Prescribing CPR: a survey of physicians.

We interviewed 55 cardiologists, internists, and family practitioners to determine attitudes and practices regarding cardiopulmonary resuscitation (CPR) counseling. There was unanimous support for citizen-CPR. However, only 40 per cent of the physicians interviewed recommended CPR training to spouses of patients with coronary heart disease and 42 per cent did not provide counseling about cardiac arrest. This suggests that the doctor's office can be better utilized in the promotion of CPR education.     

Impact on retention: comparison of two CPR training programs.

CPR trainees who completed 8-hour, 3 session and 4-hour single session courses were studied for skill and cognitive retention one year after certification. Knowledge and performance scores were significantly higher for trainees from the long course, but performance skills for both groups were below certification level when compared to American Heart Association standards. The findings suggest the need for further evaluation of course components which could improve retention levels for all trainees.     

CPR training for patients' families: do physicians recommend it?

All Seattle-area cardiologists and 25 per cent of selected other physicians were queried by mail to determine whether they recommended CPR (cardiopulmonary resuscitation) training for families of their patients. Two-thirds reported that they advocated training for some patients' families, but only 52 per cent of cardiologists and 37 per cent of the others did so for families of at least half of the patients considered at risk. Physicians who had performed out-of-hospital CPR or had received advanced or recent training were more likely to recommend instruction.     

The moonlighting decisions of resident physicians.

This paper seeks to identify the determinants of the moonlighting decisions of physicians during their residency training periods. Resident moonlighting has been an area of some controversy for hospital administrators and the medical profession. The results suggest that residents are highly responsive to economic factors and conditions of employment on the residency program when making decisions about a second job.     

Locational decisions of physicians in rural North Carolina.

Recent literature suggests that there is a rural-urban imbalance of doctors in the United States. In order to investigate this maldistribution, a survey was conducted of 504 physicians in eastern North Carolina. The objective was to determine the factors which most influenced doctors' decisions to locate their practice. A conceptual framework was used to highlight the influence of the community, medical schools and the physician's personal preferences. A discriminant analysis of rural and urban physicians revealed the doctor's personal characteristics to be most important, followed by community and medical school factors. In particular, physicians raised in smaller communities showed a greater preference for practicing in rural areas. Tactics for recruiting rural doctors and other policy recommendations are suggested.     

The paradox of physicians and administrators in health care organizations

Rapidly changing times in health care challenge both physicians and health care administrators to manage the paradox of providing orderly, high quality, and efficient care while bringing forth innovations to address present unmet problems and surprises that emerge. Health care has grown throughout the past several centuries through differentiation and integration, becoming a highly complex biological system with the hospital as the central attractive force--or "strange attractor"--during this century. The theoretical model of complex adaptive systems promises more effective strategic direction in addressing these chaotic times where the new strange attractor moves beyond the hospital.     

A comparison of attitudes towards end-of-life decisions: survey among the Dutch general public and physicians

In The Netherlands, there has been a continuing public debate about the acceptability and regulatory system for medical decision-making concerning the end of life. We studied attitudes of the Dutch general public towards different types of end-of-life decisions in various situations and compared them to attitudes of physicians. Questionnaires were mailed to 1777 members of the Dutch general public (response: 78%). A total of 391 Dutch physicians, including general practitioners, nursing home physicians and clinical specialists, were interviewed in person (response: 81%). In both the survey and physician interviews, questions were asked about attitudes towards active ending of life, terminal sedation, and increasing morphine with premature death as a likely consequence, using hypothetical cases of different patients. By logistic regression analysis, the differences between public and physicians' attitudes were assessed, as well as the associations between attitudes of the general public and their personal characteristics. Acceptance of active ending of life at the request of a terminally ill cancer patient was higher among the general public (85%) than among physicians (64%). For physicians, acceptance decreased to 36% for an incompetent adult, 11% for a patient without a serious disease, and 6% for a patient with dementia. For the general public, these percentages were 63%, 37%, and 62%, respectively. Between both groups, no differences were found in acceptance of terminal sedation and increasing morphine. For the general public, determinants of support for active ending of life were being non-religious, lower education, and having a single household. Acknowledging the observed differences in appreciation of end-of-life decision-making between the general public and physicians is important in doctor-patient communication and in public debate and policymaking. Continued monitoring of practices and informing the general public and policymakers about the clinical and ethical consequences of different types of end-of-life decisions is important.     

