Alvin R. Tarlov

The Primary Care Assessment Survey: tests of data quality and measurement performance.

OBJECTIVES The authors examine the data quality and measurement performance of the Primary Care Assessment Survey (PCAS), a patient-completed questionnaire that operationalizes formal definitions of primary care, including the definition recently proposed by the Institute of Medicine Committee on the Future of Primary Care. METHODS The PCAS measures seven domains of care through 11 summary scales: accessibility (organizational, financial), continuity (longitudinal, visit-based), comprehensiveness (contextual knowledge of patient, preventive counseling), integration, clinical interaction (clinician-patient communication, thoroughness of physical examinations), interpersonal treatment, and trust. Data from a study of Massachusetts state employees (n = 6094) were used to evaluate key measurement properties of the 11 PCAS scales. Analyses were performed on the combined population and for each of the 16 subgroups defined according to sociodemographic and health characteristics. RESULTS The 11 PCAS scales demonstrated consistently strong measurement characteristics across all subgroups of this adult population. Tests of scaling assumptions for summated rating scales were well satisfied by all Likert-scaled measures. Assessment of data completeness, scale score dispersion characteristics, and inter-scale correlations provide strong evidence for the soundness of all scales, and for the value of separately measuring and interpreting these concepts. CONCLUSIONS With public and private sector policies increasingly emphasizing the importance of primary care, the need for tools to evaluate and improve primary care performance is clear. The PCAS has excellent measurement properties, and performs consistently well across varied segments of the adult population. Widespread application of an assessment methodology, such as the PCAS, will afford an empiric basis through which to measure, monitor, and continuously improve primary care.

A National Study of Internal Medicine and Its Specialties: I. An Overview of the Practice of Internal Medicine

A nationwide study of 24 medical and surgical specialties has been conducted by the University of Southern California School of Medicine, Division of Research in Medical Education. This article is the first in a series reporting findings for general internal medicine and 10 subspecialties of internal medicine. Populations for these 11 specialties are defined and enumerated, and the specialties are compared in terms of demographic and geographic distribution. Practice comparisons are presented based on characteristics such as workload, allocation of professional time, location of encounters with patients, distribution of primary problem diagnoses, and projections of annual patient encounters. Forthcoming specialty-specific articles will present highly detailed information for general internal medicine and for the subspecialties of cardiology, gastroenterology, pulmonary disease, allergy, hematology, endocrinology, nephrology, medical oncology, rheumatology, and infectious diseases.

National Study of Internal Medicine Manpower: IX. Internal Medicine Residency and Fellowship Training: 1984 Update.

After 12 years of annual expansion, the number of entrants into internal medicine training did not increase in 1983-84. In addition, the number of United States citizens with medical degrees from other countries entering first-year residency positions in internal medicine declined in 1983-84 for the first time in many years. The number of trainees who, upon completion of residency training, chose to become subspecialty fellows increased, and the period of subspecialty training has lengthened to 3 years for one third of the fellows. The total budgets for residency stipends have not increased in real dollars since 1976-77 despite substantial rises in the number of trainees. In fact, stipend levels per resident and fellow have declined in real dollars. Internists make up about 25% of all practicing physicians. With the continuing growth in the number of practicing internists and the high rate of their subspecialization, some adjustments will be made in practice patterns over the next 2 decades.

Changes in the Supply of Internists: The Internal Medicine Population from 1978 to 1998

Between 1978 and 1985, the number of active internists in the United States increased from 64,000 to 91,000, and by 1998 the number will have increased to 141,000. This growth represents an increase of 121% for a 20-year period, during which time the population of the United States is expected to increase only 19%. Thus, the number of adults older than 17 years per active internist will drop from 2464 to 1401. Between 1978 and 1998, we expect the number of subspecialty internists to increase 206%, in contrast to a 77% increase expected for general internists. The proportion of female internists will increase from 7% to 21%. The proportion of the active internist population who are foreign medical graduates will remain stable at about 21% throughout the projection period, but within this group the proportion who are United States citizens is expected to increase while the proportion who are foreign citizens is expected to decline.

BIOCHEMICAL AND GENETIC ASPECTS OF PRIMAQUINE-SENSITIVE HEMOLYTIC ANEMIA

Excerpt Acute hemolysis, which may destroy half the red cells within a few days, occurs in approximately 10% of otherwise healthy American Negroes, very rarely in Caucasians,1, 2, 3when 30 mg. prim...

National study of internal medicine manpower: IV. Residency and fellowship training 1977-1978 and 1978-1979.

The National Study of Internal Medicine Manpower gathered data on the number of residents in training in internal medicine and the number of fellows in subspecialty training, for 1977-1978 and for 1978-1979. In the latter period, there were 16720 residents in all years of training. The 7.2% average annual increase in the number of first-year residents during the earlier half of the 1970s slowed in 1977-1978 and 1978-1979 to 4.6% and 4.2%, respectively, reflecting a similar decline in the number of medical school graduates. The most important finding of the study is that the steep rise (10.6% per year) in the number of subspecialty fellowship trainees characteristic of the years 1972-1973 through 1976-1977 has abated. The number of fellows in subspecialty training has remained essentially constant in the past 2 years. Thus, although the number of residents continued to increase and the number of fellows remained constant, the number (and percentage) of internists in training who intend to practice general internal medicine rose.

National study of internal medicine manpower: II. A typology of residency training programs in internal medicine.

This second paper of the National Study of Internal Medicine Manpower describes the differing environments of residency training programs. Using previous studies as prototypes, the authors apply factor analysis to data from questionnaires returned by residency training directors and residents to illustrate the myriad interrelations within training programs. The most important result of this study is the demonstration that the largest residency programs have the most subspecialty programs, and their residents are more likely to pursue subspecialty fellowships after completing their third residency year. However, preliminary findings show no associations between the typology (typologic categories of residencies and their trainees) used and desired practice locations in states having few physicians relative to the population or in states with fewer urban inhabitants. The typology also does not predict the future practice aspirations of residents who are more likely to care for the poor or minority populations. A separate set of factors, possibly unrelated to training environments, will help to predict such career outcomes. Further specification of these factors will be the subject of a later paper in this series.

National Study of Internal Medicine Manpower: V. Comparison of Residents in Internal Medicine—Future Generalists and Subspecialists

Questionnaire III of the National Study of internal Medicine Manpower was directed to a random sample of residents (and subspecialty fellows) in the spring of 1977. Residents were classified according to whether they sought careers as predominantly general internists (49%) or subspecialty internists (51%), and the two groups were compared. Future generalists, more often, tended to be non-Jewish, to have incurred higher debts, and to have trained in medical schools in the states where they had spent their childhoods. Training experiences also were different. Future generalists, more than subspecialists, were attracted to the field because of the ability to retain independence in their work. Subspecialists, more often, intended to have academic careers and locate in the largest cities. Although subspecialists expected greater financial rewards, neither group selected their fields on this basis. By controlling for the main criterion used to select the medical school attended, we were able to explain several factors that differentiated the two groups.

Agranulocytosis with Monohistiocytosis Associated with Ampicillin Therapy

Abstract A case is presented of a patient who developed agranulocytosis with a peripheral monocytosis and a marrow histiocytosis secondary to ampicillin therapy. A brief review of this complex, pre...

Outcomes Assessment and Quality of Life in Patients with Human Immunodeficiency Virus Infection

Excerpt The article by Wachtel and colleagues concerning quality of life in persons with human immunodeficiency virus (HIV) infection, published in this issue (1), is noteworthy in at least two way...