Non-primary Care Research Articles

The Audition Elective and Its Relation to Success in the National Resident Matching Program

Background: Many medical students take audition electives in an effort to improve their chances of being selected by a residency program. Purpose: The study was to determine if audition electives improved student success in the National Resident Matching Program. Method: A questionnaire was mailed to graduates of the University of South Dakota School of Medicine from 1977 (the charter graduating class) through 1997. Comparisons were done between students who took audition electives and those who did not. Statistical analysis was performed by chi-square or Fisher Exact tests for smaller groups. Results: The data show no statistically significant difference in first-choice matching for the total group (p =. 35), primary care (p =. 44), or nonprimary care subgroups (p =. 38). Sample size is inadequate for sufficient analysis of individual specialties. Conclusions: The limited time available to provide students with a broad education and the disadvantages of taking audition electives should be considered when advising students about 4th-year schedules.

Why are internal medicine residents at university medical centers not pursuing fellowship training in gastroenterology? A survey analysis

OBJECTIVE: The decrease in available GI fellowship positions appears to be associated with a disproportionate decrease in the quality of applicants. Thus, the aims of this study were: 1) to determine the current interest in advanced training of nonprimary care internal medicine residents at university medical centers, and 2) to identify the reasons why fellowship-bound residents are not pursuing GI. METHODS: Postage prepaid survey cards were distributed directly to the campus mailboxes of 1862 internal medicine residents at 61 university medical centers at the beginning of their second postgraduate year of training. E-mail questionnaires were then sent to 144 residents planning fellowship training and careers in academia other than in GI/hepatology. RESULTS: A total of 592 residents (32% response) returned completed survey cards. Overall, 392 (66%) indicated that they will pursue fellowship training and ∼60% wanted to remain in academia. However, <10% indicated an interest in GI/hepatology. E-mail replies were then obtained from 122 residents (87% response) planning academic careers but not in GI. The major reasons for disinterest in GI/hepatology include the perception that jobs are not widely available, that the field is intellectually unchallenging, as well as that is too procedure-oriented. CONCLUSIONS: The majority of residents at university training programs plan advanced training and want to pursue careers in academia, but not in GI/hepatology. Efforts to attract highly qualified residents to GI must emphasize the improved job market, especially as it exists in academia; must advertise research opportunities; and must de-emphasize the procedural nature of this subspecialty.

Why are internal medicine residents at university medical centers not pursuing fellowship training in gastroenterology? A survey analysis.

The decrease in available GI fellowship positions appears to be associated with a disproportionate decrease in the quality of applicants. Thus, the aims of this study were: 1) to determine the current interest in advanced training of nonprimary care internal medicine residents at university medical centers, and 2) to identify the reasons why fellowship-bound residents are not pursuing GI. Postage prepaid survey cards were distributed directly to the campus mailboxes of 1862 internal medicine residents at 61 university medical centers at the beginning of their second postgraduate year of training. E-mail questionnaires were then sent to 144 residents planning fellowship training and careers in academia other than in GI/hepatology. A total of 592 residents (32% response) returned completed survey cards. Overall, 392 (66%) indicated that they will pursue fellowship training and approximately 60% wanted to remain in academia. However, <10% indicated an interest in GI/hepatology. E-mail replies were then obtained from 122 residents (87% response) planning academic careers but not in GI. The major reasons for disinterest in GI/hepatology include the perception that jobs are not widely available, that the field is intellectually unchallenging, as well as that is too procedure-oriented. The majority of residents at university training programs plan advanced training and want to pursue careers in academia, but not in GI/hepatology. Efforts to attract highly qualified residents to GI must emphasize the improved job market, especially as it exists in academia; must advertise research opportunities; and must de-emphasize the procedural nature of this subspecialty.

