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Biomedical subjects

George E Fryer

Publications and source records attributed to George E Fryer.

At least 19 recordsLinked to original sources
PubMed2006

International medical graduates in family medicine in the United States of America: an exploration of professional characteristics and attitudes.

BACKGROUND: The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States. METHODS: This is a secondary data analysis of the 1996-1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week. RESULTS: Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs. CONCLUSION: There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

Journal Article↗
PubMed2006

Medical student attitudes to risk taking and self-perceived influence on medical practice.

CONTEXT: Little has been published on medical student risk-taking attitudes and behaviours and whether students think these attributes will affect how they treat patients. OBJECTIVES: Our aims were to assess for an association between risk-taking attitudes and behaviours, such as problematic substance use, self-reported risky behaviours, and self-reported accidents, and to test for an association between risk-taking attitudes and student perceptions of the influence of these attitudes on future clinical practice. METHODS: Three consecutive classes of Year 2 medical students (n=315) completed a self-administered, 29-item questionnaire. Risk-taking attitudes were evaluated using a 6-question, risk-taking scale adapted from the Jackson Personality Inventory (JPI). RESULTS: A significant positive correlation was demonstrated between risk-taking attitudes (JPI) and problematic substance use (r=0.34; P<0.01), self-reported risky behaviours (r=0.47; P<0.01), and self-reported accidents (r=0.33; P<0.01). Students who did not think their attitudes toward risk would affect their clinical decision making scored significantly higher on our measure of risk-taking attitudes (t306=-4.60; P<0.01). Students who did not think that their drinking, drug taking or sexual behaviour would affect how they counselled patients on these matters scored significantly higher on our measure of problematic substance use (t307=-2.51; P=0.01). CONCLUSIONS: Although risk-taking attitudes have been associated with significant differences in clinical decision making among doctors, in our sample students with high risk-taking attitudes and behaviours were significantly less likely than their colleagues to think their attitudes would affect their clinical practice. Implications for medical education are discussed.

Adult↗
PubMed2006

National Health Service Corps staffing and the growth of the local rural non-NHSC primary care physician workforce.

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.

Humans↗
PubMed2005

Using the ecology model to describe the impact of asthma on patterns of health care.

BACKGROUND: Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care. METHODS: This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings. RESULTS: In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas. CONCLUSION: The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.

Adult↗
PubMed2005

Changes in age-adjusted mortality rates and disparities for rural physician shortage areas staffed by the National Health Service Corps: 1984-1998.

OBJECTIVE: This study assesses whether the National Health Service Corps's legislated goals to see health improve and health disparities lessen are being met in rural health professional shortage areas for a key population health indicator: age-adjusted mortality. METHODS: In a descriptive study using a pre-post design with comparison groups, the authors calculated age-adjusted mortality rates at baseline (1981-1983) and follow-up (1996-1998) for the populations of 448 rural whole-county health professional shortage areas arrayed into 3 groups based on the number of study years they were staffed by National Health Service Corps physicians, physician assistants, and nurse practitioners (terms of 1 to 7, 8 to 11, and 12 to 15 years). The authors compared changes over time in age-adjusted mortality rates in the 3 county groups that had National Health Service Corps staffing with rate changes in 172 whole-county rural health professional shortage areas and 772 non-health professional shortage area rural counties that had no National Health Service Corps. RESULTS: At baseline age-adjusted mortality was higher in all 4 health professional shortage area county groups than in the non-health professional shortage area county group. Age-adjusted mortality rates improved with time in all groups, including health professional shortage area counties both with and without National Health Service Corps support, and non-health professional shortage area counties. Essentially, baseline differences in age-adjusted mortality rates between health professional shortage areas and non-health professional shortage area counties did not diminish with time, whether or not there was National Health Service Corps support. CONCLUSIONS: From the early 1980s through the mid-1990s, the National Health Service Corps's goal to see health improve in rural health professional shortage areas was met, but its goal to diminish geographical health disparities was not. Because age-adjusted mortality rates improved in all county groups, the authors conclude that improvement was likely due to a variety of factors, including decreasing poverty and unemployment rates and increasing primary care physician-to-population ratios, to which the National Health Service Corps may have contributed.

Adult↗
PubMed2004

A randomized trial of nortriptyline combined with transdermal nicotine for smoking cessation.

