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PubMed2003

All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving.

Much attention has been focused in recent years on the ethical acceptability of physicians receiving gifts from drug companies. Professional guidelines recognize industry gifts as a conflict of interest and establish thresholds prohibiting the exchange of large gifts while expressly allowing for the exchange of small gifts such as pens, note pads, and coffee. Considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize. Policies and guidelines that rely on arbitrary value limits for gift-giving or receipt should be reevaluated.

American Medical Association↗
PubMed1996

Psychiatry at a crossroad: our role in primary care.

OBJECTIVE: The shortage of primary care physicians is seen as an urgent health systems priority and is supported by a national consensus. Psychiatry is at a crossroad and must reevaluate the profession's role in primary care. This article supports the position that psychiatrists need to be able to medically evaluate and to provide basic primary medical care for seriously mentally ill patients who do not have adequate access to general health care. Many of the seriously mentally ill are difficult to treat when they contact a medical care provider. Because of their psychiatric symptoms, they often are unlikely to receive adequate medical care. Psychiatrists frequently are the only physicians with whom they have consistent contact. METHOD: This article contains a proposal for a new initiative to broaden the role of public psychiatrists to include a primary care role. In addition, new opportunities for dual or triple board certification are reviewed. RESULTS: A new curricular model for primary care training in general psychiatry programs is outlined. The new curriculum would include training for diagnostic and primary care skills to prepare psychiatrists to provide basic primary medical services for the chronically mentally ill. CONCLUSIONS: The new curricular proposal would create an elective psychiatry primary care track. This is possible within current accreditation requirements. Psychiatric residents could receive primary care training throughout their residency.

Chronic Disease↗
PubMed1998

Characteristics of psychiatrists who perform ECT.

OBJECTIVE: Use of ECT is highly variable, and previous study has linked its availability to the geographic concentration of psychiatrists. However, less than 8% of all U.S. psychiatrists provide ECT. The authors analyzed the characteristics of psychiatrists who use ECT to understand more fully the variation in its use and how changes in the psychiatric workforce may affect its availability. METHOD: Data from the 1988-1989 Professional Activities Survey were examined to investigate the influence of demographic, training, clinical practice, and geographic characteristics on whether psychiatrists use ECT. RESULTS: Psychiatrists who provided ECT were more likely to be male, to have graduated from a medical school outside the United States, and to have been trained in the 1960s or 1980s rather than the 1970s. They were more likely to provide medications than psychotherapy, to practice at private rather than state and county public hospitals, to treat patients with affective and organic disorders, and to practice in a county containing an academic medical center. CONCLUSIONS: Demographic and training characteristics significantly influence whether a psychiatrist uses ECT. Opposing trends in the U.S. psychiatric workforce could affect the availability of the procedure. Expanding training opportunities for ECT and making education, training, and testing more consistent nationwide could improve clinicians' consensus about ECT and narrow variation in its use.

Confidence Intervals↗
PubMed2003

A quality improvement process for implementing the Texas algorithm for schizophrenia in Ohio.

Medication algorithms developed in Texas are being implemented in a number of states in the United States and internationally. This report describes a quality improvement process adapted from the Texas Medication Algorithm Project that was used to implement the Texas algorithm for schizophrenia in Ohio. A total of 38 physicians were surveyed about their perceptions of barriers to implementation of the guidelines. The physicians generally thought that the schizophrenia algorithm was good, current, and applicable. Although they did not perceive barriers to its implementation, they did not seem to alter their practices to a great extent in response to the algorithm. The results of the study may guide other states in their implementation of algorithms.

Algorithms↗
PubMed1997

A spreadsheet method for calculating maximum caseload and intake capacity for CMHC psychiatrists.

OBJECTIVE: A method was sought to help administrators of community mental health centers determine a level of psychiatric staffing that is both cost-efficient and ensures high quality of care. METHODS: A survey of staff psychiatrists was conducted at a large community mental health center with seven outpatient clinics. The survey measured variables that can affect staffing requirements, including the number of hours psychiatrists have available for direct care, their preferred intervals between a patient's return visits, and the duration of appointments for an initial psychiatric assessment and for medication maintenance. A computer spreadsheet was developed to calculate the caseload capacity and intake capacity for clinics of the center. RESULTS: The survey indicated that the psychiatrists at the center had an average of 33 hours a week available for direct care. The mean preferred time between a patient's medication maintenance visits was 7.3 weeks. The mean time required for a psychiatric assessment was 80 minutes, and for a medication maintenance visit it was 33 minutes. With these data, the spreadsheet method was used to calculate intake and caseload capacity for psychiatric staff at three of the center's clinics. CONCLUSIONS: The data-based approach to calculating capacity can be modified to meet local needs. It brings objectivity to decision making about staffing, and the methods can improve resource management and enhance relationships between stakeholders and physicians.

Community Mental Health Centers↗
PubMedDate not supplied

Provider impact in diabetes education. What we know, what we would like to know, paradigms for asking.

