Physician Case Research Articles

Documenting Difference: Standardizing Foreign Physicians

This essay traces the transformation and standardization of the first cohort of Asian physicians trained outside the United States into Foreign Medical Graduates (FMGs) within the United States through documentary regimes. Congress solicited foreign physicians under the Hart-Celler Immigration and Nationality Act of 1965 to address doctor shortages in inner-city and rural communities throughout the country—a trend that continues today. Central to their migratory journey was an archive of expertise, a compilation of documents intended to verify identity, skill, and competence. Through the analysis of a physician's case file, new relations to documentation emerge that reveal how claims of underdocumentation, incorrect documentation, and overdocumentation regulate immigrant possibilities. In adopting this approach, this case study moves away from the unskilled / model minority dichotomy to show how documentary proceduralism operates as a racializing, disciplinary strategy across categories of immigrant labor.

The Importance of Informative Interventions in a Wicked Environment

The Importance of Informative Interventions in a Wicked Environment

Association between physician's case volume in prehospital advanced trauma care and 30-day mortality: A registry-based analysis of 4,032 patients.

Seriously injured patients may benefit from prehospital interventions provided by a critical care physician. The relationship between case volume and outcome has been established in trauma teams in hospitals, as well as in prehospital advanced airway management. In this study, we aimed to assess if a volume-outcome relationship exists in prehospital advanced trauma care. We performed a retrospective cohort study using the national helicopter emergency medical services database, including trauma patients escorted from scene to hospital by a helicopter emergency medical services physician during January 1, 2013, to August 31, 2019. In addition, similar cases during 2012 were used to determine case volumes. We performed a multivariate logistic regression analysis, with 30-day mortality as the outcome. Age, sex, Glasgow Coma Scale, shock index, mechanism of injury, time interval from alarm to the patient and duration of transport, level of receiving hospital, and physician's trauma case volume were used as covariates. On-scene times, interventions performed, and status at hospital arrival were assessed in patients who were grouped according to physician's case volume. In total, 4,032 escorted trauma patients were included in the study. The median age was 40.2 (22.9-59.3) years, and 3,032 (75.2%) were male. Within 30 days, 498 (13.2%) of these patients had died. In the highest case volume group, advanced interventions were performed more often, and patients were less often hypotensive at handover. Data for multivariate analysis were available for 3,167 (78.5%) of the patients. Higher case volume was independently associated with lower mortality (odds ratio, 0.59; 95% confidence interval, 0.38-0.89). When a prehospital physician's case volume is higher in high-risk prehospital trauma, this seems to be associated with more active practice patterns and significantly lower 30-day mortality. The quality of prehospital critical care could be increased by ensuring sufficient case volume for the providers of such care. Prognostic and Epidemiologic; Level III.

Labrador Emergencies and St. Anthony Institutional Care: Medical Cases of Donald McI. Johnson for the Grenfell Association, 1928-29.

In contemporaneous and retrospective publications, British physician Donald McI. Johnson wrote about medical cases in 1928-29 for the organization founded by Wilfred Grenfell in Newfoundland and Labrador. The availability of one physician's cases in published and institutional forms allows consideration of discursive representations of patients for general and clinical readers in the two decades of Johnson's writing. This study places these cases within the context of Johnson's medical background and his escape to rural practice in a remote locale, one that emphasized emergency operations in Labrador and hospital care in the organization's main hospital in St. Anthony. In this way, it broadens knowledge of medical care provided by visiting physicians and considers ways in which such physicians represented local patients in publications for the general reader. Although it determines that Johnson was unique, it indicates the value of the fuller study of publications by other physicians associated with the Grenfell organization.