Myers-Briggs Type and Medical Specialty Choice: A New Look at an Old Question

Background: Career development of health professionals is one of many uses of Myers-Briggs Type Indicator (MBTI), with many studies reported from the 1950s. Since 1977, no large-scale effort to collect data on the medical school population has been reported. Purpose: To determine (a) changes in MBTI profiles of medical students over time, (b) differences between the profiles of men and women and the effects of the increased number of women in medical school, (c) possible associations between type and career choices, and (d) possible type differences of graduates selecting primary care and specialties. Method: Twelve U.S. schools with data on 3,987 students contributed to a database of their graduates' MBTI type and specialty choice at Match. Results: Compared with data from the 1950s, the type distribution of physicians has remained fairly stable, save for a trend toward more judging types. Women in medicine today are more representative of the general population on the feeling dimension than earlier, when medicine was more male-dominated. Women are more likely than men to choose primary care specialties, as are those with preference for introversion and feeling. Feeling types choose Family Medicine significantly more often than thinking types; male, extraverted, and thinking types choose surgical specialties. Of those selecting nonprimary care, male, extraverted, and thinking types choose surgical specialties significantly more than women, introverted, and feeling types. Conclusion: Type remains useful for understanding how some aspects of personality relate to medical specialty choice.

Treatment-Refractory Depression in the Elderly: An Audit of Primary Care Referrals to Psychiatric Services in Swindon, U.K.

BACKGROUND: Our objective was to audit primary care referrals for depression to assess prereferral quality of antidepressant treatment. METHOD: We performed a retrospective audit of referrals from primary care to the Department of Old Age Psychiatry in Swindon, Wiltshire, U.K., for a new episode of depression, excluding life-threatening cases, between January 1, 1997, and December 31, 1998. To determine if treatment before referral met criteria for an adequate trial, for audit purposes we defined an adequate trial as 8 weeks at maximal dose as specified by the British National Formulary. RESULTS: A computer search identified 58 referrals: 33 cases were excluded-3 notes were unavailable for audit, 7 were wrongly coded, 8 were life-threatening, and 15 were non-primary care referrals. Of the 25 evaluable patients, 2 had had an adequate duration of treatment and 6 were taking maximal doses of antidepressants, but none was taking a dose for an adequate duration. CONCLUSION: Patients referred to secondary care for depression are often undertreated prior to referral, which may explain why the patients in this retrospective audit had failed to respond. Primary care physicians should be encouraged to use medication in elderly patients that requires little or no dose titration at high doses and for at least 8 weeks before considering the patient to be treatment refractory.

Intention to practice primary care by pediatric residents: nature or nurture?

Factors associated with the intention to practice primary care were examined in a survey of a national sample of PL-2 residents (n = 98). Socioemotional orientation (nature), faculty and peer encouragement (nurture), and clinical experiences during residency (nurture) were independently associated with a primary care career choice. For residents who changed career intentions to primary care from a nonprimary care preference, gender, encouragement by faculty and peers, and outpatient experiences during residency were associated with the change. Encouragement by both faculty and peers had the strongest influence on primary care career choice for all residents.

Characteristics of women US family physicians.

There have been no national studies comparing women family physicians (FPs) with other physicians; determining FP characteristics is useful in workforce and health systems planning and may also be of inherent interest to FPs and others. A comparison of the FP (n = 347) and other (n = 4154) respondents to the Women Physicians' Health Study. Personal and clinical practices. Women FPs are more likely to be US-born and self-defined as politically liberal than were other women physicians. Those graduating from medical school in the 1950s through 1970s were less and those graduating in the 1980s were far more likely to be board certified than were other women physicians. Although their personal and household incomes were significantly lower, their professional satisfaction was similar to those of other women specialists, and they reported a lesser frequency of severe work stress. Personal health-related habits and health status of women FPs were similar to those of other women physicians. For all 14 counseling practices examined, the amount of counseling they reported performing, the clinical relevance they ascribed to those practices, their self-confidence in performing the practices, and the amount of training they received was as high as or higher than that of other women primary care practitioners and usually exceeded those of non-primary care physicians outcomes at the P < .001 level. Although women FPs resemble other women physicians in some respects, they are more liberal, are professionally well-satisfied, and are relatively avid preventionists.

