Showing papers in "Journal of General Internal Medicine in 2001"

The PHQ-9: validity of a brief depression severity measure.

Abstract: OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

Somatic Symptom Reporting in Women and Men

Abstract: Women report more intense, more numerous, and more frequent bodily symptoms than men. This difference appears in samples of medical patients and in community samples, whether or not gynecologic and reproductive symptoms are excluded, and whether all bodily symptoms or only those which are medically unexplained are examined. More limited, but suggestive, literature on experimental pain, symptom reporting in childhood, and pain thresholds in animals are compatible with these findings in adults. A number of contributory factors have been implicated, supported by varying degrees of evidence. These include innate differences in somatic and visceral perception; differences in symptom labeling, description, and reporting; the socialization process, which leads to differences in the readiness to acknowledge and disclose discomfort; a sex differential in the incidence of abuse and violence; sex differences in the prevalence of anxiety and depressive disorders; and gender bias in research and in clinical practice. General internists need to keep these factors in mind in obtaining the clinical history, understanding the meaning and significance that symptoms hold for each patient, and providing symptom relief.

National estimates of the quantity and cost of informal caregiving for the elderly with dementia

Abstract: OBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia.

Effect of computer support on younger women with breast cancer.

Abstract: OBJECTIVE: Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved.

Conflict associated with decisions to limit life-sustaining treatment in intensive care units

Abstract: OBJECTIVE: To determine the incidence and nature of interpersonal conflicts that arise when patients in the intensive care unit are considered for limitation of life-sustaining treatment. DESIGN: Qualitative analysis of prospectively gathered interviews. SETTING: Six intensive care units at a university medical center. PARTICIPANTS: Four hundred six physicians and nurses who were involved in the care of 102 patients for whom withdrawal or withholding of treatment was considered. MEASUREMENTS: Semistructured interviews addressed disagreements during life-sustaining treatment decision making. Two raters coded transcripts of the audiotaped interviews. MAIN RESULTS: At least 1 health care provider in 78% of the cases described a situation coded as conflict. Conflict occurred between the staff and family members in 48% of the cases, among staff members in 48%, and among family members in 24%. In 63% of the cases, conflict arose over the decision about life-sustaining treatment itself. In 45% of the cases, conflict occurred over other tasks such as communication and pain control. Social issues caused conflict in 19% of the cases. CONCLUSIONS: Conflict is more prevalent in the setting of intensive care decision making than has previously been demonstrated. While conflict over the treatment decision itself is most common, conflict over other issues, including social issues, is also significant. By identifying conflict and by recognizing that the treatment decision may not be the only conflict present, or even the main one, clinicians may address conflict more constructively.

Impact of interpreter services on delivery of health care to limited-English-proficient patients.

Abstract: OBJECTIVE: To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients.

Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health care workers.

Abstract: BACKGROUND A framework for understanding and evaluating physicians' skills at providing end of life care from the perspectives of patients, families, and health care workers will promote better quality of care at the end of life.

Improving Depression Outcomes in Community Primary Care Practice: A Randomized Trial of the QuEST Intervention

Abstract: Researchers have tested a range of interventions to improve primary care management of major depression to address the poor outcomes these patients often achieve.1–6 The most successful of these interventions have utilized mental health professionals as part of multi-faceted interventions to provide extended consultation on medication management7–9 or to provide psychotherapy in the primary care setting.10,11 While impressive, these models may be difficult to disseminate widely since only one third of primary care physicians work in practices with onsite mental health professionals.12 In addition, few practices without onsite mental health professionals have reimbursement arrangements to support collaborative care. More transportable interventions have trained primary care nurses/extenders to monitor medication response13,14 or to provide brief psychotherapy.15,16 Building on these latter studies, we tested the Quality Enhancement by Strategic Teaming (QuEST) intervention. The QuEST intervention redefined roles across the primary care team to improve the detection and management of major depression without the assistance of an onsite mental health professional. Incorporating strengths from effectiveness studies, we tested the intervention with primary care professionals in community practices caring for patients meeting criteria for major depression, the population described in the Agency for Health Care Policy and Research (AHCPR) Guidelines.17,18 The primary objective of the study was to evaluate the effect of the QuEST intervention on the process and outcomes of care provided to this heterogeneous group of primary care patients with major depression. We anticipated the intervention would be more effective in improving outcomes among patients beginning a new treatment episode, because patients who remained depressed after treatment might be more treatment-resistant. Neither the AHCPR Guidelines nor the QuEST intervention provided evidence-based recommendations for treatment-resistant patients since efficacy trials are only now beginning to define the treatment these patients need. Because patient treatment preferences have a significant impact on the quality of care depressed primary care patients receive,19 we also anticipated that the intervention's effect on outcomes would be more observable in the patients who reported at baseline that antidepressant medication was an acceptable treatment for their problem.

