Type Of Medical Practice Research Articles

The organization of the medical practice and implications for delivering quality care.

The attention devoted to quality in health care has focused primarily on hospitals. With the shift in care from hospitals to outpatient clinics and physicians' offices, there has emerged a need to consider how quality should be approached in these settings. This article explores the structural barriers in the typical medical practice that must be removed in order to improve the many dimensions of quality. The typical practice must concentrate on enhancing clinical outcomes, patient satisfaction, and practice productivity. One effective strategy is to form teams of physicians and other staff to work on relevant issues. Another is to focus on how the practice can be defined to better meet the needs of patients.

Acute confusional state. Don't mistake it for dementia.

Acute confusional state is a condition that is commonly encountered in many types of medical practice. Certain patients, especially the elderly, are vulnerable to the disorder, and recognition of this fact can help prevent the development or minimize the severity of the condition. Thorough history taking and evaluation often point to the underlying cause, and attention to general principles of environmental and pharmacologic management can minimize morbidity.

Characteristics of Physicians Practicing in Alternative Primary Care Settings: A Quebec Study of Local Community Service Center Physicians

Since the early 1970s, there have been two primary care networks in Quebec: the traditional one characterized by private practice remunerated on a fee-for-service basis, and the public one comprising 15 percent of physicians and characterized by salaried practice within publicly funded local community health service centers (CLSCs). Using data collected on 616 Quebec generalists, 333 in private practice and 283 in CLSCs, we compared physicians' profiles in both networks. In contrast to their colleagues in private practice, CLSC physicians are younger, more often women, and more often graduates of innovative primary care training programs. They are more sensitive to the biopsychosocial nature of health problems and to giving patients an active role in their care. Significant differences were also observed in physicians' self-reported clinical practices, more so for women than for men. The study suggests that alternative primary care settings attract physicians that are more preventive and socially oriented. As a result, they may contribute to the emergence of a more comprehensive type of medical practice in health care delivery systems.

The Physician's Role in Preventing Alcohol-Related Injuries

Identifying potential areas for successful patient counseling to prevent or reduce high-risk behavior is one of the ongoing goals of the medical profession. Three steps are required. First, a predictive relationship between a given behavior and a harmful outcome must be documented. Second, there must be an easy way to communicate this information to the patient within the context and constraints of the typical medical practice. Third, there must be evidence that such communication can reduce risk effectively. The article by Anda et al in this issue ofTHE Journal¹clearly fulfills the first of these requirements. Prospective analysis of deaths over a nine-year period among more than 13 000 adults revealed that for both men and women, self-reported heavy consumption of alcohol is predictive of a greater likelihood of subsequent death from injury. Persons who initially reported consuming five or more drinks per occasion as their usual quantity

Do Patients Want to Participate in Medical Decision Making?

Although shared decision making by patients and clinicians has been advocated, little is known about the degree of participation in decision making that patients actually prefer or about clinicians' appreciation of these preferences. We administered questionnaires about three aspects of decision making to 210 hypertensive outpatients and to their 50 clinicians, who represented three types of medical practices. We found that 41% of patients preferred more information about hypertension; clinicians underestimated patient preferences for discussion about therapy in 29% of cases and overestimated 11% (k = .22); and 53% of patients preferred to participate in making decisions, while clinicians believed that their patients desired to participate in 78% of cases. Many patients who preferred not to make initial therapeutic decisions did want to participate in ongoing evaluation of therapy. Thus, clinicians underestimate patients' desire for information and discussion but overestimate patients' desire to make decisions. Awareness of this discrepancy may facilitate communication and decision making.

Physician Status Characteristics and Client Satisfaction in Two Types of Medical Practice

Authors developed and tested a model of client satisfaction with medical care in which sociodemographic characteristics of the physician affect client satisfaction under conditions of unmet expectations and a lack of choice. They hypothesized that in small fee-for-service practices such as solo practice, where the client chooses his or her physician, status characteristics of the doctor would be unrelated to client satisfaction. Conversely, in large prepaid group practices where the client is assigned a physician, nonnormative physician status characteristics would create lower client satisfaction. Because expectations are based on statistical norms, it was hypothesized that clients in large prepaid multispecialty groups would be most satisfied with physicians who fit the norm-middle-aged white males from higher status Protestant or Jewish backgrounds. In a sample of pediatricians and their clients, authors found their hypotheses to be strongly supported, with one modification-the relationship between client satisfaction and the physician's socioeconomic background is parabolic. Furthermore, the negative effect of nonnormative physician religious status on client satisfaction in large prepaid groups is offset by the client-physician match and by experience with the physician.

