Hoangmai H. Pham

Leaving medicine: the consequences of physician dissatisfaction.

Background:During the past decade, a confluence of forces has changed the practice of medicine in unprecedented ways. Anecdotal reports suggest that, in response, some physicians are leaving the practice of medicine or retiring earlier than they otherwise would have. Objective:We sought to examine how physician demographic characteristics, practice characteristics, and career satisfaction are related to physician decisions to leave the practice of medicine or substantially cut back their practice hours. Design:Data for this study are from the first 2 rounds of the Community Tracking Study (CTS) Physician Survey, a series of nationally representative telephone surveys of physicians first conducted in 1996. Subsequent rounds of the survey included physicians sampled in the previous round, which allowed us to ascertain their career status 2 years after their initial interviews. Subjects:Primary care and specialist physicians initially spending at least 20 hours per week in direct patient care activities were studied. Main Outcomes Measures:Physicians cutting back their practice hours to less than 20 hours per week or leaving the practice of medicine altogether. Results:Of the 16,681 physicians interviewed for whom we also had information about their career status 2 years later, 462 (2.8%) had retired and 499 (3.0%) had reduced time spent in patient care to less than 20 hours per week. In multinomial logistic analyses that examined both outcomes, full- or part-owners of practices were both less likely to retire and to cut back hours. Internal medicine specialists and psychiatrists were less likely to retire (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.48–0.99 and OR 0.33, 95% CI 0.18–0.60 respectively) whereas surgical specialists were more likely to retire (OR 1.6, 95% CI 1.1–2.2). Physician satisfaction was strongly related to both outcomes. For instance, very dissatisfied physicians were both more likely to retire (OR 2.34, 95% CI 1.6–3.5) and cut back on their hours (OR 3.6, 95% CI 2.32–5.6). Conclusions:Our findings demonstrate that dissatisfied physicians were 2 to 3 times more likely to leave medicine than satisfied physicians. These findings have implications for physician manpower projections and quality of care.

Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients

BACKGROUND Most quality metrics focus on underuse of services, leaving unclear what factors are associated with potential overuse. METHODS We analyzed Medicare claims from 2000-2002 and 2004-2006 for 35 039 fee-for-service Medicare beneficiaries with acute low back pain (LBP) who were treated by 1 of 4567 primary care physicians responding to the 2000-2001 or 2004-2005 Community Tracking Study Physician Surveys. We modified a measure of inappropriate imaging developed by the National Committee on Quality Assurance. We characterized the rapidity (<28 days, 29-180 days, none within 180 days) and modality of imaging (computed tomography or magnetic resonance imaging [CT/MRI], only radiograph, or no imaging). We used ordered logit models to assess relationships between imaging and patient demographics and physician/practice characteristics including exposure to financial incentives based on patient satisfaction, clinical quality, cost profiling, or productivity. RESULTS Of 35 039 beneficiaries with LBP, 28.8% underwent imaging within 28 days and an additional 4.6% between 28 and 180 days. Among patients who received imaging, 88.2% received radiography, while 11.8% received CT/MRI as their initial study. White patients received higher levels of imaging than black patients or those of other races. Medicaid patients received less rapid or advanced imaging than other patients. Patients had higher levels of imaging if their primary care physician worked in large practices. Compared with no incentives, clinical quality-based incentives were associated with less advanced imaging (10.5% vs 1.4% for within 28 days; P < .001), whereas incentive combinations including satisfaction measures were associated with more rapid and advanced imaging. Results persisted in multivariate analyses and when the outcome was redefined as the number of imaging studies performed. CONCLUSIONS Rapidity and modality of imaging for LBP is associated with patient and physician characteristics but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse. Metrics that encompass overuse may suggest new areas of focus for quality improvement.

Qualitative Methods: A Crucial Tool for Understanding Changes in Health Systems and Health Care Delivery

The article by Bryan Weiner and colleagues (“Use of Qualitative Methods in Published Health Services and Management Research: A Ten-Year Review”) provides a review of the contribution of qualitative research to the knowledge base of health services research and how it has changed over the past 10 years (Weiner, Amick, Lund, Lee, & Hoff, 2011). Although qualitative studies still contribute to a relatively small (and apparently decreasing) share of the total number of articles in the nine major health services research and management journals, it is noteworthy that these articles are cited as frequently as articles using quantitative methods. Clearly there is a role for qualitative research in studies of health systems, but this role is still not well understood or even widely appreciated. One limitation of the study by Weiner et al. is that their review was restricted to nine health services and management journals. Although these include some of the most prestigious journals in the field, they do not necessarily reflect the full impact that qualitative research has had on the knowledge base or on health policy. We believe that the interest and acceptance of qualitative research has grown, as well as its importance and influence among policy makers and directors of public programs, although the results of such research are often not published in academic journals. We have seen the importance of qualitative methods most directly through our experience with the Community Tracking Study (CTS), which since 1996 has included household and physician surveys, as well as site visits to 12 randomly selected Medical Care Research and Review 68(1) 34 –40

Predictors of the Growing Influence of Clinical Practice Guidelines

BackgroundDespite the proliferation of clinical practice guidelines (CPGs), physicians have been slow to adopt them.ObjectiveDescribe changes in the reported effect of CPGs on physicians’ clinical practice over the past decade, and identify the practice characteristics associated with those changes.Design and ParticipantsLongitudinal and cross-sectional analyses of rounds 1–4 of the Community Tracking Study Physician Survey, a nationally representative survey, conducted periodically between 1996 and 2005.MeasurementsThe cross-sectional outcome was the reported effect of CPGs on the physician’s practice (very large, large, moderate, small, very small, and no effect). The longitudinal outcome was the change in reported effect of CPGs between two consecutive rounds for panel respondents. Independent variables included changes in physicians’ practice characteristics (size, ownership, capitation, availability of information technology (IT) to access guidelines, whether quality measures and profiling affect compensation, and revenue sources).ResultsThe proportion of primary care physicians reporting that CPGs had a very large or large effect on their practice increased significantly from 1997 to 2005, from 16.4% to 38.7% (P < .0001). The corresponding change for specialists was 18.9% to 28.2% (P < .0001). In longitudinal multivariate analyses, practice characteristics associated with an increase in effect of CPGs included acquiring IT to access guidelines, an increase in the impact that quality measures and profiling have on compensation, and an increase in the proportion of practice revenue under capitation or derived from Medicaid.ConclusionsPromotion of wider adoption of health IT, and financial incentives linked to validated quality measures, may facilitate further growth in the impact of CPGs.

Association Between Quality of Care and the Sociodemographic Composition of Physicians’ Patient Panels: A Repeat Cross-Sectional Analysis

ABSTRACTBACKGROUNDPay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients.OBJECTIVETo test for associations between quality of care and the composition of a physician’s patient panel.DESIGNRepeat cross-sectional analysisPARTICIPANTSNationally representative sample of US primary care physicians responding to a panel telephone survey in 2000–2001 and 2004–2005MAIN MEASURESQuality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians’ patient panels.KEY RESULTSAcross eight quality measures, physicians’ quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points.CONCLUSIONSIn a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians’ quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients. To test for associations between quality of care and the composition of a physician’s patient panel. Repeat cross-sectional analysis Nationally representative sample of US primary care physicians responding to a panel telephone survey in 2000–2001 and 2004–2005 Quality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians’ patient panels. Across eight quality measures, physicians’ quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points. In a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians’ quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.