Problem Drinking and Medication Adherence Among Persons with HIV Infection

Abstract: OBJECTIVE: To examine the relation between problem drinking and medication adherence among persons with HIV infection. DESIGN: Cross-sectional survey. SETTING/PARTICIPANTS: Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998. MEASUREMENTS AND MAIN RESULTS: Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P=.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P=.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P<.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P<.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P=.10), running out of medications (15% vs 8%, P=.16), and consuming alcohol or drugs (26 % vs 3 %, P<.001). CONCLUSION: Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence.

Self-restriction of medications due to cost in seniors without prescription coverage

Abstract: OBJECTIVE: Little is known about patients who skip doses or otherwise avoid using their medications because of cost. We sought to identify which elderly patients are at highest risk of restricting their medications because of cost, and how prescription coverage modifies this risk.

Evaluating and managing acute low back pain in the primary care setting.

Abstract: Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

Between two worlds medical student perceptions of humor and slang in the hospital setting.

Abstract: OBJECTIVE: Residents frequently use humor and slang at the expense of patients on the clinical wards. We studied how medical students react to and interpret the “appropriateness” of derogatory and cynical humor and slang in a clinical setting. DESIGN: Semistructured, in-depth interviews. SETTING: Informal meeting spaces. PARTICIPANTS: Thirty-three medical students. MEASUREMENTS: Qualitative content analysis of interview transcriptions. MAIN RESULTS: Students’ descriptions of the humorous stories and their responses reveal that students are able to take the perspective of both outsiders and insiders in the medical culture. Students’ responses to these stories show that they can identify the outsider’s perspective both by seeing themselves in the outsider’s role and by identifying with patients. Students can also see the insider’s perspective, in that they identify with residents’ frustrations and disappointments and therefore try to explain why residents use this kind of humor. Their participation in the humor and slang—often with reservations—further reveals their ability to identify with the perspective of an insider. CONCLUSIONS: Medical students describe a number of conflicting reactions to hospital humor that may enhance and exacerbate tensions that are already an inevitable part of training for many students. This phenomenon requires greater attention by medical educators.

Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction".

Abstract: OBJECTIVE: To explore perceptions of the impact of erectile dysfunction on men who had undergone definitive treatment for early nonmetastatic prostate cancer. DESIGN: Seven focus groups of men with early prostate cancer. The groups were semistructured to explore men’s experiences and quality-of-life concerns associated with prostate cancer and its treatment. SETTING: A staff model health maintenance organization, and a Veterans Affairs medical center. PATIENTS: Forty-eight men who had been treated for early prostate cancer 12 to 24 months previously. RESULTS: Men confirmed the substantial effect of sexual dysfunction on the quality of their lives. Four domains of quality of life related to men’s sexuality were identified: 1) the qualities of sexual intimacy; 2) everyday interactions with women; 3) sexual imagining and fantasy life; and 4) men’s perceptions of their masculinity. Erectile problems were found to affect men in both their intimate and nonintimate lives, including how they saw themselves as sexual beings. CONCLUSIONS: Erectile dysfunction, the most common side effect of treatment for early prostate cancer, has far-reaching effects upon men’s lives. Assessment of quality of life related to sexual dysfunction should address these broad impacts of erectile function on men’s lives. Physicians should consider these effects when advising men regarding treatment options. Physicians caring for patients who have undergone treatment should address these psychosocial issues when counseling men with erectile dysfunction.

The effect of discussions about advance directives on patients' satisfaction with primary care.

Abstract: BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians’ anxiety that patients might react negatively to such discussions.

Quality of Life Is Impaired in Men with Chronic Prostatitis the Chronic Prostatitis Collaborative Research Network

Abstract: OBJECTIVE: Health-related quality of life (HRQOL) impairment may be a central component of chronic prostatitis for men afflicted with this condition. Our objective was to examine HRQOL, and factors associated with HRQOL, using both general and condition-specific instruments.

