PubMed · 12830576
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Jamie Wilson. 2003. Frequent attendance.. https://pubmed.ncbi.nlm.nih.gov/12830576/
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BACKGROUND: Referral and consultation letters ferry patients among providers, negotiating co-operative care. Our study examined how "relevance" is signalled and decoded in these letters, from the perspective of both experts and trainees in three clinical specialties. METHODS: 104 letters were collected from 16 physicians representing family medicine, psychiatry and surgery. Interviews were conducted with 14 of these physicians and 13 residents from the three specialties. All documents and transcripts were analysed for emergent themes. RESULTS: Six rhetorical factors influenced expert physicians' decisions about what material is relevant: educational, professional, audience, system-institutional, medical-legal, and evaluative. Each specialty placed different emphasis on these factors. Trainees reported having no instruction regarding how to construct rhetorically relevant letters, and they demonstrated awareness of only three of the factors identified by experts--professional, audience and evaluative. Experts and trainees differed in their understanding and application of these three factors. CONCLUSIONS: This research demonstrates that six rhetorical factors influence relevance decisions in letter writing, and that experts address these factors in tacit, dynamic and discipline-specific ways. Trainees share with experts an appreciation of the rhetorical functions of referral and consultation letters, but lack a comprehensive understanding of the influential factors and do not receive instruction in them. These findings provide a framework for instruction in this domain to equip novices to meet the expectations of their professional audiences successfully.
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BACKGROUND AND OBJECTIVES: This study assesses the influence of primary care continuity--both clinician and system--on patient outcomes. We consider the presumed benefits of physician continuity and practice coordination within a multi-specialty group. METHODS: The practices of 194 family physicians and general internists caring for 320000 adult members of a health maintenance organization were evaluated using four aggregate measures of outcomes--cancer screening in women, diabetic management examinations, patient satisfaction ratings, and ambulatory costs. Physician continuity and practice coordination were assessed using sequential sets of multiple regression models while controlling for patient panel and physician characteristics. RESULTS: Physician continuity, defined as seeing the same designated physician during 1 year, was not associated with any patient outcome. Practice coordination, measured by shared practice, team tenure, and medical clinic size, was significantly associated with three of the outcomes. Both medical clinic size and shared practice were associated with higher rates of cancer screening and diabetic management examinations. Team tenure exhibited a significant positive association with cancer screening, diabetic management, and patient satisfaction. CONCLUSIONS: While physician continuity was not associated with patient outcomes, primary care practice structure was. Practice coordination should be assessed to identify mechanisms to support improved care.