Projecting physician supply at a state level: physicians in Louisiana in 2001 and 2006

BACKGROUND: Many studies predicting physician supply are based on national statistics, which may not be applicable at the state level. METHODS: To facilitate meaningful planning of future physician supply in our state, we developed a conservative, population-based projection of the total number of generalist and specialist physicians who will practice in Louisiana per 100,000 population in 2001 and 2006. RESULTS: Our projections, which err toward our goal of overestimating physician supply, indicate that the total physician number per 100,000 population in Louisiana will rise from the current level of 139 to 162, then to 186, in 2001 and 2006, respectively. The number of primary care physicians will rise from 52 to 59, then to 67, and specialists from 87 to 103, then to 119, in 2001 and 2006, respectively. These numbers are well within the range of need reported in several widely published demand scenarios used for comparison. CONCLUSION: In planning future policies on physician supply, states should develop their own projections rather than simply extrapolating national data to their individual situations.     

Exercise stress test training in family practice residency programs

EST is a commonly indicated procedure in primary care medicine and as such is well suited for use by family physicians. At present there are few family physicians performing this procedure in their offices. Our survey of US family practice residency directors has shown an interest well above what would be expected for the level of current practice in the community; however, there remains an ambivalence on the need to provide EST training in the curriculum.     

Lafayette's family practice residency program: practice patterns of graduates

The Lafayette Family Practice Residency Program graduated 25 physicians prior to 1995. This project was undertaken to support our assumption that graduates establish their practices in communities near their residency programs. Further we surveyed the graduates to determine graduate satisfaction and practice characteristics. The vast majority (88%) of these physicians were practicing in Louisiana at the time of this survey. Over half the graduates were practicing in Acadiana. The results suggest that these physicians are indeed satisfied in their careers as family physicians.     

Firearm injury prevention counseling by pediatricians and family physicians. Practices and beliefs

OBJECTIVES: To ascertain and compare beliefs, attitudes, and counseling practices of primary care physicians of children and adolescents regarding firearm injury prevention counseling. DESIGN: Cross-sectional survey. SETTING: State of Washington. SUBJECTS: All active members of the state chapters of the American Academy of Pediatrics and American Academy of Family Physicians. A total of 979 pediatricians and family physicians (53%) responded to the survey after two mailings. MAIN OUTCOME MEASURES: Attitudes, beliefs, and current practices with regard to firearm safety counseling among families of child and adolescent patients. RESULTS: Only 25% of pediatricians and 12% of family physicians currently counsel more than 5% of their patients. Pediatricians were more likely than family physicians (70% vs 46%, P < .001, chi 2 test) to believe that physicians have a responsibility to counsel families about firearm safety. Pediatricians recommended removing guns from the home more frequently than family physicians (32% vs 19%, P < .001, chi 2 test), but most physicians of both specialties perceived that parents are rarely receptive to this advice. However, 97% of physicians from both specialties agreed that firearms should be stored locked separately from ammunition, and a substantial majority believed that parents would be receptive to this advice. Compared with physicians who owned guns (32%), non-owners were 15 times more likely (odds ratio, 15; 95% confidence interval, 10 to 23) to agree that families with children should not keep firearms in the home. CONCLUSIONS: Few primary care physicians who see children and adolescents currently counsel families about firearm safety, although many agree that they have such a responsibility. At least half of these physicians would potentially benefit from an intervention to improve their knowledge of and counseling skills on this topic.     

Integrating mental health services within primary care. A Canadian program

The increasingly prominent role of the family physician in delivering mental health care can be enhanced if productive and collaborative relationships can be established with local mental health services. This paper describes a Canadian program that has achieved this by bringing mental health counselors and psychiatrists into the offices of 87 family physicians in 35 practices in a community in Southern Ontario. The paper describes the program, the activities of counselors and psychiatrists within the practices, and the administrative structures set up to coordinate these activities. Data is presented from the evaluation of the first year of the program's operation (13 practices and 45 family physicians) during which time 3085 referrals were received. The program made mental health care more available and accessible, increased continuity of care, provided additional support for the family physician, offered new opportunities for continuing education, and led to a reduced and more efficient use of other mental health services. The components of the program can be adapted to most communities.     