California court defers to Board of Pharmacy expertise

Pharmacists sometimes get caught in the middle between prescribers who insist that their opioid prescriptions be honored, and regulations that require pharmacists to decline suspicious opioid prescriptions. Disputes between pharmacists and prescribers may lead to litigation based on alternative interpretations of pharmacy laws. A court in California recently ruled that the State Board of Pharmacy has primary jurisdiction to consider any such dispute prior to resolution of the dispute in a court of law. A pain management physician sued a pharmacy that declined to honor the physician's hydrocodone prescriptions. The physician's lawsuit sought an injunction that would force the pharmacy to honor his prescriptions. The physician based his legal argument on a state pharmacy law that says “a licensee shall not obstruct a patient in obtaining a prescription drug or device that has been legally prescribed or ordered for that patient.” The pharmacy opposed the injunction, citing another state law that recognizes a “pharmacist's responsibility to ensure that prescriptions for controlled substances are issued only for a legitimate medical purpose.” The trial court explained that a judicial order requiring the pharmacy to honor particular prescriptions “would involve judgments concerning the statutory obligations of pharmacists that the Board is both expected and equipped to resolve.” The trial court ruled that the physician should first take his complaint to the Board before pursuing his claim in court. The physician appealed this ruling. The appellate court first noted that the Board has the “background to evaluate the specific facts that are relevant to these issues.” The physician contended that the doses he prescribes “are not excessive,” and that “hydrocodone is the lowest potency pure µ-receptor opiate agonist available.” The court concluded that “the Board is better equipped than the courts to evaluate how such technical claims affect a pharmacy's statutory corresponding responsibility.” The appellate court then referred to “the context of a national opioid problem,” agreeing with the trial judge that “the Board has more experience in evaluating a pharmaceutical licensee's responsibilities in this context.” The court also noted the need for “regulatory uniformity” since pharmacy opioid prescription screening programs are likely to affect many prescribers. The court said, the “Board is well positioned to adopt a uniform approach to determining whether such programs—and implementation of them—are consistent with pharmacists’ professional obligations.” The court applied the “doctrine of primary jurisdiction” to the case. Under this doctrine, the issue is not whether courts are capable of adjudicating claims based on state laws, but whether those claims require the “resolution of issues which, under a regulatory scheme, have been placed within the special competence of an administrative body.” The court explained that referral of the physician's case to the Board will not have any effect on the physician's right to eventually proceed with his case in a court of law, but “a ruling from the Board will provide a benefit to the court in ruling on issues that are reserved for its decision.” The physician was instructed to file a complaint with the State Board of Pharmacy prior to proceeding with his court case against the pharmacy. Judicial restraint has not been frequently exercised in the numerous legal cases brought against pharmacists and/or pharmacies based on allegations that opioid prescriptions were unlawfully honored when they should have been declined, or that opioid prescriptions were declined when they should have been honored. The California case is a very sensible and welcome exception. State Boards of Pharmacy are well positioned and well qualified to review claims of illegal conduct by the pharmacists or pharmacies that are licensed by them. Under the doctrine of primary jurisdiction, the determination of a Board of Pharmacy is not binding on a court of law, yet it can be useful and persuasive. Justice is best served when legal claims are examined by knowledgeable reviewers.

The Lifestyle Medicine Physician's Case to Self-Insured Employers: A Business Model for Physicians, a Bargain for Companies.

A majority of Americans have health care insurance through their employers, the cost for which is rising at an alarming rate. Unfortunately, higher expenditure on insurance has not translated into healthier employees. In this article, we present a value-based design plan for self-funded employers, administered by lifestyle medicine board-certified providers, which is purported to save money for employers and yet may demonstrate better health outcomes for employees by engaging them in evidence-based lifestyle interventions such as plant-based nutrition, regular physical activity and minimizing sedentary behaviors, sleeping well, tobacco cessation, and so on.

Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States

ObjectiveThis study provides the first United States (US) national data regarding frequency, cost and mortality rate of epidural hematoma (EDH) and determines the factors affecting the morbidity and deaths in the patients with EDH undergoing surgical evacuation. MethodsA retrospective analysis was performed by searching the Nationwide Inpatient Sample (NIS) from 2003 to 2010, the largest all payer database of non-federal community hospitals in the US. All cases of EDH were indentified using ICD-9 codes. ResultsA total of 5189 admissions were identified in the NIS database, and incidence was highest in the second decade (33.4%). The median length of stay in the hospital was about 4 days in each year (2003–2010) without significant difference. The percent of discharge disposition other than home was about 2–3% in the entire cohort, with the highest in 2009 (3%). The average cost per admission increased significantly (80%) from $45,850 in 2003 to $82,800 in 2010. The inhospital mortality and complication rate was 3.5% and 2.9%, respectively. Factors affecting in-hospital mortality rate were age (≤18 yr vs. >18 yr, P<0.001), insurance type (medicare vs. private insurance, P<0.001), co-morbidities (high vs. low, P<0.001), hospital volume (high vs. low volume, P<0.001), physician's case volumes (high vs. low volume, P<0.02), hospital type (teaching vs. non-teaching, P<0.01) and hospital region (South vs. others, P<0.02). Similarly, factors affecting adverse outcome at discharge were age (≤18 yr vs. >18 yr, P<0.001), female gender (P<0.001), median income (fourth quartile vs. other, P<0.001), ethnicity (African–American vs. non-African–American, P<0.02), insurance type (medicare vs. private insurance, P<0.001), co-morbidities (high vs. low, P<0.001), hospital case volume (4th quartile volume vs. other, P<0.001), physician's case volume (4th quartile volume vs. other, P<0.0001), hospital type (teaching vs. non-teaching, hospital bed size (small vs. large, P<0.001), hospital region (Northeast vs. others, P<0.001) and hospital location (urban vs. rural, P<0.001). ConclusionNationally, there has been no significant change in the frequency of EDH. However, its cost is increasing rapidly.

The relationship between physician case volume and in-hospital mortality of critically ill children with a diagnosis of pneumonia: A cross-sectional observational analytical study

PurposeThe aim of this study is to examine the relationship between physician case volume and the outcomes of critically ill children with pneumonia. Materials and methodsThis is a population-based cohort study analyzed data provided from by the National Health Insurance Research Database of Taiwan, 2006-2009. Children (aged 3 months to 17 years) having records of intensive care unit (ICU) admission and a diagnosis of pneumonia were included. A total of 9754 critically ill children and 1042 attending physicians were enrolled. The children were assigned to 1 of 4 groups based on the physician's pneumonia case volume. ResultsThe patients in the very high case volume group had a significantly lower length of hospital stay, in-hospital mortality rate, and hospitalization expenses, and a significantly higher ratio of ICU to hospital stays than the other 3 groups (P < .001). The probability of death tended to be lower when the physician's case volume was higher. The risk-adjusted odds ratio for in-hospital mortality of very-high case volume group was 0.48 (95% confidence interval, 0.35-0.65; P < .001) compared to low case volume group. ConclusionsA higher physician's pneumonia case volume is associated with a lower length of hospital stay, lower in-hospital mortality rate, and lower hospitalization expenses among critically ill children with pneumonia.

Impact of socioeconomic adjustment on physicians' relative cost of care.

Ongoing efforts to profile physicians on their relative cost of care have been criticized because they do not account for differences in patients' socioeconomic status (SES). The importance of SES adjustment has not been explored in cost-profiling applications that measure costs using an episode of care framework. We assessed the relationship between SES and episode costs and the impact of adjusting for SES on physicians' relative cost rankings. We analyzed claims submitted to 3 Massachusetts commercial health plans during calendar years 2004 and 2005. We grouped patients' care into episodes, attributed episodes to individual physicians, and standardized costs for price differences across plans. We accounted for differences in physicians' case mix using indicators for episode type and a patient's severity of illness. A patient's SES was measured using an index of 6 indicators based on the zip code in which the patient lived. We estimated each physician's case mix-adjusted average episode cost and percentile rankings with and without adjustment for SES. Patients in the lowest SES quintile had $80 higher unadjusted episode costs, on average, than patients in the highest quintile. Nearly 70% of the variation in a physician's average episode cost was explained by case mix of their patients, whereas the contribution of SES was negligible. After adjustment for SES, only 1.1% of physicians changed relative cost rankings >2 percentiles. Accounting for patients' SES has little impact on physicians' relative cost rankings within an episode cost framework.

