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PubMed1986

Influencing physician distribution in the South: lessons from a study in Texas.

Analysis of recent and projected trends in the geographic distribution of Texas physicians indicates that maldistribution may continue to be a problem into the foreseeable future. A survey of manpower officials in other southern states and a review of research on the effectiveness of various policy interventions reveals that programs involving preferential medical school admissions and Medicaid reimbursement levels may hold the most promise for Texas and other southern states seeking to alleviate physician maldistribution.

Delivery of Health Care↗
PubMed1996

Survey of physicians' attitudes about risks and benefits of chest computed tomography.

To investigate physicians' use of computed tomography (CT) of the chest and their attitudes regarding the risks and benefits of chest CT, we conducted a nationwide survey of 1,000 board certified physicians from several specialties of medicine, using a self-administered mail questionnaire. Three hundred thirteen surveys were completed. Overall, CT ordering practices varied with specialty. While the majority of physicians believed that CT provided new information (64%) and influenced patient management (62%), fewer physicians (30%) perceived that CT improved patient outcome. More than 90% of physicians either did not know or significantly underestimated the degree of radiation associated with CT (equivalent to 100 posteroanterior chest radiographs). We conclude that, given the paucity of prospective controlled trials establishing clear indications for the use of chest CT, physicians across all specialties should give careful consideration to the anticipated benefits and potential risks of chest CT before using this test.

Female↗
PubMed1992

Do general practitioners facilitate the breast screening programme?

Mammography uptake has been discouragingly low since the introduction of breast cancer screening in Northern Ireland. This questionnaire survey was undertaken to appraise the views of participating general practitioners (GPs) about mammography and the extent to which they followed good practice in facilitating the screening programme. Of 173 GPs, 152 returned a questionnaire. Approximately three-quarters of these GPs believed the screening programme was worthwhile for the eligible women on their list. When sent the prior notification lists from the screening unit, less than half of the GPs always checked the accuracy of patients' addresses. Fifty-five per cent of the GPs said they routinely took opportunities (as they arouse) during normal surgeries to counsel women about mammography and 90% did so in health promotion or well-woman clinics. Despite this, only 56% routinely recorded non-attendance in patients' case notes and less than 20% contacted non-attenders to advocate mammography. Such a pro-active approach was more commonly adopted with women who had not attended when invited for a cervical smear. There was no significant difference in mammography uptake among the women on the lists of GPs with differing views or whose doctors differed in their degree of active commitment to the programme. The results point to a need for the screening unit to evaluate its own advocacy role to GPs and for Health Board to devise effective appraisal strategies for health promotion clinics in primary care.

Attitude of Health Personnel↗
PubMed2006

Tobacco use, cessation advice to patients and attitudes to tobacco control among physicians in Ukraine.

To examine the relationship between physicians' smoking behaviors and their attitudes toward tobacco use by their patients and tobacco control in the Ukraine, a 70-item questionnaire was administered to 799 general practitioners (287 men and 512 women) working in both rural (278 physicians) and urban (521 physicians) areas of three regions of Ukraine. In all, 13.9% of physicians were current smokers and 21.6% reported being past smokers, with significantly (P<0.001) more men than women being current or past smokers. Odds ratios from logistic regression analysis reveal that physicians who are heavy smokers are 26% less likely to record tobacco use by patients than medium smokers. Heavy smokers devote significantly less effort to providing cessation information to patients and are 36% less likely to support the complete prohibition of smoking in the physician's workplace. Older physicians, female physicians and physicians working in urban areas are significantly more likely than younger, male and rural physicians to advise their patients on smoking. The provision of smoking cessation to patients by general practitioners in Ukraine is influenced by several factors, a major one being the smoking status of the physician. If smoking among physicians declines, this will encourage the patient to consider a serious quit attempt in several ways, most notably: (1) physicians act as societal role models and can promote non-smoking as a norm and (2) the likelihood that a patient will be provided smoking cessation counseling increases.

Adult↗
PubMed1990

Why doctors do what they do: determinants of physician behavior.

Direct payments to physicians account for about 20% of the medical care dollar, but physician decisions cause over 80% of the costs of medical care. Decision making can be viewed in a number of ways: as pure information processing, as an interaction with various stimuli, including financial penalties and incentives, and as social behavior, interacting with and reacting to peer and leadership influence. The model that accounts for the greatest amount of the available data is a multifactorial one that takes all of these views into account. The most successful behavior change efforts use a variety of mutually reinforcing approaches, and must be present constantly or behaviors revert to highly variable (lower quality) actions and decisions. This appears to be a behavioral version of the second law of thermodynamics (entropy increases spontaneously). The best practice model to manage costs and quality appears to be one in which physicians and administrators have adequate up to date information available, make group decisions, develop and continuously improve agreed upon methods of practice, interact and think before acting, and have rewards for such behavior.

