Samuel Cykert

Health insurance does not guarantee access to primary care: a national study of physicians' acceptance of publicly insured patients.

The roles of reimbursement and other predictors that affect physicians’ willingness to accept publicly insured continuing care patients were examined in a national survey. The response rate was 47%. Eighty-eight percent of the respondents were accepting new patients. Forty-two percent of these physicians were willing to accept new continuing care patients insured by Medicaid, 70% reported accepting those paying by Medicare assignment, and 85% said they accept patients covered by Medicare plus balance-billing payments. Low reimbursement was the strongest predictor for lack of acceptance. The results suggest that systems of multitiered reimbursement are associated with diminished access for patients insured in the lower tiers.

Telephone Medicine for Internists

The role of the telephone in medical practice is important, but often problematic. Mistakes in telephone diagnosis and triage can have severe consequences. An effective office system can reduce liability risks, and in some cases telephone contact can substitute for office visits. Internists feel unprepared to provide telephone care. Therefore, residency education needs to focus on documentation, consultant availability, and performance feedback. Research should focus on improving outcomes, reimbursement issues, and technologic advances. This article describes internists’ telephone interactions with ambulatory patients, preparation for telephone medicine, and aspects of office telephone systems and makes comparisons with other primary care fields.

Surgical decisions for early stage, non-small cell lung cancer: which racially sensitive perceptions of cancer are likely to explain racial variation in surgery?

Objectives. Twenty-three percent of white and 36% of African American patients who suffer from early stage non–small cell lung cancer do not undergo potentially curative surgery. A simple decision model is presented to probe for elements of surgical decision making that could explain decisions against lung cancer surgery and racial variation in these decisions. Methods. A survey of 181 diverse individuals to measure health utility scores for conditions relevant to lung cancer surgery was performed. These scores were inserted into a simple model that calculates quality-adjusted survival related to decisions for and against cancer surgery. Results. The health utility score (HUS) for progressive lung cancer, as determined by a survey using the standard gamble approach, is nearly twice as high in African Americans as whites (0.32 v. 0.18). However, in a model incorporating African American utility data, lung cancer surgery remains heavily favored compared to the no-surgery decision (2.32 v. 0.48 quality-adjusted life years). Sensitivity analysis shows that factors that lead to a belief of cancer “cure” in the absence of surgical intervention are much more important than variations of HUS in directing model results away from surgery. Conclusion. This analysis illustrates that racial differences in quality-of-life ratings of progressive lung cancer as measured by HUS exist but may not explain decisions against surgery as much as other elements of patient care.

Telephone Management Training in Internal Medicine Residencies: A National Survey of Program Directors.

Background Little is known about how internal medicine residents train for and practice telephone management. To address this deficiency, a national survey of program directors at accredited internal medicine training sites was conducted to evaluate residents training for and practice of telephone medicine. Method A 43-item questionnaire was mailed in December 1993 to all program directors at the 416 accredited internal medicine training sites in the United States. A limited questionnaire, regarding the most essential training questions, was mailed to all non-responders. Results The response rate was 60% (250) for the full questionnaire. Only 15 (6%) of the programs offered formal training in telephone management to their residents. This training usually consisted of single lectures (nine programs) or reading materials (seven programs). The respondents felt that formal training in telephone management was very important (155, 62%) and that such training should be a part of every internal medicine curriculum (150, 60%). Conclusion Few internal medicine programs offered training in telephone management. When training occurred, it was usually limited and informal. Most program directors felt that training was important and that current training efforts were unsatisfactory, emphasizing the need for curriculum development and implementation in telephone management.

Translating Medical Evidence to Promote Informed Health Care Decisions

OBJECTIVEnTo examine the effects of a community-based intervention on decisions about prostate-specific antigen (PSA) screening using multiple measures of informed decision making (IDM).nnnDATA SOURCES/STUDY SETTINGnNonequivalent control group time series design collecting primary data in late 2004 and 2005.nnnSTUDY DESIGNnWe developed a multimodal intervention designed to convey the medical uncertainty about the benefits of PSA screening and early treatment and the limited predictive ability of both the PSA test and pathological specimens collected from prostate biopsy. We examined (1) patients recognition that there is a decision to be made about PSA screening, (2) prostate cancer knowledge levels, (3) their preferred and actual levels of participation in decision making about screening at three points in time, and (4) screening decision.nnnDATA COLLECTIONnBaseline data collection occurred in community-based organizations. These organizations served as recruiting sources and as sites for the intervention. We collected follow-up data by mail with telephone reminders.nnnPRINCIPAL FINDINGSnOur intervention was associated with greater recognition of the PSA test as a decision to be made, levels of knowledge, both preferred and actual levels of involvement in decision making, but did not have an impact on the screening decision.nnnCONCLUSIONSnCommunity-based interventions can influence key measures of IDM about PSA screening.

Communication Message Strategies for Increasing Knowledge About Prostate Cancer Screening

Background. This community-based intervention study examined the effects of 2 different message strategies for presenting information about the prostate specific antigen (PSA) test. Methods. A quasi-experimental longitudinal design with 2 intervention and 1 control group. Results. Knowledge increased significantly among participants who received either version of the intervention message and remained elevated at 12 months. Presenting information in the context of other men’s health issues was associated with greater increases in knowledge relative to PSA only. Conclusions. Community-based interventions can increase knowledge about prostate cancer screening. Clinicians need to take careful account of what their patients understand and correct misperceptions.

Issues affecting residents’ attitudes about telephone medicine for ambulatory patients

Background: Telephone medicine is an important component of internists’ practices. Their patients’ calls are often complex and lead to further medical care. However, telephone medicine skills are seldom taught during internal medicine residencies. Purpose: This study sought to identify characteristics of residency education and issues important to residents that shape their attitudes about telephone management of ambulatory patients. Methods: Residents (N = 388) in 10 diverse programs were surveyed confidentially. Responses were grouped into descriptive and attitudinal items and analyzed using factor analysis. Descriptive scales and demographic items were used as independent variables to predict attitudinal scales. Results: The residents surveyed expressed discomfort with telephone medicine. However, they identified receiving performance feedback from a variety of sources, having access to consultants, having charts available, and documenting calls as important components to their satisfaction with teleph...

Asthma associated with worsening leg ulcer: a case of vasculitis in primary care.

A 71-year-old black woman was admitted to the hospital with a 2-month history of a nonhealing leg ulcer. Her medical history included diabetes mellitus type 2, congestive heart failure, allergic rhinitis, and asthma. The patients asthma was labile and steroid-dependent until 2 years before admission, at which time zafirlukast therapy was started. On further questioning, the patient revealed a 6-month history of malaise and a 40-lb weight loss. A physical examination showed a 2-cm Stage 3 ulcer on the medial aspect of the right ankle with diminished sensation in both feet and left footdrop. Electromyography revealed mononeuritis multiplex. The patients white blood cell count was 11,100/mm3 with 60% eosinophils. A sural nerve biopsy showed vasculitis consistent with Churg-Strauss syndrome. One week after prednisone therapy was initiated, the patients foot strength was nearly normal and her eosinophilia had resolved. Although Churg-Strauss syndrome is a rare disorder, in the setting of asthma and multiple disparate signs and symptoms, the broad diagnostic category of serious vasculitic illness should be considered.