Developing leaders vs training administrators in the health services.

In these difficult times, health care institutions need leaders, not simply managers. Leaders' breadth of skills and perspective come from understanding the values involved in health care delivery; managers know the right way to do things, but leaders know which are the right things to do. Schools of public health are moving away from their potential contribution to leadership development in health services administration. The result is a lack of accountability to the community. Leadership skills and an examination of values should be part of health services administration programs in schools of public health, which should see their mission as helping to identify and train leaders, not simply technical specialists in management.     

Hospice referral decisions: the role of physicians

In our study, we collected and evaluated the opinions of physicians in the Lowcountry of South Carolina (Berkeley, Charleston, and Dorchester counties) regarding their referrals to hospice programs and the extent of influence that their patients and families had on the decision. The research questionnaire was sent to 362 physicians who made referrals to hospice (53 percent response rate) and to 337 physicians who did not make referrals (40 percent response rate). Results revealed that medical doctors take the initiative in referrals. They felt that late referrals were due to reluctance on the part of the patient and the patient's family to admit that death was imminent. No differences were found in age, sex, medical specialty percent of terminally ill patients per practice, or initiative taken. However when the age and sex of physicians were evaluated, a statistically significant difference was found; females younger than 45 years of age were more likely to make referrals than younger males. Younger physicians were more likely to perceive that the family's reluctance to admit that death was near was a barrier to hospice referrals.     

Nontraditional graduate training for administrators of neighborhood health centers.

Because of the shortage of qualified health care administrators who are members of minority groups, many neighborhood health centers, organized as a result of the Great Society legislation of the 1960''s, suffered from their staffs'' lack of administrative skills and from rapid turnover as staff members gained experience and moved upward to other jobs. To rectify this shortage, the National Association of Neighborhood Health Centers was funded to offer master''s degree programs at the University of Michigan and the University of Southern California. These on job/on campus programs, which began in 1972, allowed participants to work and study concurrently. At Michigan, students attended class 8 hours a day, 4 days a month, for 2 years. At U.S.C., they attended classes for 14 consecutive days 3 times a year for 2 years. Since the usual admission requirements of established graduate programs limit access of minority students, who frequently lack adequate educational backgrounds, admission criteria were modified for the 56 persons enrolled in the program. For example, the Graduate Record Examination scores were not considered in the program at Michgan. Findings in an independent evaluation conducted in 1974 indicated that the programs at both universities were successful in providing graduate education relevant to the special needs of the staffs of neighborhood health centers. Only four students were dropped for academic reasons. More special programs in health administration are needed in both graduate and undergraduate schools to train people in the effective administration of health care centers, particularly those serving communities of disadvantaged persons.     

A performance comparison: USMG-FMG attending physicians.

To determine whether patterns of differences in performance exist between United States Medical Graduate and Foreign Medical Graduate attending Physicians, two types of inpatient hospital audits (Payne Process Audit and the Joint Committee on Accreditation of Hospitals' Performance Evaluation Program-P.E.P. Audit) were conducted in 22 Maryland and Pennsylvania non-federal, short-term hospitals. A total of 6,980 medical records were abstracted from eight diagnostic categories for 1,321 attending physicians; 985 of which were USMGs and 331 were FMGs. The results from both audits indicate that while there is evidence of a strong hospital-type of physician interaction for many of the diagnoses, there was no significant overall difference in performance between USMG and FMG attending physicians. The largest and most consistent differences in physician performance were associated with hospital characteristics, not physician characteristics.