Behavior↗
PubMed2000

Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment.

To examine influences of medical factors (e.g., viral load) and nonmedical factors (e.g., patient characteristics) on treatment decisions for highly active antiretroviral therapy (HAART), we sent a survey to a random sample of 995 infectious disease physicians who treat patients with HIV/AIDS in the United States in August, 1998. The response rate was 53%. Respondents were asked to report their current practices with respect to antiretroviral treatment and the extent to which each of three medical and 17 nonmedical factors would influence them for or against prescribing HAART to a hypothetical HIV-positive patient. Most reported initiating HAART with findings of low CD4+ cell counts and high viral loads, and weighing CD4+ cell counts, viral load, and opportunistic infection heavily in their decisions to prescribe HAART. Patients' prior history of poor adherence was weighed very much against initiating HAART. Patient homelessness, heavy alcohol use, injection drug use, and prior psychiatric hospitalization were cited by most physicians as weighing against HAART initiation. Thus, most physicians in this sample follow guidelines for the use of HAART, and nonmedical factors related to patients' life situations are weighed as heavily as disease severity in treatment decisions. As HIV increasingly becomes a disease associated with economic disadvantage and other social health problems, it will be essential to develop interventions and care support systems to enable patients experiencing these problems to benefit from HIV treatment advances.

Anti-HIV Agents↗
PubMedDate not supplied

A comparison of physician and nonphysician acupuncture treatment for chronic low back pain.

BACKGROUND: Although up to a third of the 10,000 acupuncturists in the United States are medical doctors, little is known about the acupuncture techniques they use or how their practices compare with those of nonphysician licensed acupuncturists. This is the first study providing descriptive data on physician acupuncture and comparison to nonphysician acupuncture. PURPOSE: This study describes how a random sample of physician acupuncturists in the United States diagnose and treat chronic low back pain and contrasts their practices with those of nonphysician licensed acupuncturists. METHODS: A total of 464 questionnaires were mailed to physician acupuncturists randomly sampled from 3 sources: web-based Yellow Pages, American Academy of Medical Acupuncturists (AAMA) membership, and Pain Clinics associated with American College of Graduate Medical Education-approved fellowship programs. Responses (n=137, 30%) were analyzed using descriptive statistics. The results of this survey were compared with data published from a similar survey of nonphysician licensed acupuncturists in Washington State. RESULTS: Physicians who perform acupuncture use a mixture of styles and emphasize neuroanatomic approaches to needle placement. Most physicians received training in French Energetic acupuncture. In contrast, most nonphysician licensed acupuncturists use a traditional Chinese medicine approach to needle placement. Despite this apparent difference in their predominant styles of acupuncture, there was a high correlation between physician and nonphysician licensed acupuncturist acupoint selection to treat low back pain. In addition to acupuncture needling, physicians use other medical treatments, whereas nonphysician licensed acupuncturists' employ a variety of traditional Chinese medicine adjuncts to needling. CONCLUSION: This study provides new information about the nature of physician acupuncture practice in the United States and how it compares to acupuncture provided by nonphysician licensed acupuncturists. Further research is necessary to determine if the different types of acupuncture provided by physicians and nonphysician acupuncturists affect treatment outcomes and costs for patients with chronic low back pain.

Acupuncture Therapy↗
PubMed2004

Intrapartum elective cesarean delivery: a previously unrecognized clinical entity.

