National survey of job satisfaction and retirement intentions among general practitioners in England

Objectives To measure general practitioners' intentions to quit direct patient care, to assess changes between 1998 and 2000, and to investigate associated factors, notably job satisfaction. Design Analysis of national postal surveys conducted in 1998 and 2001. Setting England. Participants 1949 general practitioner principals, of whom 790 were surveyed in 1998 and 1159 in 2001. Main outcome measures Overall job satisfaction and likelihood of leaving direct patient care in the next five years. Results The proportion of doctors intending to quit direct patient care in the next five years rose from 14% in 1998 to 22% in 2001. In both years, the main factors associated with an increased likelihood of quitting were older age and ethnic minority status. Higher job satisfaction and having children younger than 18 years were associated with a reduced likelihood of quitting. There were no significant differences in regression coefficients between 1998 and 2001, suggesting that the effect of factors influencing intentions to quit remained stable over time. The rise in intentions to quit was due mainly to a reduction in job satisfaction (1998 mean 4.64, 2001 mean 3.96) together with a slight increase in the proportion of doctors from ethnic minorities and in the mean age of doctors. Doctors' personal and practice characteristics explained little of the variation in job satisfaction within or between years. Conclusions Job satisfaction is an important factor underlying intention to quit, and attention to this aspect of doctors' working lives may help to increase the supply of general practitioners

Checklists improve experts' diagnostic decisions

Context Checklists are commonly proposed tools to reduce error. However, when applied by experts, checklists have the potential to increase cognitive load and result in expertise reversal'. One potential solution is to use checklists in the verification stage, rather than in the initial interpretation stage of diagnostic decisions. This may avoid expertise reversal by preserving the experts' initial approach. Whether checklist use during the verification stage of diagnostic decision making improves experts' diagnostic decisions is unknown. Methods Fifteen experts interpreted 18 electrocardiograms (ECGs) in four different conditions: undirected interpretation; verification without a checklist; verification with a checklist, and interpretation combined with verification with a checklist. Outcomes included the number of errors, cognitive load, interpretation time and interpretation length. Outcomes were compared in two analyses: (i) a comparison of verification conditions with and without a checklist, and (ii) a comparison of all four conditions. Standardised scores for each outcome were used to calculate the efficiency of a checklist and to weigh its relative benefit against its relative cost in terms of cognitive load imposed, interpretation time and interpretation length. Results In both analyses, checklist use was found to reduce error (more errors were corrected in verification conditions with checklists [0.29 +/- 0.77 versus 0.03 +/- 0.61 errors per ECG], and fewer net errors occurred in all conditions with checklists [0.39 +/- 1.14 versus 1.04 +/- 1.49 errors per ECG];

Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam

Background Few studies have investigated whether clinicians can use checklists to verify their diagnostic decisions. Checklists may improve accuracy by prompting clinicians to reconsider or recollect information but might impair decision making by adding to clinicians' cognitive load. This study assessed whether checklists improve cardiac exam diagnostic accuracy, and whether this benefit is dependent on collecting additional information. Methods 191 internal medicine residents examined a cardiopulmonary simulator. They provided a diagnosis, subjective rating of certainty, and key findings before and after using a checklist. Residents were randomised; half were allowed access to the simulator and half were prohibited access to the simulator while using the checklist. Residents rated their cognitive load in each step: prechecklist diagnosis, checklist use and postchecklist diagnosis. Result Verifying with a checklist resulted in improved diagnostic accuracy; 88 residents (46%) made the correct diagnosis before using the checklist compared with 97 (51%) afterwards, p=0.04. The benefit of checklist use was restricted to residents allowed to re-examine the simulator (10 changed to correct diagnosis and one to an incorrect diagnosis) whereas no net benefit was seen among residents unable to re-examine the simulator (two changed to a correct diagnosis and two to an incorrect diagnosis, p=0.03). Those able to re-examine the simulator were slightly more confident after checklist use, whereas those unable to re-examine were slightly less confident after checklist use (p=0.01). The opportunity to re-examine the simulator had no effect on the accuracy of key findings reported. Of the three steps, checklist use was associated with the lowest cognitive load (F-1,F-189=68

Routine care provided by specialists to children and adolescents in the United States (2002-2006).

