Biomedical subjects
Publications and source records attributed to W B Weeks.
A case history of a family practice illustrates some of the difficulties of providing health care in an era of changing economic realities. Although some of the problems appear obvious and easily solved, the physicians in the practice may well be hesitant to invest more time in its operation, despite recognition that such an investment would pay off.
In previous articles in this issue, other authors have detailed many issues regarding how to improve care for a geriatric population. However, those analyses were done based on survey data that are often difficult to translate into the setting of an actual practice. This article presents a case study of Bob Collins, MD, a practicing geriatrician whose life is altered dramatically as external pressures from the health care system force him to make changes in his practice. It concludes with an analysis of how Dr. Collins could improve his practice life and the care he delivers by considering the perspectives of his patients, his coworkers, and his organization.
BACKGROUND: It has been assumed that patients using advance directives would direct terminal care away from the intensive care unit and choose shorter, less costly, less technological terminal hospital stays. METHODS: This retrospective cohort study examined 336 consecutive patients who died in a university tertiary care medical center: 242 without advance directives, 66 with a previously completed advance directive, 13 admitted for the express purpose of terminal care, and 15 who signed an advance directive during their terminal hospitalization. Total charges (hospital and physician) were calculated for all patients and were adjusted using both physician and hospital diagnosis-related group weights. Patient participation in end-of-life decisions was determined by chart review. RESULTS: The group without advance directives had dramatically higher mean total ($49,900 vs $31,200) terminal hospitalization charges than the group with previously completed advance directives, producing a charge ratio of 1.6. After diagnosis-related group adjustment, the charge ratio was 1.35 (95% confidence interval, 1.07 to 1.72) for physician charge, 1.36 (95% confidence interval, 1.06 to 1.74) for hospital charge, and 1.35 (95% confidence interval, 1.08 to 1.73) for total charge. Multiple regression analysis controlling for age, sex, and cancer diagnosis confirmed these findings. Patients with advance directives were significantly more likely to limit treatment and to participate in end-of-life decisions. CONCLUSION: Patients without advance directives have significantly higher terminal hospitalization charges than those with advance directives. Our investigation suggests that the preferences of patients with advance directives are to limit care and these preferences influence the cost of terminal hospitalization.
BACKGROUND: Efforts at physician-payment reform in the United States have focused largely on the relative incomes of primary care physicians and specialists, who more often have procedure-based practices. Comparisons of the incomes of physicians and other professional groups have received less attention. METHODS: We used standard financial techniques to determine the return on educational investment over a working lifetime for five groups of professionals: primary care physicians, specialist physicians, dentists, attorneys, and graduates of business schools. RESULTS: In current dollars, the difference in the average future hourly income between a given professional and a high-school graduate of the same age, after educational expenses are subtracted (average hours-adjusted net present value of the educational investment) was greatest for specialist physicians and attorneys; dentists and businesspeople had intermediate values; and primary care physicians had the lowest value. The annual yield on the educational investment over a working life (hours-adjusted internal rate of return) was 15.9 percent for primary care physicians, as compared with 29.0 percent for businesspeople, 25.4 percent for attorneys, 20.9 percent for specialist physicians, and 20.7 percent for dentists. A sensitivity analysis showed that primary care physicians did less well in terms of the return on investment than the other groups even when we varied the assumptions in our model widely and that specialist physicians did less well than attorneys working in law firms and dental specialists. CONCLUSIONS: Students can expect a poorer financial return on their educational investment when they choose a career in primary care medicine than when they choose a procedure-based medical or surgical specialty, business, the law, or dentistry.
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