Initiating a Clinical Trials Cooperative Group in an Increasingly Managed Care Environment: Successes and Problems in Establishing Collaboration

The Communication Sciences and Disorders Clinical Trials Research Group (CSDRG) was organized in 1995 and funded in 1997 by the National Institute on Deafness and Other Communication Disorders (NIDCD) as a cooperative clinical trials group. It designs and conducts multi-institutional randomized clinical trials focusing on treatments delivered by speech-language pathologists (SLPs) and audiologists for disorders of speech, language, hearing, balance, and voice/swallowing. Data are presented on a comparison of the number of site participants from the group's onset in 1995 through 31 December 1997. Successes and problems experienced by CSDRG are defined with regard to organizing the group, and designing and conducting clinical trials in a managed care environment with nonprimary care professionals. Different barriers to participation are identified at various levels of care/types of institutions and with various types of patient populations, for example, children receiving their health care through the schools versus elderly, demented individuals in nursing care facilities.

Accuracy of Self-Report of Mammography and Pap Smear in a Low-Income Urban Population

Background: Cancer screening history can often be obtained only by self-report, particularly for disadvantaged populations. We examined the accuracy of self-report of mammography and Pap smear for an urban, low-income population. Methods: Women attending non-primary care clinics (mostly surgery and orthopedics) at a large public teaching hospital in Minneapolis between July 1992 and May 1993 were queried about their screening history (n = 477). The women were interviewed by a trained peer-recruiter and asked whether they had ever heard of a Pap smear or mammogram, whether they had ever had one, where it was done, and when the last one was. We verified self-report by checking medical records where the test was performed. Results: The positive and negative predictive value of recall of mammography in the previous year was 72.4% and 90.6%, respectively. The figures for Pap smear recall were somewhat lower, 65.5% and 85.9%, respectively. We found a record of a mammogram in 88% of women able to recall the year. Of these, slightly over two-thirds recalled their mammogram in the same year as their record indicated. Inaccurate recalls were more commonly of the “telescoping” type, i.e., tests were recalled as having occurred more recently than was the case. Recall was substantially better for recent tests. Results for Pap smear recalls were broadly similar. Conclusions: The accuracy of self-report of mammography and Pap smear is relatively poor for medical practice but is acceptable in population surveys with appropriate correction for overreporting.

Influence of Third-Year Clerkships on Medical Student Specialty Preferences.

Purpose - The purpose of this study was to investigate influences on third-year medical students' specialty preferences.Method - A survey questionnaire was mailed to third-year medical students at two medical schools. The questionnaire asked students to rate the degree to which various aspects of the third-year curriculum and perceived specialty characteristics influenced their specialty preferences.Results - A total of 214 (70%) of eligible students responded, of whom 46% were female and 57% preferred primary care (PC) specialties. The most frequently cited influential clerkship was internal medicine. Most clerkships (72%) had a positive influence on students' preferences. PC clerkships had more positive influences than non-primary care (NPC) clerkships, especially among PC-oriented students. The most influential aspects of clerkships were faculty and residents, especially in PC clerkships. For both PC- and NPS-oriented students, the diagnostic and patient-related characteristics of their preferred specialties were highly influential. PC-oriented students were more likely to be attracted to prevention and biopsychosocial aspects of specialties, and NPC-oriented students to the opportunity to do procedures and intervene in illnesses. Student gender appeared to have little influence on response patterns, except as a proxy for specialty preference, which, for women, was more likely to be a primary care specialty.Conclusion - These findings suggest that the third-year clerkships, especially at non-university sites, play an important role in specialty choice, and that factors attracting students to PC differ significantly from those attracting students to NPC.

Reliance on High Technology Among SeniorMedical Students

To gain a better understanding of senior medical students who perceive high-technology medicine as the desirable form of medical practice, we developed and evaluated a structural equation model. Intolerance to clinical uncertainty, Machiavellianism, and authoritarianism characterized students who scored higher on reliance on high-technology medicine. High scorers also tended to have a negative orientation toward patients' psychological problems and were unlikely to choose careers in primary care medicine. Students who perceive high technology as a panacea in clinical medicine share personal traits and attitudes toward patients that are not conducive to achieving the national goal of a 50:50 ratio between primary and non-primary care physicians.

The economic returns to hospital admitting privileges.