Do Gender and Race Affect Decisions About Pain Management

Abstract: OBJECTIVE: To determine if patient gender and race affect decisions about pain management. DESIGN, SETTING, AND PARTICIPANTS: Experimental design using medical vignettes to evaluate treatment decisions. A convenience sample of 111 primary care physicians (61 men, 50 women) in the Northeast was asked to treat 3 hypothetical patients with pain (kidney stone, back pain) or a control condition (sinusitis). Symptom presentation and severity were held constant, but patient gender and race were varied. MEASUREMENTS AND MAIN RESULTS: The maximum permitted doses of narcotic analgesics (hydrocodone) prescribed at initial and return visits were calculated by multiplying mg per pill × number of pills per day × number of days × number of refills. No overall differences with respect to patient gender or race were found in decisions to treat or in the maximum permitted doses. However, for renal colic, male physicians prescribed higher doses of hydrocodone to white versus black patients (426 mg vs 238 mg), while female physicians prescribed higher doses to blacks (335 mg vs 161 mg; F1,85=9.65, P=.003). This pattern was repeated for persistent kidney stone pain. For persistent back pain, male physicians prescribed higher doses of hydrocodone to males versus females (406 mg vs 201 mg), but female physicians prescribed higher doses to females (327 mg vs 163 mg; F1,28=5.50, P=.03). CONCLUSION: When treating pain, gender and racial differences were evident only when the role of physician gender was examined, suggesting that male and female physicians may react differently to gender and/or racial cues.

Disparities in health and health care: moving from describing the problem to a call for action.

Abstract: During the past two decades the overall health of the nation has improved. However, the dramatic disparities in the morbidity and mortality experienced by African Americans, Latinos, Native Americans, Asians, and Pacific Islanders provide compelling evidence that many Americans have not experienced this health dividend.1 Disparities in health and in access to health care have been documented repeatedly across a broad range of medical conditions and for a wide variety of traditionally disadvantaged groups such as those in racial or ethnic minorities, women, and older persons. These differences have been noted in health outcomes such as quality of life2,3 and mortality,4–10 processes of care such as utilization of cardiac procedures after myocardial infarction6,7,11–15 or access to primary prevention,16,17 quality and appropriateness of care,18–24 and the prevalence of common chronic medical conditions.25

Teaching the one-minute preceptor. A randomized controlled trial.

Abstract: OBJECTIVE: The One-Minute Preceptor (OMP) model of faculty development is used widely to improve teaching, but its effect on teaching behavior has not been assessed. We aim to evaluate the effect of this intervention on residents’ teaching skills. DESIGN: Randomized controlled trial. SETTING: Inpatient teaching services at both a tertiary care hospital and a Veterans Administration Medical Center affiliated with a University Medical Center. PARTICIPANTS: Participants included 57 second- and third-year internal medicine residents that were randomized to the intervention group (n=28) or to the control group (n=29). INTERVENTION: The intervention was a 1-hour session incorporating lecture, group discussion, and role-play. MEASUREMENTS AND MAIN RESULTS: Primary outcome measures were resident self-report and learner ratings of resident performance of the OMP teaching behaviors. Residents assigned to the intervention group reported statistically significant changes in all behaviors (P<.05). Eighty-seven percent of residents rated the intervention as “useful or very useful” on a 1–5 point scale with a mean of 4.28. Student ratings of teacher performance showed improvements in all skills except “Teaching General Rules.” Learners of the residents in the intervention group reported increased motivation to do outside reading when compared to learners of the control residents. Ratings of overall teaching effectiveness were not significantly different between the 2 groups. CONCLUSIONS: The OMP model is a brief and easy-to-administer intervention that provides modest improvements in residents’ teaching skills.

Mobility difficulties are not only a problem of old age.

Abstract: BACKGROUND: Lower extremity mobility difficulties often result from common medical conditions and can disrupt both physical and emotional well-being.