OBJECTIVE: The purpose of the study was to investigate the incidence of intrapartum patient choice cesarean delivery-patients' requesting cesarean delivery and physicians' offering it during labor-and factors possibly influencing these requests and offers. METHODS: For a 6-month period from May 1, 2002, to October 31, 2002, obstetricians were asked to complete a questionnaire after all intrapartum cesarean deliveries regarding whether cesarean delivery was offered by the obstetrician or requested by the patient before being medically indicated. Patient medical records and physician demographic information were reviewed. RESULTS: There were 422 cases that met inclusion criteria. Questionnaires were completed in 100% of cases. Cesarean delivery was offered in 13% before a clear medical indication and requested in 8.8%. Older obstetricians, maternal-fetal medicine specialists, and full-time faculty were significantly more likely to offer cesarean delivery (P =.009, P <.001, and P =.015, respectively). Patients who were unmarried or undergoing labor induction were less likely to request cesarean delivery (P =.029 and P =.035, respectively). Maternal age, parity, stage or length of labor, epidural use, gestational age, insurance status, day of week, and time of delivery did not affect whether patients requested or were offered cesarean delivery. CONCLUSION: This study documents a heretofore unrecognized clinical entity: intrapartum elective cesarean delivery. Physician characteristics, as opposed to patient characteristics or intrapartum factors, are a major determinant of whether laboring patients are being offered cesarean delivery. LEVEL OF EVIDENCE: III

Adult↗
PubMed2003

A comprehensive public health approach to address the burden of renal disease in singapore.

With the epidemic rise of ESRD in multiple regions of the world, there is an urgent need to implement programs to address this increasing burden of kidney disease. We illustrate a public health approach using the program of the National Kidney Foundation of Singapore that incorporates stepwise primary, secondary, and tertiary strategies for prevention. Components of the program include an aggressive public education program, routine surveillance for kidney disease and associated chronic diseases, the implementation of a disease management program to improve physician practice patterns, and the provision of comprehensive services in the community through a network of Prevention Centers designed to optimize the care of patients at risk for kidney disease. Finally, an equally important aspect is the clinical and epidemiologic research component, because this will provide clear benchmarks to determine the program's effect on ESRD as well as generate information that can be used to identify future directions for this evolving program.

Female↗
PubMed2004

Medical staff attitudes: views and positions regarding blood transfusion to terminally ill cancer patients.

Blood transfusion is a widely used supportive treatment of cancer patients, most of whom are anemic. In the particular subset of cancer patients that undergoes chemotherapy, blood transfusion is viewed as an essential part of supportive care. However, the place of blood transfusion in anemic terminally ill cancer patients is far less established. There are no well-defined blood transfusion guidelines ("transfusion trigger") for these patients. Hence, transfusion decisions are greatly influenced by the personal views of the medical team. Therefore, a mail survey of 500 physicians (from several specialties) and nurses was initiated to assess their personal opinions on this topic. The overall response rate was relatively high (70%). There was broad agreement that blood transfusions, as a rule, should not be withheld from terminal cancer patients. On the other hand, only nurses were of the opinion that these patients should be transfused "as usual." Significantly, there was but a slight majority (53% of participants) that was of the opinion that transfusions to these patients do not prolong suffering. There emerged a short list of agreed-on suggestions for blood transfusion--namely, Hb level < or = 7 mg/dL, active bleeding (acute and/or occult), functional deterioration of the patient, presence of anemia resulting from chemotherapy, anginal symptoms, dyspnea, and worsening congestive heart failure. The agreed-on suggestions for transfusions in terminally ill cancer patients may serve as a reasonable physician standard for this complex clinical, medical-legal, and emotional issue.

Attitude of Health Personnel↗
PubMedDate not supplied

Differences in physician referral practices and attitudes regarding hereditary breast cancer by clinical practice location.

PURPOSE: To compare physician referral practices and attitudes regarding hereditary breast cancer by clinical practice location. METHODS: A self-administered survey of 214 physicians in Ohio's tri-state region. RESULTS: Rural-practice physicians were less likely to have ever referred for an indication of hereditary breast cancer than urban- and suburban-practice physicians combined. Rural-practice physicians reported stronger barriers to referral, including distance, lack of awareness, lack of effective cancer risk reduction, and lack of patient interest. CONCLUSION: These findings demonstrate a need for increased clinical genetics outreach, physician education, and public awareness of genetic services for hereditary breast cancer in rural areas.

Attitude of Health Personnel↗
PubMedDate not supplied

Patients' and clinicians' attitudes after the Women's Health Initiative study.

