Edward J. Callahan

The influence of gender on physician practice style.

As more women enter medicine, intriguing questions arise about how physician gender impacts practice style. To measure this influence in primary care encounters, 118 male and 132 female adult new patients, having no stated preference for a specific physician, were randomly assigned to university hospital primary care residents, and their initial encounters were videotaped. Forty-eight male and 33 female physicians participated. Patient health status was assessed before the visit with the Medical Outcomes Study Short-Form General Health Survey. Physician practice style was evaluated by using the Davis Observation Code to analyze videotapes of each initial visit. Patient satisfaction with medical care was assessed with satisfaction questionnaires. Contrary to prior reports, the difference between male and female physicians in total time spent with patients was small and statistically insignificant, and diminished further when controlling for patient gender and health status. Female physicians, however, were observed to engage in more preventive services and to communicate differently with their patients. These differences in practice style appear to explain partially the observed higher patient satisfaction scores for female physicians. This study underscores the importance of careful measurement and control of potential confounding factors in clarifying the impact of physician gender on practice style.

Physician practice styles and patient outcomes: differences between family practice and general internal medicine.

OBJECTIVES This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine. METHODS New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured. RESULTS There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation. CONCLUSIONS There were significant differences in practice styles between family physicians and internists; however, it was the physicians behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.

Patient gender differences in the diagnosis of depression in primary care.

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.

The influence of patient age on primary care resident physician-patient interaction.

OBJECTIVES: To explore resident physician‐patient interaction in primary care to address issues relevant to quality of care for older people.

Patients' perceptions of omitted examinations and tests : A qualitative analysis

AbstractOBJECTIVES: To understand the nature of patients’ expectations for parts of the physical examination and for diagnostic testing and the meaning patients ascribe to their desires. DESIGN: Qualitative inquiry based on patient interviews and focused on perceived diagnostic omissions as “critical incidents.” SETTING: Three general internal medicine practices (21 practitioners) in one mid-sized northern California city. PATIENTS: Of 687 patients visiting these practice sites and completing a detailed questionnaire, 125 reported one or more omissions of care and 90 completed an in-depth telephone interview. This study focuses on the 56 patients interviewed who did not receive desired components of the physical examination or diagnostic tests. MEASUREMENTS: Qualitative analysis of key themes underlying patients’ unmet expectations for examinations and tests, as derived from verbatim transcripts of the 56 interviews. MAIN RESULTS: The 56 patients perceived a total of 113 investigative omissions falling into four broad categories: physical examination (47 omissions), conventional tests (43), highcost tests (10), and unspecified investigations (13). Patients considered omitted investigations to have value along both pragmatic and symbolic dimensions. Diagnostic maneuvers had pragmatic value when they were seen to advance the technical aims of diagnosis, prognosis, or therapy. They had symbolic value when their underlying purpose was to enrich the patient-physician relationship. Patients in this study were often uncomfortable with clinical uncertainty, distrusted empiric therapy, endorsed early detection, and frequently interpreted failure to examine or test as failure to care. CONCLUSIONS: When patients express disappointment at failing to receive tests or examinations, they may actually be expressing concerns about the basis of their illness, the rationale for therapy, or the physician-patient relationship.

Differences between family physicians' and general internists' medical charges.

OBJECTIVES Data from 509 primary care patients were analyzed to determine whether practice style differences between family physicians and general internists generate differential utilization of health care resources leading to differential medical charges. METHODS New adult patients were prospectively randomized to care by family physicians and general internists. Utilization of medical care services and associated charges then were monitored for 1 year of care. RESULTS Family practice patients had a significantly higher mean number of visits to their primary care clinic and significantly fewer emergency room visits than patients assigned to Internal Medicine. Mean charges for primary care and emergency department treatment were significantly lower for patients assigned to Family Practice than for those assigned to General Internal Medicine. There were no significant differences in charges for specialty clinic visits, hospitalizations, or diagnostic services. CONCLUSIONS Practice style differences between family physicians and general internists were associated with differential medical charges, with family physicians generating lower charges for some aspects of care.

Comparison of Primary Care Resident Physicians' Practice Styles During Initial and Return Patient Visits

New adult patients (n=212) were randomly assigned to 58 primary care resident physicians. Physician practice styles during initial and return visits were analyzed using the Davis Observation Code. Compared with initial patient visits, return visits were shorter, but more work-intensive, Return visits displayed significantly less technically oriented behavior (including history taking, physical examination, and treatment planning) and fewer discussions regarding use of addictive substances; however, there was more emphasis on health behaviors and active involvement of patients in their own care. These physicians’ practice style differences between initial and return patient visits suggest that physician-patient familiarity affects what happens during the medical interview.

Patient Pain in Primary Care: Factors That Influence Physician Diagnosis

BACKGROUND The accurate recognition of patient pain is a crucial, but sometimes difficult, task in medical care. This study explored factors related to the physician’s diagnosis of pain in primary care patients. METHODS New adult patients were prospectively randomized to care by primary care providers at a university medical center clinic. Study participants were interviewed prior to the initial visit, and their level of self-reported pain was measured with the Visual Analog Pain Scale and the Medical Outcomes Study Short Form-36. The medical encounter was videotaped in its entirety and later analyzed using the Davis Observation Code to characterize physician practice style. Patient satisfaction was measured immediately after the visit. A review of the medical record was used to assess physician recognition of patient pain. RESULTS For all patients (N = 509), as the amount of pain increased, the percentage of patients having pain diagnosed by the physician also increased. Female patients reported a greater amount of pain than male patients. When women were in severe pain, they were more likely than men to have their pain accurately recognized by their physician. The correct diagnosis of pain was not significantly related to patient satisfaction. Physician practice styles emphasizing technically oriented activities and health behavior discussions were strongly predictive of the physician diagnosing patient pain. CONCLUSIONS The diagnosis of pain is influenced by the severity of patient pain, patient gender, and physician practice style. If the routine use of pain assessment tools is found to be effective in improving physician recognition and treatment of patients’ pain, then application of these tools in patient care settings should be encouraged.

Behavioral Treatment of Hyperemesis Gravidarum

Hyperemesis gravidarum, while no longer a serious threat to maternal mortality, is a serious disorder endangering pregnancy. While recognition of psychological factors in the etiology of the disord...

Issues and Challenges of Non-Tenure-Track Research Faculty: The UC Davis School of Medicine Experience

Nationally, medical schools are appointing growing numbers of research faculty into non-tenure-track positions, paralleling a similar trend in universities. The American Association of University Professors (AAUP) issued a statement expressing concern that the marked growth in non-tenure-track faculty can undermine educational quality, academic freedom, and collegiality. Like other medical schools, the UC Davis School of Medicine has had a rise in non-tenure-track faculty in order to enhance its research mission, in particular in the Salaried Adjunct faculty track (SalAdj). SalAdj faculty have more difficulty in achieving promotion, report inequitable treatment and less quality of life, have less opportunity to participate in governance, and feel second-class and insecure. These issues reflect those described by the AAUP. The authors describe the efforts at UC Davis to investigate and address these issues, implementation of a plan for improvement based on task force recommendations, and the lessons learned. Supporting transfer to faculty tracks in the academic senate, enhancing financial support, ensuring eligibility for internal grants, and equitable space assignments have contributed to an improved career path and more satisfaction among SalAdj faculty. Challenges in addressing these issues include limited availability of tenure-track positions, financial resources, adequate communication regarding change, and compliance with existing faculty search policies.