the temporary availability of minority physicians for rural health professional shortage areas. However, as of 1991, many minority NHSC physicians placed in rural areas would have preferred urban sites, which resulted in their lower satisfaction.
Adult↗
The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations.
OBJECTIVES: This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times. METHODS: Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states. RESULTS: The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations. CONCLUSIONS: These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.
Awareness↗
The Vaccines For Children program: issues of physician accountability and patient verification.
To address the issue of low immunization rates, President Clinton in 1993 introduced the Child Immunization Initiative (CII). One part of the CII is the Vaccines for Children (VFC) program, a federally-funded and state-operated vaccine supply program. Recently, congress has raised concerns regarding the extent to which noneligible children may be receiving VFC vaccine. This article explores, from several perspectives, the major issues related to VFC accountability. The two major accountability systems under consideration, benchmarking and vaccine replacement, are reviewed and analyzed for their potential accuracy, their effects on physician office practice, and their impact on the entire VFC program.
Benchmarking↗
Rural physician satisfaction: its sources and relationship to retention.
This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified. These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.
Data Collection↗
Pediatrician and family physician agreement with and adoption of universal hepatitis B immunization.
BACKGROUND: The purpose of this study was to assess (1) rates of agreement with and adoption of the universal hepatitis B vaccine recommendation among practicing pediatricians and family physicians in nine selected states; (2) physicians' attitudes related to hepatitis B immunization; and (3) physicians' perceptions of parental attitudes regarding the hepatitis B vaccine series. METHODS: Self-administered questionnaires were mailed to 3014 pediatricians and family physicians in selected metropolitan areas and non-metropolitan areas of nine states. Outcome variables were agreement with and adoption of the hepatitis B vaccine recommendation. Predictor variables included physicians' characteristics, practice type and location, and proportion of managed care and Medicaid patients. Other variables that were studied include physicians' attitudes related to hepatitis B immunization, sources of immunization recommendation information, personal completion of the hepatitis B immunization series, and physicians' impressions of parental attitudes about the vaccine. RESULTS: Pediatricians were more likely than family physicians to report that they knew "a lot" about the recommendation (95% vs 84%), agreed with it (83% vs 57%), and have adopted it into practice (90% vs 64%). More physicians in both specialties had adopted the recommendation than actually agreed with it. Doubt about long-term protection from the vaccine was a strong predictor of not agreeing with or adopting the recommendation. Parental resistance to or request for hepatitis B vaccine affected the likelihood of physicians adopting it. CONCLUSIONS: Pediatricians and family physicians continue to differ in both agreement with and adoption of universal hepatitis B immunization. Two years after the recommendation was made, less than two thirds of all family physicians have adopted this recommendation. Adoption is likely influenced by practice policy, physician attitudes, and perceived parental opinions. We recommend that as new vaccines are approved and recommended, research be conducted to explore and address issues germane to physician agreement and adoption.
Adult↗
The National Health Service Corps experience for rural physicians in the late 1980s.
OBJECTIVE: To learn from physicians in the National Health Service Corps (referred to as NHSC or the Corps) scholarship program about their experiences in rural health professional shortage areas (HPSAs), to contrast their experiences with those of other physicians working in rural HPSAs, and to learn how NHSC physicians' retention is associated with the quality of their experiences. DESIGN: Cohort study. PARTICIPANTS: Two groups of primary care physicians who moved to rural HPSAs nationwide from 1987 through 1990 were surveyed in 1991: group 1 consisted of all 675 physicians in the NHSC scholarship program, and group 2 consisted of a stratified random sample of 1000 non-Corps physicians. Response rates were 73.7% and 69.1%, respectively. Analyses used comparable subsets of 417 NHSC and 206 non-NHSC respondents. RESULTS: Among NHSC physicians, 51% initially anticipated working in underserved areas longer than 10 years, although only 14% expected to remain more than 5 years in their assigned practices. Three quarters of the Corps group felt there were few acceptable practice sites available to them, one third likely would have preferred urban sites, and two thirds were matched in states where they had not lived or trained earlier. Corps physicians felt their spouses' and children's needs were less well satisfied in their communities than non-Corps physicians. Corps physicians reported lower satisfaction in their work and personal lives and demonstrated poorer retention. Group differences in satisfaction and retention remained after controlling for various features of physicians and sites where they worked. Among NHSC physicians, retention was dramatically lower for those less well matched to their communities and those less satisfied. CONCLUSIONS: The needs and preferences of NHSC physicians and families are not well accommodated. Low morale and poor retention are endemic among NHSC physicians. The NHSC is challenged by twin goals of meeting the immediate needs of underserved communities and providing personally and professionally satisfying environments where physicians can pursue long-term careers.