OBJECTIVE: To assess the effect of the publication of the Women's Health Initiative (WHI) study on patients' and physicians' attitudes in relation to hormone therapy (HT). DESIGN: A survey focused on the degree of knowledge and on the reactions to the WHI study was administered to 600 women allocated in two groups according to their socioeconomic status, high (HSES) or low (LSES). Additionally, 283 physicians were surveyed to determine their attitudes regarding HT after the publication of the WHI study. The rates of HT prescription before and after publication of the study were compared. RESULTS: Among patients, HT use and knowledge of the WHI study were less common among women of lower socioeconomic status (LSES 16.7% v HSES 47.3%, and LSES 15.7% v HSES 67.3%; P < 0.0001). Of the women in the LSES group who were HT users and had knowledge on the subject of the WHI study (n = 30), 56.7% contacted their physicians and 6.6% abandoned HT. These rates were similar for women in the HSES group. Among physicians, 97.2% of physicians referred to being aware of the WHI study, and 64.7% modified their clinical approach. The main changes were that 21.5% applied more rigorous risk/benefit assessment, 20.1% lowered hormone dosage, 18.8% decreased continuous-combined therapy use, 12.1% shortened the duration of HT, 7.7% abandoned medroxyprogesterone or conjugated estrogen use, and 5.0% increased the use of transdermal estrogens, tibolone, or other alternatives. As for prescriptions, after the publication of the WHI study, there was an 8.6% drop in the rate of HT prescriptions. This decrease was more pronounced for prescriptions based on conjugated equine estrogen and medroxyprogesterone acetate. In contrast, prescription of transdermal estrogens and tibolone increased 5.2% and 16%, respectively. CONCLUSIONS: There was a significant change in physicians' and patients' attitudes toward HT after publication of the WHI study.

Adult↗
PubMed2004

The effects of payment method on clinical decision-making: physician responses to clinical scenarios.

BACKGROUND: The influence of payment mechanisms on physician decisions is not well understood. OBJECTIVES: The objective of this study was to test 2 null hypotheses: 1) physicians' clinical decisions would not be influenced by payment incentives; and 2) physicians would have equal concern about medical decisions made under capitation or fee-for-service (FFS) arrangements. RESEARCH DESIGN: We conducted a physician survey in which patient insurance status (capitated or FFS) was randomly incorporated into 4 clinical scenarios using a Latin square design. SUBJECTS: We used a nationally representative random sample of family physicians in direct patient care. MEASURES: We used treatment decisions and physician "bother" scores (a measure of discomfort about decisions) in response to the clinical scenarios and adjusted for physician gender, age, board certification, income, practice location, practice mix, practice setting, geographic region, local area managed care penetration, and capitation or risk pool contracts in practice. RESULTS: Seventy-two percent of sampled physicians responded. Comparing decisions made under capitation to FFS, physicians were less likely to indicate they would perform discretionary care (relative risks [RR] range, .64-.82; P<0.001), but payment had no effect on selection of life-saving care (RR, 1.02, not significant). Physicians felt significantly more "bothered" when they made clinical decisions under capitated payment (P<0.001 in all scenarios), regardless of whether a treatment was discretionary or life-saving, and whether the decision was made for or against the treatment (P<0.001). CONCLUSIONS: Payment mechanism has significant effects on clinical decision-making. Reduction of resources spent for discretionary care might be achieved under capitated arrangements; however, physicians respond with greater levels of discomfort under capitation than FFS.

Attitude of Health Personnel↗
PubMed2006

Patient-delivered partner therapy for chlamydial infections: attitudes and practices of California physicians and nurse practitioners.

OBJECTIVE: The objective of this study was to examine California clinicians' use of and attitudes toward patient-delivered partner therapy (PDPT) to treat sexual partners of patients infected with chlamydia. STUDY DESIGN: In 2002, a stratified random sample of primary care physicians and nurse practitioners completed a mailed, self-administered survey. Weighted frequencies were calculated to assess partner management practices, including PDPT, and attitudes toward PDPT. Multivariate models were constructed to determine independent predictors of PDPT use. RESULTS: Of 708 physicians and 895 nurse practitioners, approximately half (47% and 48%, respectively) reported that they use PDPT usually or always. Over 90% agreed that PDPT protects patients from reinfection and provides better care for patients with chlamydia. However, providers reported concerns that PDPT may result in incomplete care for the partner, may be dangerous without knowing the partner's medical or allergy history, is an activity the practice may not get paid for, and may get them sued. Obstetrics/gynecology and family practice physicians were more likely than internal medicine physicians to report routine use of PDPT. Concerns about adverse outcomes of PDPT were associated with less PDPT use. CONCLUSIONS: Although the proportion of California healthcare providers routinely using PDPT is comparatively high, further study is warranted to examine the circumstances under which this partner management strategy is used.

Adult↗
PubMed2005

Surgeon specialty and operative mortality with lung resection.