BACKGROUND: Smoking cessation rates with current therapy are suboptimal. Tricyclic antidepressants improve cessation rates. We hypothesized that addition of nortriptyline hydrochloride to transdermal nicotine would enhance cessation rates. METHODS: We conducted a randomized, double-blind, placebo-controlled trial at a Department of Veterans Affairs medical center. Subjects were aged 18 to 65 years, smoked 10 or more cigarettes per day, and did not have current major depression. Nortriptyline hydrochloride or matched placebo was started at 25 mg 14 days before quit day, titrated to 75 mg/d as tolerated, and continued for 12 weeks after quit day. Transdermal nicotine (21 mg/d) was started on quit day and continued for 8 weeks. The behavioral intervention consisted of 12 brief, individual visits. Withdrawal symptoms were measured by means of a daily diary, and smoking cessation was defined as self-reported abstinence, expired carbon monoxide level of 9 ppm or less, and a 6-month urine cotinine level less than 50 ng/mL (284 nmol/L). RESULTS: A total of 158 patients were randomized (79 to nortriptyline and 79 to placebo). There was no significant reduction in withdrawal symptoms. The cessation rates at 6 months were 23% (18/79) and 10% (8/79), respectively (absolute difference, 13%; 95% confidence interval, 1.3%-24.5%; P = .052). Nortriptyline caused frequent side effects, including dry mouth (38%) and sedation (20%). CONCLUSIONS: Nortriptyline combined with transdermal nicotine resulted in an increased cessation rate with little effect on withdrawal symptoms. This combination may represent an option for smokers in whom standard therapy has failed.

Administration, Cutaneous↗
PubMed2004

Variation in participation in health care settings associated with race and ethnicity.

OBJECTIVE: To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN: 1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting. SETTING: Physicians' offices, outpatient clinics, hospital emergency departments, hospitals, and people's homes. MAIN MEASUREMENT: Number of people per 1,000 per month who had at least one contact in a health care setting. RESULTS: Fewer blacks and Hispanics than whites received care in physicians' offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians' offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home. CONCLUSIONS: Fewer blacks and Hispanics than whites received health care in physicians' offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.

Black or African American↗
PubMed2004

Asthma severity: the patient's perspective.

BACKGROUND: Although asthma is a common condition, limited epidemiological data exists on the distribution or course of asthma severity. We know even less about how patients or parents rate the severity of their or their child's asthma or what factors they associate with more severe asthma. A large nationally diverse sample of asthma patients' self-assessment of severity is available but has not been analyzed to look at asthma severity from the patients' perspective. METHOD: Data from the "household" and "event" files from the 1999 Medical Expenditure Panel Survey were combined to obtain a distribution of patient-reported asthma severity and the health care utilization, medication usage, and personal characteristics associated with different levels of self-reported severity for that subgroup that answered the chronic disease portion of the survey. RESULTS: Almost two thirds of patients (63% of adults) or parents (65% of children) described their or their child's asthma as very or somewhat serious. Among both children and adults, more severe asthma was associated with greater numbers of missed school and workdays, and lower overall health status. The associated differences in health utilization varied by age. Models of severity based on available NAEPP criteria explained less than 10% of the participant's variation in self-reported asthma severity. CONCLUSION: Parents and patients with asthma appear to use different metrics than physicians and researchers to define the more severe categories of asthma. This disparity suggests the need for an asthma measure that is more widely understood, and accepted by patients and clinicians to serve as a tool to improve asthma-related communications and the achievement of mutually determined therapy goals.

Adolescent↗
PubMed2004

Identification of women's coronary heart disease and risk factors prior to first myocardial infarction.

PURPOSE: To understand when women's coronary heart disease (CHD) and CHD risk factors are recognized prior to first myocardial infarction (MI). METHODS: Medical record review of the 10 years prior to incident MI among women with a confirmed incident MI between January 1, 1996, and December 31, 2001, to determine the timing of CHD diagnosis as well as assessment and treatment for risk factors. RESULTS: One hundred fifty women had incident MIs during the study period. They made 8732 ambulatory visits and had 457 hospitalizations during the period of review (mean 9.1 years, range 6.2-10 years). Average age at incident MI was 74.7 years (SD 12.6, range 38.9-99.8 years). A CHD diagnosis prior to first MI was present in 52% (n = 78) of the women but was less common in those <70 years (p = 0.001). All but 3 women had one or more modifiable risk factors identified prior to their first MI. Treatment of recognized risk factors varied from 81% (antihypertension medications) to only 28% (drug therapy for abnormal lipid levels). Having a diagnosis of CHD was associated with an increased likelihood of having identified risk factors and receiving drug treatment for identified risk factors. CONCLUSIONS: Women with undiagnosed CHD (48%) and those with unrecognized or untreated risk factors for CHD, especially younger women, represent missed opportunities for prevention of cardiac events.

