US neurologists: attitudes on rationing.

OBJECTIVE: To assess neurologists' attitudes on rationing health care and to determine whether neurologists would set healthcare priorities in ways that are consistent with cost-effectiveness research. BACKGROUND: Cost-effectiveness research can suggest ways to maximize health benefits within fixed budgets but is currently being underused in resource allocation decisions. METHODS: The authors surveyed a random sample of neurologists practicing in the United States (response rate, 44.4%) with three hypothetical scenarios. Two scenarios were designed to address general attitudes on allocating finite resources with emphasis on formulary decisions for costly drugs. The third scenario was designed to assess whether neurologists would optimize the allocation of a fixed budget as recommended by cost-effectiveness analysis. RESULTS: Three-quarters of respondents thought that neurologists make daily decisions that effectively ration healthcare resources, and 60% felt a professional responsibility to consider the financial impact of individualized treatment decisions on other patients. Only 25% of respondents thought that there should be no restrictions placed on any of the five newer antiepileptic agents. In a 1995 survey, 75% of similarly sampled neurologists agreed that no restrictions should be placed on the availability of FDA-approved medications. Nearly half (46%) of respondents favored a less effective test and would be willing to let patients die to ensure the offering of a more equitable alternative. CONCLUSIONS: Most neurologists recognize the need to ration health care, and although they think cost-effectiveness research is one method to achieve efficient distribution of resources, many think that considerable attention should also be given to equity.

Training the future neurology workforce.

OBJECTIVE: To address training demands on future neurologists, the American Academy of Neurology (AAN) surveyed its US members as to their views about training the future neurology workforce. METHODS: The survey was mailed to 575 US neurologists and 425 residents/fellows. Respondents (54%) were asked about their perceptions of current and future educational programs and settings needed to improve practice competence; issues related to subspecialization; and the role of non-neurologists in providing neurologic care. Views of neurologists were compared with those of neurology residents/fellows. RESULTS: Most respondents support additional training in outpatient, community, and staff model health maintenance organization settings. The majority of respondents oppose a required fifth year of training or a yearly competency examination, but neurologists who have a subspecialty interest and residents/fellows favor elective certification and higher fees by subspecialists. General neurologists oppose these ideas. Most neurologists feel that primary care physicians, nurse practitioners, and physician assistants can manage uncomplicated neurologic problems, although residents/fellows are less willing to accept the role of nonphysician providers for neurologic services. CONCLUSIONS: Neurology educational programs should consider addressing deficiencies that today's practitioners perceive. Increasing subspecialization, although favored by most neurologists, creates a challenge for the neurologic community as neurologists without subspecialty training see this trend as a threat to their livelihood.

Employment-seeking experiences of residents in 1996: a window into the neurology marketplace.

OBJECTIVE: To assess career choice and employment-seeking experience of senior neurology residents in 1996. METHODS: Graduating residents in adult and pediatric neurology (n = 573) were surveyed to obtain career plans, initial job selection, health care attitudes, and demographic information. Results were compared with 1996 data on all United States neurologists and data from an American Medical Association (AMA) resident survey regarding the employment status of new physicians. RESULTS: Survey response rate was 71%. There was a significant increase in international medical graduates and women entering neurology compared with the current workforce. Seventy-four percent of graduates planned to enter a fellowship position; 19%, private practice; 5%, an academic position; and 2%, a career outside of clinical medicine. Neurology residents differ from aggregate national data because only 28% of residents responding to an AMA survey across all specialties applied to fellowships in 1996. Overall, 44% of neurology graduates planned an academic career. CONCLUSIONS: Changing demographics and career choice of recent graduates may require continued monitoring and could be important in neurology workforce planning. The high rate of fellowship training and plans for academic careers in 1996 is of interest and may reflect both resident response to new demands in the changing health care market and a need to modify residency programs to enhance academic training and competitiveness of neurology graduates.

US neurologists in the 1990's: trends in practice characteristics.

BACKGROUND: The American Academy of Neurology (AAN) conducts periodic surveys of its members to profile and monitor changes in the characteristics of US neurologists and their practices. OBJECTIVE: To assess neurologists' characteristics, geographic distribution, practice arrangements, professional activities, practice volume, procedures performed, sources of revenue, involvement with managed care and capitation, and other selected topics. METHODS: The AAN Member Census survey was sent to US neurologists in the fall of 1996 (response rate = 89%), and the Practice Profile survey was sent to a random sample of 1,986 US neurologists in the summer of 1997 (response rate = 55%) who had completed a Member Census survey. The results of the Practice Profile survey were compared with those of two prior surveys conducted in 1991 to 1992 and 1993 to 1994. RESULTS: The mean age of US neurologists is 48 years, 18% are women, 93% are US citizens, and 24% are international medical graduates. The proportion of neurologists in solo practices, group practices, and medical schools/universities has not changed. The weekly hours worked has remained stable (58 hours), but the time spent in administrative activities has increased (p < 0.001). The average number of patient visits per week to neurologists appears to have increased (p < 0.001), as has the proportion of neurologists performing procedures (p < 0.05). The majority of neurologists have contracts with managed care organizations (82%), and a minority (32%) have capitated payment arrangements. Medicare continues to be the largest source of clinical revenue. Nearly 50% of all respondents have experience in developing clinical practice guidelines or critical pathways, and >20% of respondents employed physician extenders to assist in their practices. CONCLUSION: Neurologists are spending more time in administrative activities, are performing or interpreting more procedures, and are seeing more patients. Neurologists' involvement with capitation is comparable with that in a nationally representative sample of physicians, and they are exploring innovative ways, such as developing practice guidelines and using physician extenders, to improve the quality and efficiency of providing neurologic care.

Extended workdays in an underground mine: a work performance analysis.

Many companies in different industrial sectors are exploring alternative work schedules to deal with diverse problems associated with shiftwork. The use of extended workday schedules (regular shift lengths exceeding 8 h with compressed workweeks) is attracting growing interest in many industries that use continuous operations. To address concerns regarding possible fatigue effects on safety and work performance associated with such schedules, the U.S. Bureau of Mines conducted a two-phase study at an underground metal mine in western Canada. Data were collected before and after a group of workers employed at the mine changed from an 8- to a 12-h schedule. Results indicate nearly unanimous acceptance and improved sleep quality associated with the new schedule. In general, fatigue-sensitive behavioral and physiological performance measures show either no change or improvement with 12-h shifts. We conclude that the extended workday schedule should be retained but periodically reevaluated.