Transition of young adults with phenylketonuria from pediatric to adult care

Transition from pediatric to adult health care is a particularly vulnerable period for patients with inborn metabolic diseases. Aim of the present study was to evaluate the current transition situation of patients with phenylketonuria (PKU) in Leipzig, Germany, by analysis of the medical care, metabolic control, patients' satisfaction, socio-economic and psychosocial status, in order to identify areas of weakness and potential improvement. Patients who had been transferred from pediatric to adult medical care between 2005 and 2008 were identified. An interview was performed using a questionnaire. Pediatric case notes and the present physician's case notes were analyzed retrospectively. Socio-demographic data were compared to data derived from the annual statistics of the city of Leipzig, Germany in 2008. seventy two transferred patients were identified and included in the study, 48 patients responded to the questionnaire, the data of 24 non-responders were analysed retrospectively. About 90% of the responding patients with PKU were satisfied with the current transition situation. However, they agreed to several suggestions of improvement. Most specifically an interdisciplinary appointment before the definite transfer to the adult clinics was asked for. At the time of transition, most of the patients were in good metabolic control according to current treatment guidelines (median dried blood phenylalanine concentration 853μmol/l before versus 690μmol/l after transition). Of the interviewed patients 92% were still on a low phenylalanine diet in combination with the intake of a phenylalanine free amino acid mixture. Of the interviewees 77% carried a secondary school certificate or a secondary modern school qualification, but only 19% had achieved senior high school diploma (controls 38.2%). Marital status was comparable with the population of Leipzig. However, fewer patients with PKU had children (15% versus 37%). Transition of patients with PKU from pediatric to adult care seems to be successful in Leipzig. Patients were mostly satisfied with the transition situation. Still, some suggestions for improvements appeared to be desirable. During transition medical care and metabolic control were stable. However, with regard to psychosocial and socioeconomic data differences to the control population were detected.

Physician's Case Volume of Intensive Care Unit Pneumonia Admissions and In-Hospital Mortality

Although several studies have investigated volume-outcome relationships for surgical procedures, there has been no such study of intensive care unit (ICU) patients admitted for pneumonia. This study examines associations between in-hospital mortality of ICU-admitted pneumonia patients and their attending physician's case volume. We used 2002-2004 claims data from Taiwan's National Health Insurance for all 87,479 adult ICU admissions for pneumonia. Patients were assigned to one of four groups, on the basis of their physician's ICU pneumonia case volume (low volume, <36 cases; medium volume, 37-114 cases; high volume, 118-314 cases; and very high volume, > or =315 cases). Generalized estimating equations (conditional on hospital, and unconditional) were used, adjusting for physician demographics and specialty, hospital characteristics, patient characteristics (including clinical severity and comorbidities), and physician-level random effect (clustering effect) to assess whether physicians' case volume predicts in-hospital mortality. In-hospital mortality systematically declined with increasing physician case volume: 14.7, 14.3, 11.4, and 8.1% from low-volume to very-high-volume groups. Adjusted unconditional odds of mortality among low-volume physicians' patients were 2.04 times those of very-high-volume physicians, 1.35 times that of high-volume physicians, and 1.09 times those of medium-volume physicians (all P < 0.001). The relationship is sustained when the odds are estimated conditional on hospital, when initial 5-day mortality is separated from 30-day mortality, and when pulmonologists' and critical care specialists' patients are studied separately. Physician volume significantly predicts inpatient mortality among ICU patients with pneumonia. Detailed study of clinical approaches, decision algorithms, and treatment plans of high-volume physicians is recommended to identify possible mediating factors in this phenomenon.