BACKGROUND: Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings. METHODS: Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected. RESULTS: Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit. CONCLUSION: Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

The Portrayal of Complementary and Alternative Medicine in Mass Print Magazines Since 1980

Objectives: The objectives of this study were to examine and describe the portrayal of complementary and alternative medicine (CAM) in mass print media magazines. Design: The sample included all 37 articles found in magazines with circulation rates of greater than 1 million published in the United States and Canada from 1980 to 2005. The analysis was quantitative and qualitative and included investigation of both manifest and latent magazine story messages. Results: Manifest analysis noted that CAM was largely represented as a treatment for a patient with a medically diagnosed illness or specific symptoms. Discussions used biomedical terms such as patient rather than consumer and disease rather than wellness. Latent analysis revealed three themes: (1) CAMs were described as good but not good enough; (2) individualism and consumerism were venerated; and (3) questions of costs were raised in the context of confusion and ambivalence

A survey of primary and specialised health care provision to prisons in England and Wales

Background Prison health care in England, including primary care, is now incorporated into the National Health Service; the impetus for the change is in part due to concern about standards of health care within prisons. The demographic characteristics and health status of patients within prisons are relatively well understood, as are the problems faced by health care professionals. Less is known about current health care provision. Aims To describe the organisation of primary health care and specialised services in prisons and compare services available to different types of prison. Method A piloted questionnaire was sent to the governors of all prisons in England and Wales for completion by the health care manager. Findings Completed questionnaires were received from 122 (89%) of 138 prisons. The survey showed a low use of information technology (IT). Problems were reported with the recruitment and retention of general nurses in more than 50% of prisons. Prisoners in category A/B (higher security) prisons had available to them a greater range of health care services compared with those in other prisons. The results suggest that provision of services for chronic diseases and improvements in IT are needed. Problems with the recruitment and retention of general nurses need addressing. The reasons why lower-security prisoners are receiving a narrower range of specialised health care services compared with higher-security prisoners need justifying

Documentation of best interest by intensivists: a retrospective study in an Ontario critical care unit

<p>Abstract</p> <p>Background</p> <p>Intensive care physicians often must rely on substitute decision makers to address all dimensions of the construct of "best interest" for incapable, critically ill patients. This task involves identifying prior wishes and to facilitate the substitute decision maker's understanding of the incapable patient's condition and their likely response to treatment. We sought to determine how well such discussions are documented in a typical intensive care unit.</p> <p>Methods</p> <p>Using a quality of communication instrument developed from a literature search and expert opinion, 2 investigators transcribed and analyzed 260 handwritten communications for 105 critically ill patients who died in the intensive care unit between January and June 2006. Cohen's kappa was calculated before analysis and then disagreements were resolved by consensus. We report results on a per-patient basis to represent documented communication as a process leading up to the time of death in the ICU. We report frequencies and percentages for discrete data, median (m) and interquartile range (IQR) for continuous data.</p> <p>Results</p> <p>Our cohort was elderly (m 72, IQR 58-81 years) and had high APACHE II scores predictive of a high probability of death (m 28, IQR 23-36). Length of stay in the intensive care unit prior to death was short (m 2, IQR 1-5 days), and withdrawal of life support preceded death for more than half (n 57, 54%). Brain death criteria were present for 18 patients (17%). Although intensivists' communications were timely (median 17 h from admission to critical care), the person consenting on behalf of the incapable patient was explicitly documented for only 10% of patients. Life support strategies at the time of communication were noted in 45% of charts, and options for their future use were presented in 88%. Considerations relevant to determining the patient's best interest in relation to the treatment plan were not well documented. While explicit survival estimates were noted in 50% of charts, physicians infrequently documented their own predictions of the patient's functional status (20%), anticipated need for chronic care (0%), or post ICU quality of life (3%). Similarly, documentation of the patient's own perspectives on these ranged from 2-18%.</p> <p>Conclusions</p> <p>Intensivists' documentation of their communication with substitute decision makers frequently outlined the proposed plan of treatment, but often lacked evidence of discussion relevant to whether the treatment plan was expected to improve the patient's condition. Legislative standards for determination of best interest, such as the Health Care Consent Act in Ontario, Canada, may provide guidance for intensivists to optimally document the rationales for proposed treatment plans.</p