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Biomedical subjects

S A Skootsky

Publications and source records attributed to S A Skootsky.

10 recordsLinked to original sources
PubMed1999

Attitudes toward managed care and cost containment among primary care trainees at 3 training sites.

OBJECTIVE: To study the attitudes of entering first year (Y1) and graduating third year (Y3) primary care physician trainees from 3 different training program sites (a university hospital system site [UHS], a large staff-model health maintenance organization managed care system site [MCS], and a large public hospital system site [PHS]) toward selected aspects of managed care. DESIGN: A self-administered questionnaire was used in a cross-sectional study. PARTICIPANTS AND OUTCOME MEASURES: Participants were all Y1 and Y3 primary care trainees in internal medicine, pediatrics, and family medicine programs from 3 training program sites. Survey questions dealt with attitudes toward health services, managed care cost containment, and the role of the physician in society. RESULTS: Of eligible primary care trainees (n = 218), 91% completed the instrument. Trainees at the MCS generally held more positive views of managed care systems than trainees at the UHS or PHS. Internal medicine trainees held more negative attitudes towards managed care systems than trainees in pediatrics or family medicine. UHS and PHS trainees more often thought that managed care systems interfere with the doctor-patient relationship and that these systems are more concerned with economics than in providing quality patient care. Approximately one quarter of the Y1 trainees at all sites thought that reducing the cost of healthcare is beyond the control of doctors. No Y3 trainee at the PHS believed that reducing costs was beyond the control of doctors. The majority of trainees endorsed routine peer review of clinical decisions to control healthcare costs. Most trainees believed that managed care systems will eventually predominate and that physician independence is being impaired. CONCLUSION: The data suggest that attitudes of internal medicine, family medicine, and pediatric trainees toward various aspects of managed care vary not only by their year of training but also by their training environment. Thus, managed care educational programs for trainees should consider both the baseline attitudes of trainees and characteristics of the training site itself.

Attitude of Health Personnel↗
PubMed1997

Preparing residents for managed care practice using an experience-based curriculum.

Many U.S. residency graduates will practice in various types of managed care organizations, where they will be expected to arrive skilled in managed care activities such as prescribing with formularies and adhering to preauthorization processes for procedures, referrals, and hospital admissions. Residency programs must prepare their trainees to negotiate for their patients' needs within such systems. This article describes a University of California, Los Angeles, UCLA School of Medicine curriculum that teaches managed care skills to residents in two internal medicine residency training programs. The residents in one program participate in a commercial health maintenance organization plan via a group-model faculty practice. Managed care activities for residents in this program were gradually introduced beginning in 1990. This reflected previous years' gradual yet enforced introduction of managed care activities that occurred for this program's faculty and most group practice physicians in California. Residents in the other program train at a public hospital where managed care practice is simulated. Managed care activities were not required by this program's institution but were voluntarily introduced for their educational value beginning in 1994. Responding to this program's trainee and faculty requests, these activities were rapidly implemented over two years with the goal of preparing residents for joining practices in a market with high managed care penetration. Since 1994, the centerpiece of the curriculum has been residents' participation in ambulatory utilization review and related activities. Residents learn managed care principles through problem-based learning, experiential exercises, and feedback on resource utilization. The curriculum has affected residents' attitudes toward managed care and changed their patterns of referrals and resource use. Residents trained with this curriculum perceive managed care practices as familiar and less intrusive. They submit fewer requests for referrals, perhaps with review in mind. However, precautions may be required to avoid undercare. The authors found that the reduction of referrals requested was greater than what they had expected. Residents may find scrutiny by colleagues intimidating. Also, this curriculum requires a substantial time commitment from residency training, with its already busy teaching agenda. The authors feel that initiating a managed care curriculum is an important investment in time for U.S. residency programs. Given that most graduates of residency programs will have their health care management decisions scrutinized while in practice, the authors feel it is important that residents' first exposure to managed care be while they are still in the supportive residency environment. They believe that early exposure will not only give residents the confidence to overcome the intimidation of colleague scrutiny, but may also give graduates the tools for involvement with the development of future managed care health policy.

Ambulatory Care↗
PubMed1997

Referrals by general internists and internal medicine trainees in an academic medicine practice.

Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed.

Academic Medical Centers↗
PubMed1994

Health care reform as perceived by first year medical students.

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% completed the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.

Attitude of Health Personnel↗
PubMed1994

Entering first-year medical students' attitudes toward managed care.

PURPOSE: To study the attitudes of entering first-year medical students toward reform of the U.S. health care system. METHOD: All 631 first-year medical students at the five medical schools in the University of California System were asked during orientation (late summer of 1992) to complete a self-administered questionnaire regarding their attitudes toward and knowledge about health care reform. Statistical methods used were chi-square tests and factor analyses. RESULTS: Of the 631 students, 594 (94%) responded. Of the respondents, 392 (66%) felt that there should be a national health insurance plan, and 428 (72%) felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health care costs, the students identified reform of the medical malpractice system (374, 63%) and increased spending on preventive health (356, 60%) as the most likely to be effective. The students generally held negative attitudes toward managed care organizations; only 59 (10%) indicated they would choose to receive care in health maintenance organizations. CONCLUSION: The students held strong opinions about access to care, managed care organizations, and strategies intended to reduce health care spending. Medical educators not only need to find creative methods of introducing these content areas into medical school curricula but should also anticipate the need for strategies to deal with negative attitudes held by students.

Adult↗
PubMed1993

The changing relationship between clinicians and the laboratory medicine specialist in the managed care era.

Largely because of increased health-care costs, a variety of managed-care programs have been developed, and payment plans based on capitation will probably predominate in the future. Capitated, per-case, or per diem payment plans alter the traditional independence of health-care providers from the payment system. In these systems, clinical laboratory use becomes a resource to be managed, rather than a neutral third party or a source of income. Under capitated payment systems, clinicians will be motivated to reevaluate their own clinical laboratory resource use. Successful laboratory medicine specialists will understand these trends as well as the impact of newer payment plans on the relationship between themselves and clinicians, and develop new strategies to work with clinical colleagues to effect change.

Capitation Fee↗
PubMed1989

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.

Adult↗
PubMed1988

Continuous oxygen consumption measurement during initial emergency department resuscitation of critically ill patients.

A portable microcomputer-based monitoring system was adapted to permit frequent, on-line measurement of oxygen consumption (VO2) in critically ill, unstable patients in the ED during initial resuscitation. Nine adult patients were monitored with this system; they were found to have initial VO2 values that were markedly elevated, averaging 409 +/- 53 ml/min.m2. In the 11 major physiologic events which were observed in these patients, VO2 changes appropriately reflected alterations in the patients' clinical condition induced by therapeutic interventions or changes in cardiorespiratory state. This study demonstrates the feasibility of VO2 monitoring during initial resuscitation and suggests that measurement of VO2 in the ED may assist in the management of critically ill patients in this setting.

Adolescent↗
PubMed1986

Immune thrombocytopenia and response to splenectomy in chronic liver disease.

Six patients had chronic liver diseases of diverse origin, persistent unexplained thrombocytopenia, and no palpable splenic enlargement. Platelet-associated IgG levels were increased in all cases. Two patients underwent splenectomy; the spleens weighed 375 and 230 g. Each patient had prompt, complete, and sustained platelet count normalization. Two other patients treated briefly with prednisone had no response. These observations indicate that a minimally enlarged spleen may be responsible for thrombocytopenia in chronic liver disease and suggest that immune mechanisms may contribute to thrombocytopenia in this setting.

Adult↗