Legal suits contesting the denial or termination of hospital staff privileges are the most common antitrust cases involving medical markets. There is, however, very little evidence about the economic implications for the physicians of having staff privileges. Using a nationally representative sample of self-employed physicians from 1992, this article presents estimates of the effects of hospital admitting privileges on physician earnings. The results indicate that for nonprimary care specialists with few admitting privileges, gaining an additional privilege increase earnings. This effect diminishes as the number of admitting privileges increases, however, and there are no economic gains beyond having three to four admitting privileges. Among primary care physicians, we detect no statistically significant effect of hospital admitting privileges on earnings. With the growing emphasis on managed care, physicians are being scrutinized both in terms of the quality of care they deliver and their impact on the economic performance of hospitals and managed care organizations. This suggests that the frequency of lawsuits involving the denial or rescission of medical staff privileges may assume even greater importance.

Reliance on high technology among senior medical students.

To gain a better understanding of senior medical students who perceive high-technology medicine as the desirable form of medical practice, we developed and evaluated a structural equation model. Intolerance to clinical uncertainty, Machiavellianism, and authoritarianism characterized students who scored higher on reliance on high-technology medicine. High scorers also tended to have a negative orientation toward patients' psychological problems and were unlikely to choose careers in primary care medicine. Students who perceive high technology as a panacea in clinical medicine share personal traits and attitudes toward patients that are not conducive to achieving the national goal of a 50:50 ratio between primary and non-primary care physicians.

Role modelsʼ perceptions of themselves and their influence on studentsʼ specialty choices

To examine the perceptions of faculty role models to learn whether their perceptions of role models' behaviors are congruent with those of their students. In 1996 a survey was mailed to 210 student-identified faculty role models at the University of Washington School of Medicine and the University of North Carolina at Chapel Hill School of Medicine. The nominees were asked to rate to what extent each of 32 student-identified role model characteristics was representative of their behavior. They were then asked to rank order the characteristics they felt were most important to model for students. The role models were also asked to rate how much influence they perceived themselves to have on their students' specialty choices. A final, open-ended question inquired about the single characteristics they modeled to students that most influenced the students' specialty choices. The role models' specialties were grouped as either primary care (PC) or non-primary care (NPC). Data were analyzed with several statistical methods. Of the 210 mailed surveys, a total of 177 were returned, for a response rate of 84%. The role models perceived their behaviors much like their students did; the role models' self-ratings were generally high for all of the student-defined characteristics. Although clinical reasoning was considered the most important characteristic to model for students, the role models also believed that enthusiasm and love for their work were the characteristics that most influenced their students' specialty choices. Few differences were found between the PC and the NPC role models. The role models in this study agreed with their students about what is important to model. They did not intentionally try to recruit students to join their specialties but felt that demonstrating enthusiasm and a sincere love for what they did has a strong influence toward this end.

The provision of primary care: does managed care make a difference?

Drawing on a nationally representative survey of physicians, this paper examines the extent to which physicians split their time between primary care and non-primary care activities and whether managed care makes a difference. We find that managed care does matter: Physicians have been narrowing their scope of practice, and the trend is linked to their involvement with managed care plans. These findings have implications for workforce policy and training, regulation of managed care contracting, and the quality of care.

Effects of second office and hospital consulting practices of physicians on rural communities.

This research examined the prevalence of second offices and hospital consulting practices of physicians in Missouri, the characteristics of physicians participating in such practices, the change in availability of services through these practices, the characteristics of counties and hospitals involved, and the practice organization of participating physicians. The assessment of the factors was conducted within the conceptual framework of community and physician characteristics, practice form and organization, and health system resources. In 1993, 64 of the 93 nonmetropolitan counties in Missouri gained, on average, 1.3 full-time equivalent physicians through second office and hospital consulting practices. Eighteen nonmetropolitan counties lost, on average, 0.4 full-time equivalent physicians through these practices; 11 nonmetropolitan counties were not affected. The majority of physicians engaged in these two types of practices are nonprimary care specialists. Consequently, in addition to the net contribution to total physician service availability, many nonmetropolitan counties gained access locally to a wider variety of specialty services. This change in availability of physician services, not generally incorporated in decisions, needs to be considered when policy efforts are undertaken to change the spatial and specialty distribution of physicians.

