The future of physician profiling.

Although enthusiasm for physician profiling dates back to the origins of scientific medicine, the track record of profiling as an intervention is not strong. Profiling appears to be most valuable for simple interventions and processes, but its acceptance, usefulness, and impact will be influenced by future trends. Health care organizations will continue to be complex, and multiple overlapping profiles will be the norm. Technology will advance, but concerns over privacy and confidentiality will influence the social, political, and regulatory approaches to profiling. Public sector purchasers and consumers will increasingly demand profiling, but data will continue to lack the ability to interpret complex profiling data. Medical practice will increasingly accept profiling as part of ongoing quality improvement efforts, but profiling may become focused on key processes, not outcomes. Statistical, cognitive, and epistemological challenges to profiling will remain, and profiling may simultaneously become more complex and more simplified with the rise of information brokers. Greater attention to the human side of profiling will enhance its effectiveness.

Managed care and chronic care: challenges and opportunities.

As managed care enrolls an increasing proportion of the population, increased attention needs to be paid to the care of persons with chronic conditions. This trend is occurring in the context of medical care in the United States that is deeply rooted in the acute care model of illness. The distinctive character of chronic conditions requires a reorientation of clinical practice and the way in which medical and nonmedical services are organized. Optimal chronic care systems are characterized by the integration of primary and specialty care, integration of medical and nonmedical services, and emphasis on functional status and quality of life. Analyzing enrollment data, beginning chronic disease care improvement efforts, and redesigning key support systems are all targets for HMO action.

Challenges to generalism: views from the delivery system.

The declining interest in primary care among U.S. medical students is an ominous trend for the national health system. The medical school environment, the powerful financial incentives promoting specialism, and the practice environment itself have contributed to the decline of generalism. During a day-long meeting sponsored by the Robert Wood Johnson Foundation, representatives of group practices, HMOs, community health centers, and military medicine noted the universal shortage of primary care physicians, the fact that medical education does not prepare physicians for the realities of practice, the concern that "burnout" is a significant problem for retention and physician satisfaction, and the problem that the optimal design of primary care practice is not yet known. To reverse these trends, concerted action must take place within academic medicine, by public policy makers, and by the delivery system itself.

What makes young HMO physicians satisfied?

While much attention has been paid to the effect of managed care on patient outcomes and health care costs, little attention has been focused on the ways in which managed care affects the satisfaction of physicians. Examination of the practice and career satisfaction of 189 young physicians practicing in group and staff model HMOs finds high levels of satisfaction. More than 82% are satisfied with their current practice. The most important factor influencing physician satisfaction appears to be the extent of perceived autonomy. Neither the number of hours worked per week nor yearly income were strongly associated with decreases in satisfaction. The fact that minority and female physicians report less satisfaction with some dimensions of practice raises important issues for HMO physicians and managers.