The ideology of the American medical profession: An attribution perspective∗

Physicians have a variety of opinions about the failures of American health care and who is responsible for those failures. (Failure is defined here as the unexpected illness or death of a patient.) Attribution theory specifies the processes involved social construction of beliefs that attribute responsibility for unexpected events to self and others, and the specification of social situations that are likely to result in different types of attributions. This paper suggests that attribution theory is a useful perspective for understanding the diversity and character of public policy statements made by medical specialists in the years since Medicare. Using existing literature on the nature of medical practice we infer what types of medical practices are likely to increase a physician's interest in unexpected illness and death and to produce explanations of these events that attribute responsibility for them to self (the physician), to the limits of medical knowledge, to the patient's environment, to misfortune and to the patient. We show evidence that medical specialists make all these types of attributions and that the types they make are associated with the conditions of practice in their fields. We develop hypotheses relating to the nature of the decision-making process resulting in different types of attributions for future research on professional ideology, which we define here as the set of beliefs shared by members of a profession or groups thereof concerning the relative role responsibilities of the profession to its patients and to society.

The doctor's husband.

A study of 162 females, actively employed as medical practitioners, was conducted to examine perceived characteristics of their husbands and to determine whether such attributes might relate to the women's commitment to and satisfaction with medical practice. A questionnaire assessing personality characteristics of such husbands was produced by a factor analytic technique, and the final measure is tabled. Eighteen items loaded clearly on one of three factors measuring perceptions of general support by husbands, levels of type A characteristics within the husbands, and the degree to which husbands were against their wives' medical career. Factor-specific scores on those dimensions were examined against other variables, and associations were found linking scale scores with variables in the female practitioners including age, type of medical practice, hours of employment, and satisfaction with medical practice. Husbands who were medical graduates were scored higher on type A characteristics and fathered more children than the other husbands.

Pregnancy in women with kidney disease

The outlook for pregnancy in gravidas with kidney disorders and the effect of gestation on the remote outcome of the underlying disease remain uncertain, and conception in such women continues to generate anxiety for them as well as their physicians. There is general agreement that a moderately severe decrease in renal function (that is, a serum creatinine concentration in excess of 2 mg/dl), especially in the presence of significant hypertension, reduces drastically the chances for conception, and all the more for a successful outcome of the gestation [1–7]. Women with preserved kidney function and normal blood pressure have an increased incidence of preeclampsia; but except for this complication, the outlook for the pregnancy does not seem to be worse than it is in other gravidas [1–7]. The situation is less clear in regards to the effects of gestation on the mother's kidney disease: Most investigators believe that pregnancy does not affect adversely the natural course of renal disorders as long as kidney function is, at most, mildly impaired and hypertension is absent at conception [1, 3–11]. In contrast, several reports in the older literature (reviewed in Ref. 2) and more recent studies describing mainly patients from Australia maintain that in such women pregnancy often leads to a worsening of the morphologic lesions and a deterioration of renal function [12–15]. The cause of these divergent views is not readily apparent, but it is probably due in no small measure to the lack of studies where the diagnosis was established by renal biopsy and in which clinical, functional, and pathologic observations were correlated in sufficiently large numbers of gravidas studied prospectively. We organized the present study as a joint project between three medical centers with a long-standing interest in the subject, in order to include a large number of patients originating from various types of medical practice and geographic location: The University of Chicago Lying-in Hospital is a perinatal referral center that also serves a large inner-city population; Yale University School of Medicine is a referral center for most of the State of Connecticut; and the Princess Mary Maternity Hospital serves the population of Newcastle-upon-Tyne and the surrounding area of Northern England. Analysis of renal-function profiles and pregnancy outcome was based on the same criteria for patients from all three centers. The gravidas were selected for inclusion in the study by the availability of a biopsy diagnosis, and their course was studied through subsequent gestations, if any, or for various periods until the end of followup. This survey represents therefore a combined prospective and retrospective study that, although not free of some of the shortcomings of earlier reports, we hope contributes useful information on a subject of obvious interest to obstetricians and nephrologists alike.

Utilization and productivity of the Duke physician's associate

The objectives of this study were as follows: (1) Formulate a theoretical model of the typical medical practice as a system for producing medical care, with particular attention to the role of middle-level health workers such as graduates of Duke University's Physician's Associate Program. (2) Develop a methodology for collecting data necessary to estimate the relevant parameters in the model, and to describe current patterns of utilization of Duke PA's. (3) Draw substantive conclusions, insofar as the model and data collection methodology permit, about the actual and potential productivity of Duke PA's. As of October 1971 Duke University had graduated 68 PA's from its Physician's Associate Program. Of these, 34 are employed as assistants in family practice or general medicine in a variety of private and institutional settings. Data were collected on eleven of these 34 PA's. No attempt was made to study the other 34 graduates engaged in clinical specialties, administration, or other functions. Neither was any attempt made to collect data on or draw inferences about the utilization and productivity of graduates of any other program such as the MEDEX Program. § § A partial listing and description of such programs is given in [1].