Oxidative damage to the eye lens caused by cigarette smoke and fuel smoke condensates

The degree to which a reformed U.S. health care system relies on an adequate supply of primary care physicians will determine the urgency of change in the composition of the medical workforce. In many areas of the United States, the demand for primary care physicians, particularly in managed care settings, far exceeds the supply. In contrast, reports of reduced practice opportunities for medical and surgical subspecialists in the same settings are increasing. As opportunities for and incomes of primary care physicians are enhanced, some medical subspecialists may seek retraining in primary care. This article provides a context for understanding the development of physician retraining programs, examines precedents for retraining physicians, describes four possible pathways through which medical subspecialists might acquire primary care training, and emphasizes the importance of defining the scope of practice and necessary skills for providing primary care. Obstacles to retraining appear to be economic (Who will pay? Is the cost worth the benefit?) and jurisdictional (Who will define core competencies? Who will credential programs and trainees?). The current absence of demand for such retraining programs suggests either that marketplace-induced changes will not take place or that the notion of a primary care provider shortage and an oversupply of medical subspecialists is overstated. The inclusion of physician retraining programs in proposed health reform legislation suggests that policymakers are convinced that such programs offer one viable solution to the nation's medical workforce needs.     

Skills that Iowa family physicians desire in a new physician partner

BACKGROUND AND OBJECTIVES: The importance of specific skills in primary care continues to be debated. As a result, there is not consensus on which skills need to be stressed during residency training. Our project asked community-based family physicians to rate the importance of specific skills in a new family physician partner. METHODS: Data were collected through a cross-sectional survey of all active members of the Iowa Academy of Family Physicians. Participants were surveyed by mail, using a list of 83 skills pertinent to primary care. Physicians were asked to rate the importance of a new member of their practice having the individual skills on this list. RESULTS: A total of 546 family physicians (67%) completed questionnaires. Fourteen skills (seven cognitive and seven psychomotor) were reported to be "essential" or "very important" by at least 80% of the physicians. A total of 43 skills were rated as "essential" or "very important" by at least 50% of responding family physicians. Many of the hospital-based procedural skills, particularly those used in an intensive care setting, were rated as less important. The importance ratings of many skills were associated with the physicians' ages, size of their primary hospitals, and availability of other medical specialties. CONCLUSIONS: Family physicians tended to rate office-based procedural skills, counseling skills, and management skills as "essential or very important" to their practices. These rating might be used to guide residency training in family practice.     

A program to increase the number of family physicians in rural and underserved areas: impact after 22 years

CONTEXT: The shortage of physicians in rural areas is a longstanding and serious problem, and national and state policymakers and educators continue to face the challenge of finding effective ways to increase the supply of rural physicians. OBJECTIVE: To determine the direct and long-term impact of the Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) on the rural physician workforce. DESIGN: Retrospective cohort study. PARTICIPANTS AND SETTING: A total of 206 PSAP graduates from the classes of 1978 to 1991. MAIN OUTCOME MEASURES: The PSAP graduates currently practicing family medicine in rural and underserved areas of Pennsylvania, compared with all allopathic medical school graduates in the state, and with all US and international allopathic graduates. All PSAP graduates were also compared with their non-PSAP peers at JMC regarding their US practice location, medical specialty, and retention for the past 5 to 10 years. RESULTS: The PSAP graduates account for 21% (32/150) of family physicians practicing in rural Pennsylvania who graduated from one of the state's 7 medical schools, even though they represent only 1% (206/14710) of graduates from those schools (relative risk [RR], 19.1). Among all US and international medical school graduates, PSAP graduates represent 12% of all family physicians in rural Pennsylvania. Results were similar for PSAP graduates practicing in underserved areas. Overall, PSAP graduates were much more likely than their non-PSAP classmates at JMC to practice in a rural area of the United States (34% vs 11%; RR, 3.0), to practice in an underserved area (30% vs 9%; RR, 3.2), to practice family medicine (52% vs 13%; RR, 4.0), and to have combined a career in family practice with practice in a rural area (21% vs 2%; RR, 8.5). Of PSAP graduates, 84% were practicing in either a rural or small metropolitan area, or one of the primary care specialties. Program retention has remained high, with the number of PSAP graduates currently practicing rural family medicine equal to 87% of those practicing between 5 and 10 years ago, and the number practicing in underserved areas, 94%. CONCLUSIONS: The PSAP, after more than 22 years, has had a disproportionately large impact on the rural physician workforce, and this effect has persisted over time. Based on these program results, policymakers and medical schools can have a substantial impact on the shortage of physicians in rural areas.     