Career Choice↗
When 1 + 2 does not equal 3 for hard-working rural physicians.
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Career Choice↗
Studying the retention of rural physicians.
Rural communities and policy-makers struggle with efforts to enhance the retention of rural physicians. Research available to guide these efforts is often weak methodologically and thus may be pointing retention efforts in nonproductive directions. This article discusses a range of methodologic issues encountered in rural physician retention studies for the purpose of strengthening future studies. Ideal study approaches to answer causal questions, including questions about the "causes" of rural physician retention, must demonstrate good internal validity, for which chance, bias, and confounding are accounted. Retention studies that rely simply on asking physicians why they stay or leave rural areas can be useful at times, but are too prone to bias and their findings difficult to verify. Simply identifying what physicians find satisfying or dissatisfying about rural work also will not reliably reveal why they stay or leave, a related but still distinct question. Stronger approaches to studying retention include the traditional quantitative study--in which retention factors are identified when they are statistically related to physicians' retention, and the increasingly popular qualitative study--in which retention issues are revealed through prolonged, in-depth interactions with physicians. This article also discusses various definitions of retention, the use of survival curves to present retention findings, and the importance of studying retention in inception cohorts. The benefits and downside of studying retention with prospective and retrospective study designs are described.
Career Mobility↗
Medical education and the retention of rural physicians.
OBJECTIVE: This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN: Design is a prospective cohort study. PARTICIPANTS: Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION: In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS: Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS: These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.
Adult↗
Querying physicians' beliefs in career choice studies: the limitations of introspective causal reports.
Numerous studies in family medicine literature explore the determinants of physicians' specialty and practice location choices. A research approach frequently used in these studies has been to ask study physicians what led them to make specific career choices, labeled here as the introspective causal reports study design. This paper explores the validity of introspective causal reports and their usefulness in making health manpower policy recommendations. The accuracy of people's beliefs about the causes of their own behaviors is examined, and social psychology literature is drawn upon in this examination. Data are presented characterizing the use of introspective causal reports in recent family medicine literature. Recommendations are made for stronger research designs in future physician career choice determinant studies.
Behavior↗
Estimating rural health professional requirements: an assessment of current methodologies.
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Evaluation Studies as Topic↗
When access-to-care indicators meet. Designated shortage areas and avoidable hospitalizations.
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Health Services Accessibility↗
The comparative retention of National Health Service Corps and other rural physicians. Results of a 9-year follow-up study.
OBJECTIVE: To contrast the retention of physicians serving National Health Service Corps (NHSC) Scholarship Program obligations in rural settings to that of non-NHSC physicians working in the same or similar practices, and to identify promising retention-enhancing strategies. DESIGN: Cohort study. PARTICIPANTS: Four hundred twelve primary care physicians initially identified during an earlier study as working in a national stratified random sample of 178 externally subsidized rural clinics in 1981. Thirty-six percent were serving obligations to the NHSC, nearly all through the NHSC's Scholarship Program. The NHSC and non-NHSC inception cohorts (those first coming to their 1981 [or "index"] practices from May 1979 through December 1981) were created from within the entire group for use in most analyses. INTERVENTION: In 1990, physicians were resurveyed to learn of their backgrounds, experiences in their index practices, and their subsequent career moves. RESULTS: By 1984 and in each year thereafter, fewer NHSC than non-NHSC physicians of the entire respondent cohort remained (1) in their index practices, (2) in their index communities, and (3) in practice in any rural county (P less than .001). In the inception cohort, fewer NHSC than non-NHSC physicians were retained within all three settings by the third year after their initial dates of employment (P less than or equal to .01). After 8 years of employment, group retention rates for NHSC and non-NHSC inception cohort physicians were 12% vs 39% in the index practice and 29% vs 52% in nonmetropolitan practice. Physicians in both NHSC and non-NHSC groups who left their index practices generally left rural practice altogether. CONCLUSIONS: When compared to non-NHSC physicians working in comparable rural settings, the retention of rural NHSC physicians is seen to be poor and only partially explained by fixed physician, practice, or community variables. Long-term retention of NHSC providers is now receiving much needed attention at the federal level.
Adult↗
The nutritional content of pharmaceutical company sponsored promotions.
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Drug Industry↗