Antecedent and concurrent correlates of primary care practice

Background: Understanding factors in specialty choice may increase the number of primary care practitioners. Purpose: The purpose of this study was to learn how primary and nonprimary care graduates differed on entry to medical school, during medical school, and as practitioners. Methods: We surveyed 1983 to 1987 graduates of 1 school about their careers, achievements, and values; 76% of the 430 responded. Of these, 117 were primary care practitioners. School records provided data on graduates’ admissions characteristics and student performance levels, and we analyzed data by descriptive statistics, Student's t test, and chi‐square test. Results: Primary and nonprimary care graduates were alike on entry to medical school. Their performance in medical school differed on 7 of 15 measures. Many practice patterns were similar, but whereas primary care practitioners stressed a clinician role oriented to people and community, nonprimary care practitioners emphasized more a scholarly role. Conclusion: Only differences in student performance foreshadowed a differentiating thrust in graduates’ roles as primary and nonprimary care practitioners.

Perceptions of teaching behaviors by primary care and non-primary care residents.

To ascertain the most helpful and least helpful faculty teaching behaviors as perceived by primary care and non-primary care residents and to assess differences in those perceptions between the two resident groups. A cross-sectional mailed survey was undertaken in 1993-94 of all 1,046 residents (including interns) in U.S. Army graduate medical education programs. The survey asked the residents to rate the 38 teaching behaviors of Wolverton and Bosworth. Mean ratings were calculated for each teaching behavior, and the ratings of the two resident groups were compared using Kendall's coefficient of concordance. In all, 490 (47%) of the residents responded: 191 (45%) of 421 in primary care, and 299 (48%) of 625 in non-primary care. The primary care and non-primary care groups had a high degree of concordance in ranking of the 38 teaching behaviors (W = .953). The exact rank orders differed slightly, but there was disagreement on only one behavior each within the rankings of both the ten most helpful and the ten least helpful behaviors. Army residents in all of the major specialties have similar perceptions of what they consider helpful behaviors from their faculty.

In pursuit of generalism: Basic factors influencing the specialty decisions of osteopathic medical school seniors in 1995

An analysis of survey responses of seniors graduating from osteopathic medical school in 1995 shows that the selection of the medical specialty they planned to pursue in their postgraduate training was considerably influenced by 10 common factors. These factors ranged from the students' orientation to people or techniques, to prestige and income associated with the specialty. The People orientation factor exerted a strong influence on students planning to pursue primary care specialties (defined as Family Practice, General Internal Medicine, and General Pediatrics) Similarly, for students planning to pursue a nonprimary care specialty, the Prestige/income, the Intellectual Content factor, and the Research Factor, with its absence of stress and opportunity for research in other nonprimary care fields, swayed their decision. These findings have implications for the medical school admissions process. If that process can be used to identify students who relate well to people and are more oriented to dealing with preventive medicine and the broad spectrum of health problems presented by individual patients, then it could become an even greater force in the movement toward generalism in medicine.

Appropriateness of Referrals for Open-Access Endoscopy

Open-access endoscopy allows nongastroenterologist physicians the opportunity to directly schedule elective common endoscopic procedures for their patients without having them first examined in the gastrointestinal clinic. There are few data as to whether nongastroenterologist physicians in the United States schedule patients for appropriate indications. To examine our practice to see whether patients undergoing open-access endoscopy were scheduled for appropriate indications and to see whether there were differences among physicians in various medical specialties. We prospectively tracked 310 consecutive patients scheduled for open-access esophagogastroduodenoscopy (EGD) and colonoscopy by nongastroenterologist physicians over a 9-month period in our academic practice setting to determine whether the indications for performing the procedures were appropriate. The American Society for Gastrointestinal Endoscopy criteria (revised in 1992) were used as the standard for comparison. Primary care physicians (family practitioners and general internists) did a superior job of scheduling patients for appropriate indications for EGD and colonoscopy than did non-primary care physicians (internal medicine subspecialists and surgeons): 97.0% vs 81.3% for EGD (P = .04) and 84.9% vs 66.7% for colonoscopy (P = .02), respectively., Primary care physicians were significantly more likely to schedule patients for open-access EGD and colonoscopy for appropriate indications than were non-primary care physicians. The frequency of inappropriate indications for colonoscopy referrals was greater than for EGD. The reasons for the differences among primary care physicians, surgeons, and internal medicine subspecialists require further exploration.