Primary Care Physicians In California Research Articles

Language-Concordant Primary Care Physicians for a Diverse Population: The View from California.

Purpose: The population with limited English proficiency (LEP) in California is growing. We sought to determine whether enough primary care physicians (PCPs) have the language skills to meet patient needs.Methods: The authors determined the number of PCPs who self-report proficiency in the five most common non-English languages spoken in California (Spanish, Cantonese, Mandarin, Tagalog, and Vietnamese) using Medical Board of California data from 2013 to 2015. The authors estimated LEP populations during 2011–2015 using Census data. They calculated PCP supply (the ratio of PCPs/100,000 LEP individuals) compared to a federal standard to judge adequacy. They performed a sensitivity analysis adjusting the percentage of LEP patients in a bilingual physicians' practice from 100% to the percentage of LEP individuals in California who spoke that language.Results: Of 19,310 PCPs in California, 15,933 (83%) provided information about languages they speak. There were 5,203 (33%) Spanish-, 486 (3%) Cantonese-, 986 (6%) Mandarin-, 956 (6%) Tagalog-, and 671 (4%) Vietnamese-speaking PCPs. PCP supply, compared to a federal standard, was adequate if we assumed that bilingual PCPs only care for LEP patients. However, if one assumes the number of LEP patients in a PCP's practice reflects the percentage in the general population, there is a large PCP undersupply for all languages.Conclusion: Estimates of access to language-concordant PCPs for LEP individuals are sensitive to assumptions about the percentage of LEP patients in a PCP's panel. Ensuring language-concordant access will require deliberate effort to match LEP patients with bilingual PCPs.

California Nurse Practitioners Are Positioned To Fill The Primary Care Gap, But They Face Barriers To Practice.

Nurse practitioners are well prepared to help fill care gaps arising from shortages of primary care physicians in California. This article reports findings from a survey of California nurse practitioners that examined their employment and practice barriers. The number of nurse practitioners per capita varies across California counties and is positively correlated with the number of physicians per capita. Hispanic and Filipino nurse practitioners are more likely to live in underserved areas. Nurse practitioners and their education programs are concentrated in the same counties that have high physician-to-population ratios. In these counties, recently graduated nurse practitioners are more likely to report that they plan to relocate to another state in the next five years. Expanding education programs in underserved areas, increasing the diversity of the nurse practitioner workforce, and ensuring that nurse practitioners feel empowered to fully use their skills are necessary to meet both current and future primary care needs.

Increasing confidence and changing behaviors in primary care providers engaged in genetic counselling

BackgroundScreening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions.MethodsOne hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information.ResultsPCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients.ConclusionWhile our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.

Attributing Sources of Variation in Patients’ Experiences of Ambulatory Care

Public reporting and pay-for-performance programs increasingly rely on patient experience data to evaluate individual physicians and guide quality improvement efforts. The extent to which performance variation is attributable to physicians versus other system-level units, however, remains unclear. Using ambulatory care experience survey data from 61,839 patients of 1729 primary care physicians in California (response rate = 39.1%), this study assesses the proportion of explainable performance variation attributable to various organizational units in composite measures of physician-patient interaction, organizational features of care, and global assessments of care. For each measure, multilevel regression models that controlled for respondent characteristics and used random effects to account for the clustering of patients within physicians, physicians within care sites, care sites within medical groups, and medical groups within primary care service areas, estimated the proportion of explainable performance variation attributable to each system-level unit. System-level factors explained between 27.9% to 47.7% of variation, with the highest proportion explained for the access to care composite and the lowest explained for the quality of chronic care composite. Physicians accounted for the largest proportion of explainable variance for all measures (range: 35.1%-49.0%). Care sites and primary care service areas explained substantial proportions of variance (>20% each) for the access to care and care coordination measures. Medical groups explained the largest proportions of variation (>20%) for global assessments of care. Individual physicians and their care sites are the most important foci for patient experience improvement efforts. Because markets contribute substantially to performance variation on organizational features of care, future research should clarify the extent to which associated performance deficits are modifiable.

Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences

We undertook an in-depth exploration of the unintended consequences of pay-for-performance programs In England and California. We interviewed primary care physicians in California (20) and England (20) and compared unintended consequences in each setting. Interview recordings were transcribed verbatim and subjected to thematic analysis. Unintended consequences reported by physicians varied according to the incentive program. English physicians were much more likely to report that the program changed the nature of the office visit. This change was linked to a larger number of performance measures and heavy reliance on electronic medical records, with computer prompts to facilitate the delivery of performance measures. Californian physicians were more likely to express resentment about pay for performance and appeared less motivated to act on financial incentives, even in the program with the highest rewards. The inability of Californian physicians to exclude individual patients from performance calculations caused frustration, and some physicians reported such undesirable behaviors as forced disenrollment of noncompliant patients. English physicians are assessed using data extracted from their own medical records, whereas in California assessment mostly relies on data collected by multiple third parties that may have different quality targets. Assessing performance based on these data contributes to feelings of resentment, lack of understanding, and lack of ownership reported by Californian physicians. Our study findings suggest that unintended consequences of incentive programs relate to the way in which these programs are designed and implemented. Although unintended, these consequences are not necessarily unpredictable. When designing incentive schemes, more attention needs to be paid to factors likely to produce unintended consequences.

Gender Disparities in Physician-Patient Communication Among African American Patients in Primary Care

This study investigates the role of gender in physician-patient communication among African American patients in primary care. Patients (N = 137) aged 33 to 67 were nested within 79 southern California primary care physicians' practices. In 48 interactions (35%), the physician was female and/or a member of a minority group. The study directly assessed gender differences through audiotaped physician-patient interactions as well as by measuring patients' and physicians' perceptions of their visit. This study employed a multi-informant design, in which independent raters assessed both physician and patient in audiotaped interactions, and both physician and patient self-reported on aspects of their visit. Discussions of prevention and health promotion were found to be significantly more common with male patients than with female patients but only when the physician was a nonminority male; these disparities disappeared when the physician was female and/or minority. Findings are discussed in terms of physician training, particularly for men and nonminorities.

Patient Samples for Measuring Primary Care Physician Performance

In measuring patients' experiences with individual primary care physicians (PCPs), the reliability and validity of data based on samples of "established" patients of a physician's panel have been shown. However, as large-scale initiatives seek the least costly approach to obtaining these data, little is known about the implications of expanding samples to include any patient who has seen the physician in the relevant time period. A brief validated patient questionnaire was administered to a random sample of patients visiting 67 PCPs in California between January and October 2005. We evaluated the concordance between administrative and patient-reported information on whether the physician was the patient's PCP. Response rates, data quality, and experiences reported by confirmed "established" patients were compared with those of "unestablished" patients. Administrative data designating patients as established to a PCP were highly concordant with patient self-report (96.5%). For unestablished patients, concordance was considerably lower (40.0%). Response rates among established patients were higher than those of patients believed to be unestablished (35.5% vs. 22.2%). Compared with established patients of a PCP's practice, unestablished patients reported significantly less favorable experiences with the doctor (interaction quality, P < 0.001; health promotion, P < 0.001; access, P < 0.001; integration, P < 0.05). The ranking of individual physicians differed for established and unestablished patient samples. Initiatives measuring patients' experiences with individual primary care physicians will achieve different results (response rates, physician scores) if samples include any patient who has seen the physician versus those whom administrative data indicate as established members of the physician's panel.

Evaluating Patients’ Experiences with Individual Physicians

There is increasing interest in measuring patients' experiences with individual physicians, and empirical evidence supports this area of measurement. However, the high cost of data collection remains a significant barrier. Survey modes with the potential to lower costs, such as Internet and interactive voice response (IVR) telephone, are attractive alternatives to mail, but their comparative response rates and data quality have not been tested. We randomly assigned adult patients from the panels of 62 primary care physicians in California to complete a brief, validated patient questionnaire by mail, Internet (web), or IVR. After 2 invitations, web and IVR nonrespondents were mailed a paper copy of the survey ("crossover" to mail). We analyzed and compared (n = 9126) the response rates, respondent characteristics, substantive responses, and costs by mode (mail, web and IVR) and evaluated the impact of "crossover" respondents. Response rates were higher by mail (50.8%) than web (18.4%) or IVR (34.7%), but after crossover mailings, response rates in each arm were approximately 50%. Mail and web produced identical scores for individual physicians, but IVR scores were significantly lower even after adjusting for respondent characteristics. There were no significant physician-mode interactions, indicating that statistical adjustment for mode resolves the IVR effect. Web and IVR costs were higher than mail. The equivalence of individual physician results in mail and web modes is noteworthy, as is evidence that IVR results are comparable after adjustment for mode. However, the higher overall cost of web and IVR, as the result of the need for mailings to support these modes, suggests that they do not presently solve cost concerns related to obtaining physician-specific information from patients.

