Use of imaging in the emergency department: physicians have limited effect on variation.

PURPOSE: To quantify interphysician variation in imaging use during emergency department (ED) visits and examine the contribution of factors to this variation at the patient, visit, and physician level. MATERIALS AND METHODS: This study was HIPAA compliant and approved by the institutional review board of Partners Healthcare System (Boston, Mass), with waiver of informed consent. In this retrospective study of 88 851 consecutive ED visits during 2011 at a large urban teaching hospital, a hierarchical logistic regression model was used to identify multiple predictors for the probability that low- or high-cost imaging would be ordered during a given visit. Physician-specific random effects were estimated to articulate (by odds ratio) and quantify (by intraclass correlation coefficient [ICC]) interphysician variation. RESULTS: Patient- and visit-level factors found to be statistically significant predictors of imaging use included measures of ED busyness, prior ED visit, referral source to the ED, and ED arrival mode. Physician-level factors (eg, sex, years since graduation, annual workload, and residency training) did not correlate with imaging use. The remaining amount of interphysician variation was very low (ICC, 0.97% for low-cost imaging; ICC, 1.07% for high-cost imaging). These physician-specific odds ratios of imaging estimates were moderately reliable at 0.78 (95% confidence interval [CI]: 0.77, 0.79) for low-cost imaging and 0.76 (95% CI: 0.74, 0.78) for high-cost imaging. CONCLUSION: After careful and comprehensive case-mix adjustment by using hierarchical logistic regression, only about 1% of the variability in ED imaging utilization was attributable to physicians.

Medical students, money, and career selection: students' perception of financial factors and remuneration in family medicine.

BACKGROUND AND OBJECTIVES: Medical students have had a declining interest in family medicine as a career. Some studies have shown a small inverse relationship between debt levels and primary care, but it is unclear how students perceive remuneration in different specialties and how these perceptions might influence career choice. METHODS: Medical students at one school were surveyed to understand their perceptions of physician remuneration and to gain insight into how these perceptions might affect career selection. RESULTS: Response rate was 72% (560/781 students). Students' estimates of physician income were accurate throughout training, with the overall estimate for family medicine being lower than the actual income by only $10,656. The vast majority of students agreed with the statement that family physicians get paid too little (85%-89% of each class). The importance of payment as a factor in career decision making increased with higher debt and with advancing training. CONCLUSIONS: Students are able to accurately predict income by specialty from an early stage of training and have a negative perception of income in family medicine. The perception that family physicians make too little money could be an important driver--or at least a modifier--in the lack of interest in family medicine.

Anticipated debt and financial stress in medical students.

BACKGROUND: While medical student debt is increasing, the effect of debt on student well-being and performance remains unclear. AIM: As a part of a larger study examining medical student views of their future profession, data were collected to examine the role that current and anticipated debt has in predicting stress among medical students. METHOD: A survey was administered to medical students in all four years at the University of Toronto. Of the 804 potential respondents across the four years of training, 549 surveys had sufficient data for inclusion in this analysis, for a response rate of 68%. Through multiple regression analysis, we evaluated the correlation between current and anticipated debt and financial stress. RESULTS: Although perceived financial stress correlates with both current and anticipated debt levels, anticipated debt was able to account for an additional 11.5% of variance in reported stress when compared to current debt levels alone. CONCLUSIONS: This study demonstrates a relationship between perceived financial stress and debt levels, and suggests that anticipated debt levels might be a more robust metric to capture financial burden, as it standardizes for year of training and captures future financial liabilities (future tuition and other future expenses).