Physician Profiling -- An Analysis of Inpatient Practice Patterns in Florida and Oregon

Physician profiling is a method of cost control that focuses on patterns of care instead of on specific clinical decisions. It is one cost-control method that takes into account physicians' desire to curb the intrusion of administrative mechanisms into the clinical encounter. To provide a concrete example of profiling, we analyzed the inpatient practice patterns of physicians in Florida and Oregon. Data for 1991 from Medicare's National Claims History File were used to profile 12,720 attending physicians in Florida and 2589 in Oregon. For each attending physician, we determined the total relative value of all physicians' services delivered during each patient's hospital stay. Relative value was measured in relative-value units (RVUs), according to the resource-based relative-value scale used by Medicare in determining payments to physicians. The mean number of RVUs per admission was then adjusted for the physician's case mix according to the patients' assigned diagnosis-related groups. The influence of the physician's specialty and of selected types of services (such as imaging and endoscopy) was also examined. Florida physicians used markedly more resources, on average, than their colleagues in Oregon (46 vs. 30 case-mix-adjusted RVUs per admission). The difference was apparent for all specialties and all types of service. To illustrate the profiling data potentially available to the medical staffs of individual hospitals, we examined specific data on individual attending physicians and for various types of service for three hospitals' staffs. Despite similar overall profiles that fell below the national mean, each staff had a different practice pattern and would require different efforts to improve efficiency. In an effort to encourage further debate, we have described one method of physician profiling. Profiling data help identify and characterize differences in practice style to which individual physicians or hospital staffs can respond. Because profiling is not based on rigid rules, it is a cost-containment strategy that can easily accommodate legitimate exceptions; it is therefore preferable to methods in which the appropriateness of each clinical decision is judged separately.

Next-of-kin attitudes regarding participation in an epidemiologic case-control study.

We assessed next-of-kin's attitudes about participating in an epidemiologic case-control study of adult acute nonlymphocytic leukemia. Responses from a mailed questionnaire indicated that 95 per cent were glad they participated. While 74 per cent benefited, 18.5 per cent were bothered in some way. Results concerning the need to obtain physician permission before contacting next-of-kin were inconclusive; however, 8 of 10 females contacted by the case's physician considered consent necessary.

Variables affecting the decision making of a review panel.

This study was designed to identify the variables that influence a review panel's decision to discharge or detain an involuntary patient. A group of fifty patients consecutively discharged by the review panel of a provincial mental hospital were compared according to thirty-five variables, with a group of forty-five patients consecutively detained by the panel. The variable set included information on the patient's psychiatric history, current hospitalization and treatment as well as ratings of dangerousness, insight and psychopathology, as reflected in the attending physician's case summary prepared for the review panel. The released and detained groups were found to be remarkably similar. They differed on ten of the thirty-five variables measured, but they did not differ on some variables that one would expect to form the basis of the panel's decision, including diagnosis and a history of suicide attempts. On the other hand, when the predictive value of the variable set as a whole was examined using discriminant analysis, the results indicated that there was a substantial amount of predictability to the review panel process. The group membership of 77.5% of the patients can be predicted from only nine variables that contribute to the discriminant function. The results will be of interest to clinicians who deal with review panels on a regular basis and the findings have implications for other practical issues including discharge planning and readiness for community living.

New Instrument.

<h3>A NEW TREATMENT CASE AND STERILIZER.</h3> MARK D. STEVENSON, M.D. Oculist to the City Hospital. AKRON, OHIO. I have devised a case which will particularly appeal to the eye, ear, nose and throat specialist. The following claims are made for it: First—When closed it is small and looks well, much like any physician's case. Second—There is no waste space in it, even the lid being utilized. Third—AS originally designed and as illustrated below, its contents are as follows: 4 glass stoppered half-ounce tincture bottles. 7 glass stoppered half-ounce salt mouth bottles. 4 screw cap quarter-ounce ointment jars, 5 dropping bottles of half-ounce capacity, with bulbs of cellulose, a material that is not affected by medicaments, and therefore to be preferred to the old soft rubber which must frequently be renewed; 4 dropping vials, each of 2 dram capacity, for the storing of small quantities of medicine, also provided with cellulose