Do physicians tailor their recommendations for breast cancer risk reduction based on patient’s risk?

To investigate how physicians tailor their recommendations for breast cancer prevention and risk reduction. Cross-sectional, mail survey. Random sample of primary care physicians in California (N = 822). Six standardized patient scenarios were used to assess how women's breast cancer risk factors influence physicians' recommendations for screening mammography, counseling about lifestyle behaviors, genetic testing, the use of tamoxifen, prophylactic surgery, and referral to a breast specialist. Over 90% of physicians endorsed mammography for all of the scenarios. Similarly, approximately 80% of physicians endorsed counseling about lifestyle factors for all of the scenarios. Five-year risk of developing breast cancer and family history were both strongly associated with each of the 6 recommendations. Importantly, however, physicians were more likely to endorse the discussion of genetic testing, the use of tamoxifen, and prophylactic surgery for women with a family history of breast cancer compared with women at a higher risk of developing breast cancer but without a family history. Obstetrician-gynecologists were more likely to endorse most of these practices compared with internists. Mammography and counseling about lifestyle behaviors are widely endorsed by physicians for breast cancer prevention and risk reduction. Whereas physicians are generally able to tailor their recommendations for prevention and risk reduction based on risk, they may perhaps underutilize genetic evaluation and newer therapeutic options for primary prevention for women who are at high risk of developing breast cancer but do not have a family history.

Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians.

Although practice guidelines encouraging the screening of patients for intimate partner abuse have been available for several years, it is unclear how well and in which circumstances physicians adhere to them. To describe the practices and perceptions of primary care physicians regarding intimate partner abuse screening and interventions. Cross-sectional survey of a stratified probability sample of 900 physicians practicing family medicine, general internal medicine, and obstetrics/gynecology in California. After meeting exclusion criteria, 582 were eligible for participation in the study. Reported abuse screening practices in a variety of clinic settings, based on a 24-item questionnaire, with responses compared by physician sex, practice setting, and intimate partner abuse training. Surveys were completed by 400 (69%) of the 582 eligible physicians, including 149 family physicians, 115 internists, and 136 obstetrician/gynecologists. Data were weighted to estimate the practices of primary care physicians in California. An estimated majority (79%; 95% confidence interval [CI], 75%-83%) of these primary care physicians routinely screen injured patients for intimate partner abuse. However, estimated routine screening was less common for new patient visits (10%; 95% CI, 7%-13%), periodic checkups (9%; 95% CI, 6%-12%), and prenatal care (11%; 95% CI, 7%-15%). Neither physician sex nor recent intimate partner abuse training had significant effects on reported new patient screening practices. Obstetrician/gynecologists (17%) and physicians practicing in public clinic settings (37%) were more likely to screen new patients. Internists (6%) and physicians practicing in health maintenance organizations (1%) were least likely to screen new patients. Commonly reported routine interventions included relaying concern for safety (91%), referral to shelters (79%) and counseling (88%), and documentation in the medical chart (89%). Commonly cited barriers to identification and referral included the patients' fear of retaliation (82%) and police involvement (55%), lack of patient disclosure (78%) and follow-up (52%), and cultural differences (56%). These findings suggest that primary care physicians are missing opportunities to screen patients for intimate partner abuse in a variety of clinical situations. Further studies are needed to identify effective intervention strategies and improve adherence to intimate partner abuse practice guidelines.

Screening for adolescent smoking among primary care physicians in California.

This study determined how often primary care physicians ask adolescents about smoking. We surveyed a stratified random sample of community-based, board-certified California physicians, using a mailed questionnaire. Overall, physicians (n = 343; 77% response rate) screened younger adolescents for regular smoking during 71.4% (95% confidence interval [CI] = 67.9, 74.9) of routine physical exams and older adolescents during 84.8% (95% CI = 82.3, 87.4) of such visits. For acute-care visits, the screening rates were 24.4% (95% CI = 20.6, 28.1) for younger and 40.2% (95% CI = 36.4, 44.0) for older adolescents. Physicians asked 18.2% (95% CI = 15.2, 21.3) of younger and 35.6% (95% CI = 32.0, 39.1) of older adolescents about experimental smoking. Screening varied by specialty. These data imply that physicians are missing opportunities to screen adolescents for smoking.

The clinician-teacher in managed care settings.