Adult↗
PubMed2004

Who are the uninsured elderly in the United States?

Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade.

Activities of Daily Living↗
PubMed2004

The health impact of resolving racial disparities: an analysis of US mortality data.

The US health system spends far more on the "technology" of care (e.g., drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176,633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886,202 deaths. Achieving equity may do more for health than perfecting the technology of care.

Black or African American↗
PubMed2004

Modifiable determinants of healthcare utilization within the African-American population.

BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of healthcare have focused on black-white differences rather than focusing on "within-group" analysis of African Americans. OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on healthcare utilization within the African-American population. METHODS: Secondary data analysis of 3462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally representative survey of the civilian, noninstitutionalized U.S. population in 1999. RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3462 African-American respondents who represent a U.S. population of 36,538,639 persons. Personal nonmodifiable characteristics such as age and gender were significantly related to healthcare utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of healthcare utilization for Afrcan-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors. CONCLUSIONS: The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients and could be independently targeted for intervention.

Adolescent↗
PubMed2003

Receipt of preventive care among adults: insurance status and usual source of care.

OBJECTIVES: This study ascertained the separate and combined effects of having insurance and a usual source of care on receiving preventive services. METHODS: Descriptive and multivariate analyses of 1996 Medical Expenditure Panel Survey data were conducted. RESULTS: Receipt of preventive services was strongly associated with insurance and a usual source of care. Significant differences were found between insured adults with a usual source of care, who were most likely to have received services, compared with uninsured adults without regular care, who were least likely to have received services. Those with either a usual source of care or insurance had intermediate levels of preventive services. CONCLUSIONS: Having a usual source of care and health insurance are both important to achieving national prevention goals.

Adolescent↗
PubMed2003

The effects of the 1997 Balanced Budget Act on family practice residency training programs.

BACKGROUND AND OBJECTIVES: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States. METHODS: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis. RESULTS: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988-1997 to 4.8 per year in the 4 years following passage of the BBA. CONCLUSIONS: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.

Budgets↗
PubMed2002

Family practice in the United States: position and prospects.

Family practice became the 20th U.S. medical specialty in 1969. It has delivered on its promise to reverse the decline of general practice and care for people with diverse problems in all areas of the country. But many important health care problems remain unsolved, in part because of poor role delineation for family physicians, poor differentiation of family practice from other fields, and insufficient changes in the cultural and political environment. Family practice's problems include confusion about whether it is a reform movement or an incumbent specialty; disagreement about its role in controlling and assuring care; confusion about whether family physicians are generalists or specialists; lack of clarity about family practice as vital for all versus a possible option for some; misunderstanding about the knowledge requirements for family practice; and inadequate business models. Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable.

Family Practice↗
PubMed2002

The increase in international medical graduates in family practice residency programs.

BACKGROUND AND OBJECTIVES: The number of filled positions in family practice residency programs decreased by 18.6% from 1997-2001. This study sought to determine the degree of reliance on international medical graduates (IMGs) to fill family practice residency positions and the relative proportion of US citizen IMGs. METHODS: We analyzed the 1992-2001 National Resident Matching Program results, the 2000 American Medical Association Masterfile, and the 1992-2001 American Academy of Family Physicians Annual Survey of Family Practice Residency Programs. RESULTS: The percentage of IMGs matching in family practice remained stable between the years of 1992-1996 (10.0%-11.8%) but since 1997 has increased to a high of 21.4% in 2001. This rise in IMGs corresponds with a drop in the total percentage of family practice residency positions filled in the Match from 90.5% in 1996 to 76.3% in 2001. Despite the drop in Match numbers, the percentage of first-year family practice positions filled in July has remained in the range of 95.5%-97.8% since 1996. IMGs account for an increasing percentage of post-Match fills from 16.7% in 1996 to 47.9% in 2001. In 1999, a majority of family practice programs (279 [55.6%]), had at least one IMG. Of these, 48 programs (9.6%) had at least 50% of residents who were IMGs, and eight programs (1.6%) were entirely composed of IMGs. In five states (Connecticut, Illinois, Michigan, New Jersey, and New York), more than 25% of family practice residents were IMGs. CONCLUSIONS: Family practice is becoming increasingly reliant on IMGs to fill residency positions.

Career Mobility↗