PURPOSE: A literature search from 1985 to the present was performed using Web-based search engines to identify evidence-based studies of diabetes education. METHODS: Twelve studies were identified in which a provider characteristic was defined as a discriminate variable associated with impact or efficacy of the education intervention. Provider was defined as all those participating in diabetes care and education (e.g., patient, education and care teams, funding and policy agencies). The Certified Diabetes Educator credential also was described. RESULTS: Specialty or discipline of the provider/care team, technology when used to assist providers, and physician practice patterns have been assessed. There is a paucity of research that assesses provider impact or the specific impact of provider characteristics on diabetes outcomes in a controlled and scientifically rigorous fashion. CONCLUSIONS: Suggestions for evaluating provider impact based on literature concerning psychotherapy and healthcare education outcomes are: identify provider characteristics/attitudes/skills and link them to outcomes, define therapeutic alliance in diabetes care/education and assess its contribution to outcomes; and use performance measures as provider characteristics.

Diabetes Mellitus↗
PubMed2003

Impact of differential response rates on the quality of data collected in the CTS physician survey.

Survey administrators face trade-offs between expending additional survey resources to maximize response rates versus using fewer resources and accepting lower response rates. Using data from the Community Tracking Study's Physician Survey, we examined how survey estimates and data quality changed as additional respondents completed the survey. Results showed that improvements in response rates over the range examined (i.e., up to 65%) did not change estimates appreciably nor affect data quality. As long as these results are not overstated to imply that extremely low response rates are credible, this study may permit researchers to disseminate interesting results in peer-reviewed journals even when the response rate falls slightly short of current standards. It must also be emphasized, however, that we were unable to measure the nonresponse effect of those who were never interviewed. Achieving a response rate significantly above 65% might have changed the survey results appreciably.

Data Collection↗
PubMedDate not supplied

The impact of an online evidence system on confidence in decision making in a controlled setting.

OBJECTIVE: To examine the impact of online evidence retrieval on clinicians' decision-making confidence and to determine if this differs for experienced doctors and nurses. METHODS: A sample of 44 doctors and 31 clinical nurse consultants (CNCs) answered 8 clinical scenarios (600 scenario answers) before and after the use of online evidence resources. Clinicians rated their confidence in scenario answers and in the evidence they found using the information system. RESULTS: Prior to using online evidence, 37% of doctors and 18% of CNCs answered the scenarios correctly. These clinicians were more confident (56% very confident or confident) in their answers than those with incorrect (34%) answers. Doctors with incorrect answers prior to searching rated their confidence significantly higher than did nurses who were incorrect. After searching, both groups answered 50% of scenarios correctly. Clinicians with correct answers had greater confidence in the evidence found compared to those with incorrect answers. Doctors were more confident in evidence found confirming an initially correct answer than were nurses. More than 50% of clinicians who persisted with an incorrect answer after searching reported that they were confident or very confident in the evidence found. Clinicians who did not know scenario answers before searching placed equal confidence in evidence that led them to a correct or incorrect answer. CONCLUSIONS: The information obtained from an online evidence system influenced clinicians' confidence in their answers to the clinical scenarios. The relationship between confidence in answers and correctness is complex. Both existing knowledge and professional role were mediating factors. The finding that many clinicians placed confidence in information that led them to incorrect answers warrants further investigation.

Attitude of Health Personnel↗
PubMedDate not supplied

Judgment analysis of surgeons' prioritization of patients for elective general surgery.

BACKGROUND: Access to elective general surgery in New Zealand is governed by clinicians' judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and transparency. Our objective was to describe this judgment in terms of previously elicited cues. METHODS: We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS. RESULTS: Agreement between surgeons was poor (ra=0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R2=0.66). DISCUSSION: The level of agreement reflects surgeons' practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.

Elective Surgical Procedures↗
PubMed1985

Hospital response to DRG-based prospective payment.

The introduction of the Medicare Prospective Payment System (PPS) is markedly influencing the environment in which hospitals care for patients, teach medical students and residents, and perform clinical research. Hospitals, particularly teaching institutions, are responding to this challenge by developing new management reports, by analyzing physicians' practice patterns, and by estimating more precisely the fixed and variable costs of various ancillary services. The common objective of these activities is to improve our knowledge of clinical practices, and thereby improve decisions relating to the cost-effectiveness and quality of care delivered to patients in the hospital.

Cost Control↗
PubMedDate not supplied

Physicians' risk attitudes, laboratory usage, and referral decisions: the case of an academic family practice center.

Individual differences in physicians' laboratory use and referral rates are important aspects of practice variation that have real financial and health consequences. A way to explain these differences is needed. In this empirical study, physicians' risk attitudes (measured on a multidimensional scale) are shown to be good predictors of use rates for certain specific laboratory procedures, but not good predictors of physicians' referral rates. A 15-item survey form that measured risk-taking attitudes in the financial, health, social, and ethical domains was administered to all clinical faculty at an academic family practice center (n = 14). Each physician's utilization rates for the 17 most frequently ordered laboratory procedures were calculated for all patient visits for one calendar year. Overall referral rates were calculated for the same period. Physicians' risk attitudes (12 completed the survey) accounted for over 50% of the variance for several of the laboratory procedures. For example, the rank-order correlation between the complete blood count utilization rate and a Likert-scale item measuring physicians' propensity to take physical risks was 0.91 (p less than 0.001). The details of these findings help to explain an important component of practice variation.

Academic Medical Centers↗