Managed care has grown tremendously over the last decade.1 In 1985, there were fewer than 8 million members; in 1995, there were more than 53 million members. Increasing numbers of doctors are now working in managed care, and most new graduates of residency programs will spend their careers in capitated managed care practices. Ten years ago, we wrote about the benefits of affiliations between academic health centers and health maintenance organizations (HMOs).2 What was then an interesting idea now has become a necessity. Curricula in medical schools and residency training programs have begun to address the changes in medical practice, but they have not kept pace with managed care practice development. In fact, in many parts of the country academic institutions have been insulated from the changes in practice. The well-described gap between skills emphasized in residency training and those necessary for practice continues to widen.3–5 As a result, HMO medical directors consider the majority of primary care physicians to be “poorly qualified” for managed care practice.6 There is an alarming growth of physician dissatisfaction in practice. A recent study by the California Medical Association revealed the dimensions of the problem. On the basis of their current work experiences, nearly 40% of California primary care physicians under the age of 40 would not again choose careers in medicine. Physician claims for disability, another symptom of physician distress, are at an all time high. The majority of these discontented physicians attributed career dissatisfaction to negative experiences with managed care practice.7 Residency training program directors must ensure that their graduates do not suffer from these negative attitudes. Patients also express dissatisfaction that can be attributed to deficient training. When patients say that their doctors don’t listen, are rushed, devalue their opinions, and treat them like objects, they are indirectly criticizing the programs that have trained the doctors. These concerns reflect the current problems of primary care practice and medical education. Building excellent managed care practices that incorporate the training of future physicians can serve to correct these deficiencies. Learning to practice in real managed care sites—where residents and medical students interact with role models and participate in authentic clinical work—may be the best way to prepare doctors to provide high-quality care in a cost-effective manner and to take pride and pleasure in their work.8,9 In this article we will present the results of nearly 25 years of experience in the graduate medical education of primary care internists in one managed care organization, Harvard Pilgrim Health Care (HPHC, formerly Harvard Community Health Plan). We have chosen to describe our experience in depth rather than to survey the small number of programs that have addressed the challenge of teaching in managed care settings. We will present our view of the elements of clinical competence that excellent managed care practice requires. We will describe the roles of clinician-educators in HPHC's primary care program, and discuss the challenges they face in balancing clinical practice and teaching responsibilities. Finally, we will describe the value of graduate medical education to our organization, and the challenges that must be met in order to sustain training in a busy managed care setting.

Primary Care Physicians' Satisfaction With Quality of Care in California Capitated Medical Groups

Managed care and capitation have placed new responsibilities on primary care physicians, including formally acting as "gatekeepers" for specialty services and tests. Previous studies have not examined whether primary care physicians who provide services to patients under many coverage arrangements feel differently about caring for patients covered under capitation vs those covered through more traditional forms of insurance. An understanding of whether California primary care physicians feel that they deliver a different level of quality to capitated patients could help signal whether variations in care for patients with different coverage forms are evolving. To evaluate whether primary care physicians in California capitated groups report different satisfaction levels with quality of care for patients in their overall practice than for patients covered by capitated contracts and to examine whether physicians' satisfaction with capitated care quality is influenced by the characteristics of the practice setting. Cross-sectional questionnaire. A total of 89 California physician groups with capitated contracts. A total of 910 primary care physicians (80% response rate). Satisfaction with 4 aspects of quality of care provided to patients covered by capitated contracts vs patients overall. Physicians reported lower satisfaction with all 4 aspects of care for patients covered by capitated contracts than for patients in their overall practice: 71% were very or somewhat satisfied with relationships with capitated patients (compared with 88% for overall practice), 64% were very or somewhat satisfied with the quality of care they provided to capitated patients (compared with 88% for overall practice), 51% were very or somewhat satisfied with their ability to treat capitated patients according to their own best judgment (compared with 79% for overall practice), and 50% were very or somewhat satisfied with their ability to obtain specialty referrals (compared with 59% for overall practice) (P< or =.001 for all comparisons). Being in a medical group practice (vs an independent practice association) and having a larger percentage of capitated patients were independently associated by multivariate analysis with higher levels of satisfaction with capitated quality of care (P< or =.005). These California primary care physicians were less satisfied with the quality of care they deliver to patients covered by capitated contracts than with the quality of care they deliver to patients covered by other payment sources. However, those in medical group practices and with a higher percentage of capitated patients were more satisfied with capitated care. National expansion of capitation should be accompanied by efforts to ensure that the satisfaction of practicing physicians with the care they deliver does not decline.