The family physician and industrial hygiene

Family physicians are increasingly being called on to become involved in the health care of workers in local industries. Many family physicians are the sole providers of occupational health care in their communities, yet their formal training is usually deficient in some of the more specialized aspects of occupational medicine. Treating work-related injuries and exposures to hazardous substances may require analyses of work sites that many family physicians have neither the time nor the expertise to perform adequately. Industrial hygienists are the consultants who are qualified to assess potential occupational hazards and are trained to perform a comprehensive analysis of the work environment as it relates to worker health. This analysis may include the measurement of potentially hazardous substances, such as ambient air concentrations of particulate matter and toxic gases, and recommendations for prevention of exposures. Two cases are presented to illustrate how valuable a consultation with an industrial hygienist can be to the family physician.     

Internal medicine in the current health care environment: a need for reaffirmation

Managed care has substantially changed the environment of health care delivery for general internists and internist-subspecialists. In the current system, one may wonder whether detailed and thoughtful workups still have a role when the direction of medical practice increasingly prizes a high volume of brief encounters. However, the very forces that drive managed care make the role of internist in the care of adults even more central. The internist's unique training and clinical approach should lead to both medically effective and cost-effective health care for adults. This type of health care will be increasingly important as the U.S. population ages and an increasing number of Americans have chronic, multisystem disease. Over the past century, internal medicine has evolved from a consultative model to a discipline that encompasses total adult care, from prevention to diagnosis and treatment of acute and chronic illness and from outpatient care in the office to inpatient care in the intensive care unit. However, the leadership role of internists in the medical care of adults is now being threatened by family medicine and by fragmentation within internal medicine itself. Managed care organizations and the general public must be shown why internists are better able than family physicians to meet the health care needs of adults. Furthermore, as the marketplace becomes more competitive, the issue of when care given by a subspecialist is superior to that given by an internist has become more prominent. The rapidly developing "hospitalist" movement also threatens the traditional role of the internist as the caregiver for adults in health and disease. Given the historic flexibility of internal medicine and the assumption that appropriate roles can be defined for family physicians, subspecialists, and hospitalists, internists will continue to play a central role in providing the best care for adults in the new world of health care delivery.     

"Doctoring" doctors and their families

Being selected to provide medical care to other physicians or their family members represents not only a gratifying professional recognition of competence by one's peers but also a challenge. Many personal and psychological factors may influence the medical care of physicians. III physicians may have difficulty with role reversal and "the VIP syndrome," while treating physicians may have to deal with their own anxiety and issues such as confidentiality, privacy, empathy, and intrusion by a physician-relative into the care of medical family members. Based on experience with more than 200 physician-patients and many adult family members of physicians, suggestions are offered for care of these patient groups.     

Characterization of acellular dermal matrices (ADMs) prepared by two different methods

This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician's office and the way in which these teams are coordinated and discusses how this "shared care" approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities.     