Does Physician Gender Affect Satisfaction of Men and Women Visiting the Emergency Department

Abstract: OBJECTIVE: To assess the association of physician gender with patient ratings of physician care. DESIGN: Interviewer-administered survey and follow-up interviews 1 week after emergency department (ED) visit. SETTING: Public hospital ED. PATIENTS/PARTICIPANTS: English- and Spanish-speaking adults presenting for care of nonemergent problems; of 852 patients interviewed in the ED who were eligible for follow-up, 727 (85%) completed a second interview. MEASUREMENTS AND MAIN RESULTS: We conducted separate ordered logistic regressions for women and men to determine the unique association of physician gender with patient ratings of 5 interpersonal aspects of care, their trust of the physician, and their overall ratings of the physician, controlling for patient age, health status, language and interpreter status, literacy level, and expected satisfaction. Female patients trusted female physicians more (P=.003) than male physicians and rated female physicians more positively on the amount of time spent (P=.01), on concern shown (P=.04), and overall (P=.03). Differences in ratings by female patients of male and female physicians in terms of friendliness (P=.13), respect shown (P=.74), and the extent to which the physician made them feel comfortable (P=.10) did not differ significantly. Male patients rated male and female physicians similarly on all dimensions of care (overall, P=.74; friendliness, P=.75; time spent, P=.30; concern shown, P=.62; making them feel comfortable, P=.75; respect shown, P=.13; trust, P=.92). CONCLUSIONS: Having a female physician was positively associated with women’s satisfaction, but physician gender was not associated with men’s satisfaction. Further studies are needed to identify reasons for physician gender differences in interpersonal care delivered to women.

Managed care, professional autonomy, and income: effects on physician career satisfaction.

Abstract: CONTEXT: Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system.

Attitudes toward colorectal cancer screening tests.

Abstract: OBJECTIVE: To examine patient and physician preferences in regard to 5 colorectal cancer screening alternatives endorsed by a 1997 expert panel, determine the impact of patient and physician values regarding certain test features on screening preference, and assess physicians’ perceptions of patients’ values. DESIGN: Cross-sectional survey. SETTING: A general internal medicine practice at an academic medical center in 1998. PARTICIPANTS: Patients (N=217; 76% response rate) and physicians (N=39; 87% response rate) at the study setting. MEASUREMENTS AND MAIN RESULTS: Patients preferred fecal occult blood testing (43%) or colonoscopy (40%). In patients for whom accuracy was the most important test feature, colonoscopy (62%) was the preferred screening method. Patients for whom invasive test features were more important preferred fecal occult blood testing (76%; P<.001). Patients and physicians were similar in their values regarding the various test features. However, there was a significant difference between physicians’ perceptions of which test features were important to patients compared with the patients’ actual responses (P<.001). The largest discrepancy was for accuracy (patient actual 54% vs physician opinion 15%) and discomfort (patient actual 15% vs physician opinion 64%). CONCLUSIONS: Patients have distinct preferences for colorectal cancer screening tests that are associated with the importance placed on certain test features. Physicians incorrectly perceive those factors that are important to patients. Physicians should incorporate patient values in regard to certain test features when discussing colorectal cancer screening with their patients and when eliciting their screening preferences.

Comparison of the mineral content of tap water and bottled waters

Abstract: OBJECTIVES: Because of growing concern that constituents of drinking water may have adverse health effects, consumption of tap water in North America has decreased and consumption of bottled water has increased. Our objectives were to 1) determine whether North American tap water contains clinically important levels of calcium (Ca2+), magnesium (Mg2+), and sodium (Na+) and 2) determine whether differences in mineral content of tap water and commercially available bottled waters are clinically important.

The evaluation of two methods to facilitate shared decision making for men considering the prostate-specific antigen test.

Abstract: OBJECTIVE: California law (Grant H. Kenyon Prostate Cancer Detection Act) requires physicians to inform all patients older than aged 50 years who receive a prostate examination about the availability of the prostate-specific antigen (PSA) test. Physicians are not given guidance on how this information should be presented. We sought to evaluate the effects upon PSA screening rates of informing patients about PSA testing by 2 different techniques.

Predictors of physical activity in community-dwelling elderly white women

Abstract: OBJECTIVE: To describe patterns of physical activity and to determine factors associated with engaging in regular exercise, especially walking, in elderly white women.

Antibiotic use in Ontario facilities that provide chronic care.

