Virginia U. Collier

When the patient does not pay: a survey of primary care physicians.

Objective:Despite ethical implications, there are anecdotal reports of health practitioners withholding services from patients who do not pay their bills. We surveyed physicians about their attitudes and experiences regarding nonpaying patients. Design:A cross-sectional mailed survey. Participants:Three hundred seventy-nine of 1000 surveyed primary care physicians participated. Measurements and Main Results:We studied how likely participants were to withhold 13 services from hypothetical patients who did not pay the physicians bills based on a 4-point Likert scale. Respondents were asked whether they had actually ever withheld such services from patients. The effects of demographic data on the number of services withheld from hypothetical and actual patients were analyzed by analysis of variance and multiple logistic regression. Most respondents (84%) would have withheld at least 1 item of service from the hypothetical patient, with 41% having ever withheld care from their actual patients. Most services involved administrative actions, but many respondents would be willing to forego other types of medical care. Being younger (P = 0.003), believing that patients are not always entitled to medical care (P = 0.002) and being in an urban practice (P = 0.03) were associated with withholding medical care from patients. Conclusions:A majority of primary care practitioners responding to our survey would be willing to withhold medical care from patients who do not pay their bills; some have actually done so despite ethical and legal mandates to the contrary. Physicians should be educated about the importance of the patient-physician relationship and their ethical obligations to patients.

Stress in Medical Residency: Status Quo After a Decade of Reform?

Surveys going back to the 1970s demonstrated more frequent depression, anger, and hostility in residents than in the general population, presumably reflecting chronic sleep deprivation and fatigue. Attempts were subsequently made to identify, manage, and lower the level of resident stress. At present, duty hours are closely regulated and program directors are obliged to monitor stress levels. New sources of stress continue to emerge, however, examples being unstable financial conditions at some academic medical centers, increased personal debt, and lower confidence in the ability to get work after completing residency. The investigators questioned residents at all 415 U.S. medicine residency programs about their financial status, educational dept, moonlighting practices, and psychological issues. The 4128 survey respondents represented a response rate of 18%. At least 42% of responding residents reported educational debt of

Stress in Medical Residency: Status Quo after a Decade of Reform?

50,000 or more, and 19% owes at least

Redesigning training for internal medicine

100,000. Monthly disposable income was

Physicians' Decisions to Withhold and Withdraw Life-Sustaining Treatment

100 or less for 43% of respondents; 16% could not afford safe housing. More than half the respondents in the second through fifth years of postgraduate training could not buy books and equipment, and 29% could not afford to take the American Board of Internal Medicine certifying examination. One third of residents, especially those with a higher debt, reported moonlighting. About half the residents reported changes in appetite, 61% had mood swings, and 45% reported depressed mood. Nearly one fourth of the residents felt that they had become less humanistic during their training, and 61% reported becoming more cynical. Depressive symptoms and cynicism correlated with increasing debt. More than one in four female residents experienced pressure from faculty to delay pregnancy. Female residents with children reported less depression than those without and less frequently reported increased cynicism. It seems that many medical residents continue to experience financial and emotional distress that could interfere with training, despite efforts to limit stress. Disturbingly, feelings of cynicism and a perception of becoming less humanistic are reported frequently. Possible ways of resolving these problems include relief from early repayment and increased salaries. Special efforts are needed to relieve stress in female medical residents.