A method of estimating physician requirements

This article describes and applies a method of estimating physician requirements for the United States based on physician utilization rates of members of two comprehensive prepaid plans of medical care providing first-dollar coverage for practically all physician services. The plan members' physician utilization rates by age and sex and by field of specialty of the physician were extrapolated to the entire population of the United States. On the basis of data for 1966, it was found that 34 percent more physicians than were available would have been required to give the entire population the amount and type of care received by the plan members. The "shortage" of primary care physicians (general practice, internal medicine, and pediatrics combined) was found to be considerably greater than of physicians in the surgical specialties taken together (41 percent as compared to 21 percent). The paper discusses in detail the various assumptions underlying this method and stresses the need for careful evaluation of all methods of estimating physician requirements.     

Critical care in Japan and Korea. The market of excellence

Medical services in general are well advanced in Japan and Korea. However, intensive and critical care medicine is still on its way to further developments. One particular problem in both countries is the shortage of positions for intensive care physicians and nurses. Although they are well equipped with therapeutic and monitoring devices, there are a limited number of ICU beds. In Korea, the estimated number of ICUs is 122 or more. In Japan, the number of ICUs is estimated to be between 229 and 944.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

New directions for hospital strategic management: the market for efficient care

An analysis of current trends in the health care industry points to buyers seeking high quality, yet efficient, care as an emerging market segment. To target this market segment, hospitals must be prepared to market the efficient physicians. In the coming years, hospitals that can identify and market their best practicing providers will achieve a competitive advantage.     

Primary malignant lymphoma of the bladder: a case report

CONTEXT: Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients. OBJECTIVE: To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff. DESIGN, SUBJECTS, AND SETTING: An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency. MAIN OUTCOME MEASURE: Quantity of drug samples taken for personal or family use. RESULTS: Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples. CONCLUSION: Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.     

Linking psychologists and family physicians for collaborative practice.

This article describes a pilot, demonstration project that linked psychologists and family physicians to improve the care of patients with alcohol and other drug abuse problems. The project facilitated collaborative practice between family physicians and psychologists to enhance treatment of patients with alcohol and other drug abuse and other psychosocial problems in rural America. Ten pairs of psychologists and family physicians in rural Texas and Wyoming participated in the project. The training successfully established linkages between psychologists and family physicians for the care of a broad range of medical and psychological problems. This article discusses the linkage training, factors that facilitated and hindered collaboration, as well as implications for future training and collaborative health care practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Screening for domestic violence in a rural family practice

This study evaluates the effectiveness of a screening form used to assess the incidence of current and past domestic abuse among patients seen in a rural family practice. Two of nine family physicians screened most adult women they saw at a rural primary care clinic for three months in early 1996. Of the 280 women who completed surveys, 94(34%) reported experiencing physical or emotional abuse at some time in the past. Twenty-three (8%) reported physical abuse within the past year. Fourteen women (5%) reported being currently afraid of their partner or someone else. Although current or past abuse was seen across all groups, women reporting abuse were more likely to be unmarried, younger, and on medical assistance. They were also more likely to have children at home. We concluded that the prevalence of women reporting current abuse in a rural family practice is sufficient to warrant mass screening.     

Family medicine in Minnesota: office costs and productivity

Clinics representing more than half of Minnesota's family physicians participated in a statewide study on the practice of family medicine conducted by the Minnesota Academy of Family Physicians. The survey was designed to provide direction for individual physicians, administrators, and the Minnesota Academy of Family Physicians as an organization. The survey identified some concerns regarding access to care. In the central portion of the state, 71% of the full-time equivalent family physicians were in practices with Medicaid patient restrictions. In the most sparsely populated towns, 35% of the reporting family physicians who provided obstetrical care three years ago discontinued that service due to the cost or availability of professional liability coverage. Statewide in 1989, 57% of the family physician positions recruited for by the practices studies were unfilled at year's end, with 82% unfilled in the most sparsely populated areas.