Abstract: OBJECTIVE: To determine the incidence and variability of antibiotic use in facilities which provide chronic care and to determine how often clinical criteria for infection are met when antibiotics are prescribed in these facilities. DESIGN: A prospective, 12-month, observational cohort study. SETTING: Twenty-two facilities which provide chronic care in southwestern Ontario. PARTICIPANTS: Patients who were treated with systemic antibiotics over the study period. MEASUREMENTS: Characteristics of antibiotic prescriptions (name, dose, duration, and indication) and clinical features of randomly selected patients who were treated with antibiotics. RESULTS: A total of 9,373 courses of antibiotics were prescribed for 2,408 patients (66% of the patients in study facilities). The incidence of antibiotic prescriptions in the facilities ranged from 2.9 to 13.9 antibiotic courses per 1,000 patient-days. Thirty-six percent of antibiotics were prescribed for respiratory tract infections, 33% for urinary infections, and 13% for skin and soft tissue infections. Standardized surveillance definitions of infection were met in 49% of the 1,602 randomly selected patients who were prescribed antibiotics. Diagnostic criteria for respiratory, urinary, and skin infection were met in 58%, 28%, and 65% of prescriptions, respectively. One third of antibiotic prescriptions for a urinary indication were for asymptomatic bacteriuria. Adverse reactions were noted in 6% of prescriptions for respiratory and urinary infections and 4% of prescriptions for skin infection. CONCLUSIONS: Antibiotic use is frequent and highly variable amongst patients who receive chronic care. Reducing antibiotic prescriptions for asymptomatic bacteriuria represents an important way to optimize antibiotic use in this population.

Effects of Drug Abuse and Mental Disorders on Use and Type of Antiretroviral Therapy in HIV-infected Persons

Abstract: Welcome recent advances in treatment have significantly reduced the morbidity and mortality associated with human immunodeficiency virus (HIV) type 1 infection.1,2 Yet access to these improved treatments has been inequitable,3 with serious deficiencies reported in the antiretroviral treatment of drug users.4–6 After first detection of an elevated viral load, delay before starting protease inhibitors has been reported to be longer for drug users and persons with depressive symptoms.7 Mental disorders are highly prevalent in HIV-infected persons8 as well as in substance abusers,9 and many persons with HIV are current or former drug users. Thus the relative contributions of drug abuse, mental disorders, and alcohol use to deficient ART prescribing patterns for HIV-infected persons merit examination. Health care and social support programs should be especially attentive to addressing such potentially key barriers to antiretroviral treatment. We used data from a nationally representative sample of persons in care for HIV in 1996 to examine the effects of previous substance abuse and probable mental disorders on 2 outcomes: 1) any antiretroviral treatment and 2) highly active antiretroviral therapy (HAART) with 3 or more drugs including at least 1 protease inhibitor or non-nucleoside reverse transcriptase inhibitor among persons on combination therapy. By 1996, monotherapy was considered a less effective form of treatment10 and by 1997, treatment with only 2 reverse transcriptase inhibitors was also viewed as less acceptable.11 We predicted that persons with mental health disorders or substance abuse histories would be less likely to receive any treatment and, when treated, would be more likely to receive the “less acceptable” forms of treatment.

Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medicine practice

Abstract: OBJECTIVE: To determine the prevalence of unrecognized lower extremity peripheral arterial disease (PAD) among men and women aged 55 years and older in a general internal medicine (GIM) practice and to identify characteristics and functional performance associated with unrecognized PAD.

Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications.

Abstract: OBJECTIVE: Oral presentation skills are central to physicianphysician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process. DESIGN: Descriptive study. SETTING: Inpatient general medicine service in a university-affiliated public hospital. PARTICIPANTS: Twelve third-year medical students during their internal medicine clerkship and 14 teachers. MEASUREMENTS: One-hundred sixty hours of ethnographic observation, including 73 oral presentations on rounds. Discourse-based interviews of 8 students and 10 teachers. Data were quanlitatively analyzed to uncover recurrent patterns of communication. MAIN RESULTS: Students and teachers had different perceptions of the purpose of oral presentation, and this was reflected in performance. Students described and conducted the presentation as a rule-based, data-storage activity governed by “order” and “structure.” Teachers approached the presentation as a flexible means of “communication” and a method for “constructing” the details of a case into a diagnostic or therapeutic plan. Although most teachers viewed oral presentations rhetorically (sensitive to context), most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (e.g., comment “be brief” resulted in reading faster rather than editing) and unintended value acquisition (e.g., request for less social history interpreted as social history never relevant). CONCLUSION: Students learn oral presentation by trial and error rather than through teaching of an explicit rhetorical model. This may delay development of effective communication skills and result in acquisition of unintended professional values. Teaching and learning of oral presentation skills may be improved by emphasizing that context determines content and by making explicit the tacit rules of presentation.