OBJECTIVE: We sought to examine the effect of subspecialty training on operative mortality following lung resection. SUMMARY BACKGROUND DATA: While several different surgical subspecialists perform lung resection for cancer, many believe that this procedure is best performed by board-certified thoracic surgeons. METHODS: Using the national Medicare database 1998 to 1999, we identified patients undergoing lung resection (lobectomy or pneumonectomy) for lung cancer. Operating surgeons were identified by unique physician identifier codes contained in the discharge abstract. We used the American Board of Thoracic Surgery database, as well as physician practice patterns, to designate surgeons as general surgeons, cardiothoracic surgeons, or noncardiac thoracic surgeons. Using logistic regression models, we compared operative mortality across surgeon subspecialties, adjusting for patient, surgeon, and hospital characteristics. RESULTS: Overall, 25,545 Medicare patients underwent lung resection, 36% by general surgeons, 39% by cardiothoracic surgeons, and 25% by noncardiac thoracic surgeons. Patient characteristics did not differ substantially by surgeon specialty. Adjusted operative mortality rates were lowest for cardiothoracic and noncardiac thoracic surgeons (7.6% general surgeons, 5.6% cardiothoracic surgeons, 5.8% noncardiac thoracic surgeons, P = 0.001). In analyses restricted to high-volume surgeons (>20 lung resections/y), mortality rates were lowest for noncardiac thoracic surgeons (5.1% noncardiac thoracic, 5.2% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for difference between general surgeons and thoracic surgeons). In analyses restricted to high-volume hospitals (>45 lung resections/y), mortality rates were again lowest for noncardiac thoracic surgeons (5.0% noncardiac thoracic, 5.3% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for differences between all 3 groups). CONCLUSIONS: Operative mortality with lung resection varies by surgeon specialty. Some, but not all, of this variation in operative mortality is attributable to hospital and surgeon volume.

Aged↗
PubMed2003

The National Health Service Corps and Medicaid inpatient care: experience in a southern state.

BACKGROUND: Since 1970, the National Health Service Corps (NHSC) has worked to increase primary care access among underserved groups. This study examined whether NHSC alumni physicians were likely to treat a high proportion of Medicaid patients in their practices. METHODS: Using licensure files and hospital discharge data, we identified all physicians practicing in South Carolina who attended at least one discharge in 1998, excluding physicians who graduated before 1969, residents, and current NHSC-obligated physicians. The outcome studied was ranking in the highest quartile for Medicaid participation. RESULTS: Former NHSC participants, after adjustment for personal characteristics, education, and specialty, were nearly twice as likely to fall into the category of high Medicaid participation. NHSC physicians were more likely to practice in community health centers and to locate in areas with a health professions shortage and counties with high percentages of minorities and people living in poverty. CONCLUSION: NHSC alumni make career choices leading them to serve low-income patients.

Black or African American↗
PubMed2006

To close or not to close, that is one of the questions? Perceptions of Trauma Association of Canada surgical members on the management of the open abdomen.

BACKGROUND: The optimal abdominal closure in critically ill surgical/trauma patients remains controversial with a wide variety of commonly employed techniques. We sought to evaluate clinical equipoise by surveying Canadian surgeons regarding the use of temporary abdominal closure strategies in damage control and emergency situations. METHODS: A structured mixed-mode (Website and paper), scenario-based questionnaire was developed by members of the Canadian Trauma Trials Collaborative and directed to surgical members of the Trauma Association of Canada (TAC). RESULTS: The overall response rate was 84% (86 out of 102). In resuscitated hemodynamically stable trauma patients, 42% (29 out of 69) of respondents elected to primarily close an "extremely tight" abdominal cavity while only 23% (16 out of 70) would primarily close the same patient when physiologic exhaustion (Damage control (DC) conditions-hypothermia, acidosis, and coagulopathy) supervened. Although the majority reported preference for temporizing abdominal closures [73% (51 out of 70) non-DC, 75% (52 out of 69) DC] when the fascia was physically impossible to close; the reported primary use of mesh in these situations was quite high [24.6% (17 out of 69) non-DC, 24% (16 out of 69) DC], including a reported 7% (5 out of 69) nonabsorbable mesh usage in a contaminated octogenarian abdomen. CONCLUSION: Reported opinions suggest an overall appreciation for markers of "Damage Control," although clinical equipoise exists regarding the preferred technique and a frequent early use of mesh. These results highlight the necessity for further research but suggest challenges in defining a common standard for multicenter trials.

Abdomen↗