Delivery of STD/HIV preventive services to adolescents by primary care physicians

To document the rates of STD/HIV preventive services delivered to adolescents by primary care physicians in California, and to identify variation owing to physician and practice-related factors. A stratified random sample of California internists, family physicians, obstetricians-gynecologists, and pediatricians was drawn from the AMA Masterfile and surveyed by mail about their practices with regard to STD/HIV prevention for 15-18-year-old adolescent patients. Sixty percent of eligible physicians responded; the final sample was 1217 physicians. Results showed that 40% of physicians reported screening all of their adolescent patients for sexual activity and 31% reported educating all of their adolescent patients about STD/HIV transmission. For their sexually active adolescent patients, 36% of physicians always provided STD/HIV education, 17% always screened for number of previous sexual partners; 12% always screened for sexual orientation; and 10% always screened for frequency of casual sex. Four percent of the physicians reported that they always provided condoms for their sexually active adolescent patients; 81% never provided condoms. Higher levels of preventive services delivery were associated with female physician gender, specialization in obstetrics-gynecology, and more recent date of medical school graduation. Physicians practicing in health maintenance organizations reported providing significantly higher rates of preventive services to sexually active adolescents than did physicians in private practice. Primary care physicians provide STD/HIV preventive services to adolescents at rates far below those recommended by current guidelines. Areas where additional research would be informative are highlighted.

Management of pelvic inflammatory disease by primary care physicians. A comparison with Centers for Disease Control and Prevention guidelines.

The Centers for Disease Control and Prevention published recommendations for clinicians on the management of pelvic inflammatory disease, but it is unknown if providers are aware of the guidelines or follow them. To compare pelvic inflammatory disease screening, diagnosis, treatment, and reporting practices among primary care physicians with the Centers for Disease Control and Prevention guidelines for pelvic inflammatory disease. A weighted random sample of California primary care physicians surveyed in November 1992 and January 1993. Of the 1,165 physicians surveyed, 553 (48%) returned completed questionnaires. Among respondents, 302 (55%) reported having treated a case of pelvic inflammatory disease during the last 12 months, and of these, 52% answered that they were unsure of or do not follow the Centers for Disease Control and Prevention guidelines for pelvic inflammatory disease. Pediatricians and those with more years since residency were less likely to deviate from the Centers for Disease Control and Prevention guidelines for pelvic inflammatory disease, and family practitioners were more likely to deviate from the guidelines. Pelvic inflammatory disease is commonly encountered by primary care physicians in California. Training and experience were important predictors of compliance with the Centers for Disease Control and Prevention recommendations; however, substantial divergence from the guidelines occurs.

Tobacco Control Activities of Primary Care Physicians in California

The primary purpose of this study was to ascertain tobacco control attitudes, practices, and level of involvement in tobacco activities funded by the California Tobacco Tax Initiative prior to and after implementation of statewide programs aimed at primary health care providers. In addition, the study compared the statewide results with a county where there has been widespread tobacco control activity aimed at health care providers. A 32-item questionnaire, developed to ascertain attitudes, practices, and policies related to tobacco contrml, was completed by 581 (35%) of the 1,680 statewide physicians contacted and 460 (31%) of the 1,500 county physicians contacted. Both cohorts who responded to the pretest questionnaire were resurveyed 1 year later Results of the two-way MANOVA revealed statistical significance on both main effects (county vs. state and pretest vs. post-test). Subsequent univariate F tests revealed statistically significant differences between groups on the set of variables measuring involvement in programs funded by Proposition 99. Results indicate that statewide tobacco control programs aimed at providers might be having an impact on physicians 'practices and level of involvement in tobacco programs.

AIDS-related competence of California's primary care physicians.

We conducted a telephone survey of a random sample of primary care physicians practicing throughout the State of California to determine their AIDS-related experiences and competencies. Interviews were completed early in 1986 with 1,000 family and general practitioners and internists, 60 per cent of those eligible. Data on practice experiences reflect the increased incidence of AIDS (acquired immunodeficiency syndrome) in Los Angeles and San Francisco. The proportion of practitioners in rural areas who evaluated possible cases (17 per cent), and counseled patients at risk (50 per cent) indicated the generalized nature of the problem. Compared to similar data obtained in 1984, levels of competency in diagnosing and counseling persons with AIDS-related disorders increased in Los Angeles. However, on a statewide basis, a majority of those interviewed lack the AIDS-related knowledge and skills required to carry out their roles in dealing with AIDS. Competency was associated with physicians' personal and professional characteristics and their level of discomfort in dealing with homosexuals.