The sucess or failure of the hair transplant.

The hair transplant operation is a reliable procedure which will give good results if attention is directed to each step of the process. Unfortunately, the results are often not good, and many patients have suffered severe emotional and physical scars. Because it appears to be a simple office procedure, many physicians with various backgrounds have been tempted to try it, apparently with little thought or preparation. Some of the poor results gathered from all parts of the country and from many types of medical practice are presented. If the procedure is not to fall into disrepute, the surgeon must be more attentive to aesthetic and surgical principles.

Smoking patterns and specialty training of Oregon physicians.

The effects of the current anti-smoking campaign on the smoking habits of physicians were studied specifically as related to (1) probable level of familiarity with pathology imputed to smoking as estimated from type of specialty practice, and (2) probable amount of exposure to the campaign as estimated by rural-urban site of practice. A pre-coded questionnaire was mailed to all members of the Oregon Medical Association residing in Oregon in May, 1964; 1790 (90 per cent) usable, completed questionnaires were obtained. The type of medical specialty practice was found to be related to present smoking habit, mention of smoking as a cause of cancer, the number of illnesses attributed to smoking and the frequency and recency of cessation of smoking; the type of medical practice is not related to the degree of hazard ascribed to smoking or to the stated reason for stopping smoking. The geographic location of an Oregon physician's medical practice is not related to these variables. These and other reported findings suggest that anti-smoking campaigns, by themselves, may produce marked changes in the smoking habits of some individuals but these represent only a rather small minority of the population. To attain more widespread reduction in smoking it will be necessary to employ a broad and diversified array of approaches.

New Types of Medical Practice

New Types of Medical Practice

SYPHILIS PRESENTING AS AN ACUTE NEUROLOGICAL ILLNESS.

Despite the increase in the incidence of early infectious syphilis during the past seven years neurosyphilis is relatively uncommon, and there is, as yet, no satisfactory evidence to suggest that it is increasing in frequency (Laird, 1962). Never theless, cases of neurosyphilis present in many types of medical practice, and lack of experience and familiarity with the clinical manifestations may lead to delay in diagnosis and to permanent damage to the central nervous system. It seems probable that more cases of neurosyphilis may occur in the future because of the rising incidence of early syphilis, not all of which is diagnosed and treated. Neurosyphilis may present as an acute neurological illness, which may not be recognized unless the wide variety of manifestations is appreciated and the possibility of syphilis considered. Recently we have seen four patients with neuro syphilis in whom the presenting symptoms and signs were those of an acute neurological disorder.

Medical practice, medical care, and modern society.

It is fallacious to consider medical care as a product or commodity, to assume that medicine has developed into a precise science, to think that medical care is not ultimately paid for by somebody, or to suppose that the interests of the community so nearly coincide with those of the individual person that he can be reduced to a file number without personalized care. There are many types of medical practice and many ways of financing the operation of hospitals and offices, the wages of personnel, and the costs of equipment and medicaments. The experience of the California Medical Association shows that it is possible to develop successful programs that will interfere but little with the traditional relationship between doctor and patient.

Preventive Trend in the Practice of Medicine

THE trend of medical practice toward prevention is inevitable and it behooves the average citizen to study carefully the means to this end. The reason lies in the fact that the possibilities in the direction of prevention by the application of scientific knowledge are very great. It should be obvious even to the most superficial observer that this is the consideration which will bear the greatest weight in the determination of the type of medical practice which will prevail in the future. The common good will unquestionably be the criterion of adjustment. How radical that adjustment will be remains to be seen. The traditional type of medical practice is based on the possibilities of cure. Up to the last 50 years little thought was given to prevention because there was little knowledge of how to prevent. Today our point of view is changing with the increase in our scientific knowledge. We know that, largely as the result of the application of the work of Pasteur, about 18 years have been added to the expectation of life in a little over 50 years. Some of this has been due to the application of scientific knowledge in ordinary medical practice; much of it has resulted from communal action in which the health officerusually a physician, working in a profession the practice of which is so unlike ordinary medical practice that he-may be said to be a member of a new profession-plays a very great part. Today we attempt to ascertain how much more remains to be done and how it is to be done, particularly the part which is to be played by the medical practitioner-using the term in its accepted sense. That much remains to be done cannot be gainsaid; nor the tremendous social significance of the task and its achievement be denied. Illness is too prevalent and preventable illness and postponable death are too costly. Investigators tell us that 2 per cent of our entire population is constantly suffering from disabling illness. Irving Fisher estimates that 2.5 per cent of all workers in the United States are constantly ill. An English investigator estimates that workmen