Doctor discontent. A comparison of physician satisfaction in different delivery system settings, 1986 and 1997.

Abstract: By many accounts, American physicians are becoming increasingly dissatisfied with many aspects of their professional life A number of recent articles and editorials report that the level of discontent is rising1–6 The question inevitably follows: should we care about unhappy doctors? There are a number of reasons why physician satisfaction matters Numerous studies report that dissatisfaction leads to increased physician turnover, which leads to decreased continuity of care for patients and increased costs to the medical system7,8 Other research has found a positive relationship between physician satisfaction and patient satisfaction with the medical encounter9–12 It is also probable that physician satisfaction affects the morale of health care workers and office staff who work closely with physicians Doctors may also be demonstrating their dissatisfaction in new ways: there is talk of unionization and opting out of managed care,1,13,14 and disability claims for physicians have increased markedly over the past few years15,16 From a financial point of view, society has invested a large amount of money in the training of each physician, and to have them leave the work force early, because of either disability or retirement, is a poor investment Satisfaction can be conceptualized as the difference between expectations and reality That is, one can think of physician satisfaction as being determined both by factors intrinsic to the physician (eg, the satisfaction derived from a job well done or a diagnostic challenge met) and by extrinsic factors (eg, hours worked, financial remuneration, and working relationships with patients and colleagues) It follows that satisfaction is not a stable property of the medical profession itself, but a balance between physicians' changing expectations and the shifting environment within which physicians work The research literature suggests that dissatisfaction in the medical profession is not new Studies of physician job stress and physician satisfaction in the past have consistently identified excessive workloads and time pressures,9,17–20 limited personal time,17 paperwork associated with patient care,20,21 problems associated with patient communication,22 and patients not responding to treatment21 as causes of physician stress and dissatisfaction It has been suggested that these problems reflect stresses that are an inevitable part of the practice of medicine23 More recent studies have identified new areas of dissatisfaction, which have appeared on the horizon since the advent of managed care: decreased professional autonomy over clinical decisions2,24–31 and decreased time with patients2,27 There is some evidence to suggest that these problems increase with increasing level of managed-care penetration within a region or within an individual practice2,3,26,32–36 Why would physician satisfaction be related to the presence of managed care? Some research suggests that physicians are less satisfied when working in larger organizations than in smaller practice settings37 Other studies report that physicians struggle to balance their traditional role as patient advocate with the financial incentives from managed care that seek to control spending1,38,39 and time with patients34 However, it may be an oversimplification to consider the relationship between physician satisfaction and managed care without reference to the type of practice setting in which care is provided It seems likely that physician satisfaction in managed care settings will depend, in part, on physician's professional expectations and also on the substantive characteristics of the practice setting (ie, expectations and reality) In particular, one may expect to find differences in the professional satisfaction among physicians in open- versus closed-model practice settings By closed-model settings, we refer to practices in which physicians work exclusively for one HMO (ie, staff- and group-model HMO), while open-model practices refer to those in which physicians serve patients with multiple forms of insurance (ie, they do not have an exclusive relationship with any single health plan) Closed-model physicians actively selected to practice in a managed care organization (staff- or group-model HMO), while physicians in open-model practice settings may have come to work with managed care plans largely out of necessity as the plans became increasingly prevalent in their area over the past decade Thus, the two groups may differ substantially in their expectations concerning their professional life, and their objective work environments may differ as well, leading to differences in their satisfaction Indeed, a recent California-based study found that physicians in closed-model HMO practices were more satisfied with their autonomy and administrative issues, but less satisfied overall, than physicians in open-model settings34 The present study uses data from two surveys of Massachusetts physicians, one in 1986 and one in 1997, to compare the professional satisfaction of physicians in open- and closed-model practice settings, and to examine how physician satisfaction changed during a period of substantial delivery system change Using data from a longitudinal study of health care delivery in Massachusetts, we compared physician satisfaction in open- and closed-model systems in 1997 Using a second longitudinal study from 1986, we examined whether there was an observable shift in physician satisfaction from 1986 to 1997, and whether this differed by practice model-type