Marketplace reforms and primary care career decisions.

A dramatic shift in the postgraduate career choices of medical school graduates toward primary care occurred during the mid-1990s. While some attributed this shift to changes in medical school curricula, perceptions stemming from marketplace reforms were probably responsible. For the most part, these perceptions were probably generated through informal communications among medical students and through the media. More recently, additional marketplace influences, such as the consumer backlash toward managed care and unrealized gains in primary care physicians' personal incomes, may have fostered contrasting perceptions among medical students, leading to career choices away from primary care, particularly family practice. The authors offer two recommendations for enhancing the knowledge of medical students concerning workforce supply and career opportunities: an educational seminar in the second or third year of medical school, and a public-private partnership between the Bureau of Health Professions and the Association of American Medical Colleges to create a national database about the shape of the primary care and specialty workforces, accessible through the Internet for educators, students, and policymakers. The authors conclude that appropriate career counseling through these efficient methods could avoid future abrupt swings in specialty choices of medical school graduates and may facilitate a more predictable physician workforce supply.

Physicians in home care: past, present, & future.

Physician house calls began declining in the 1960s and still are relatively rare. What caused this distancing of physicians from home care, and what needs to be done to bridge the gap?

The case for medical direction in home care agencies.

Good medical directors can add value across all areas of agency operations. With relevant training, good communication, and fair reimbursement, agencies can benefit from the knowledge and expertise of physicians who are committed to home care.

Home care in the urban setting--a challenge to medical education.

The rapid growth in the use of the home as the site of care delivery necessitates that the home setting be incorporated as a teaching site into the curriculum of medical schools. Urban medical schools have a unique advantage in that they have a large population base readily available to students and preceptors as well as an array of allied health providers. Urban institutions can be in the forefront of developing programs that simultaneously promote: clinically competent care; the maximal function of large numbers of acutely and chronically ill persons; research into issues of cost-effectiveness; and, most importantly, professional humanism. Specific educational objectives are included.

Teaching home care to physicians during residency.

Residency is a pivotal time in a physician's education when lifetime patterns are often established. Thus, during residency physicians need to learn about home care and--more than just learn--become enthusiastic and committed to this type of health care. What can medical schools do to instill these values?

Reported home health agency referrals by internists and family physicians.

OBJECTIVE: To evaluate the frequency of home health agency referrals (HHRs) by internists and family physicians. DESIGN: Telephone survey of a randomly selected, nationally representative, stratified physician sample. PARTICIPANTS AND SETTING: One thousand one hundred sixty-one interviews with 576 family physicians and 585 internists selected from the American Medical Association Physician Masterfile. MAIN RESULTS: Most respondents (88%) reported making HHRs (mean for those making HHRs = 43/year). Physicians with > or = 48 annual HHRs (n = 315) reported a mean of 2.6 hours/week in home care telephone management and 2.1 hours/week on related paperwork. Rural internists and family physicians (n = 230) reported less availability of several types of non-physician home health services than non-rural respondents (n = 931), yet rural physicians were more likely to refer patients to home health agencies. Using multivariate linear regression, the reported frequency of HHRs was significantly related to rural practice location, number of home-bound patients, proportion of geriatric patients, number of house calls, graduation from a U.S. or Canadian medical school, physician knowledge of community resources, and physician experience either as a medical director, a member of the board of directors, or a consultant for a home health agency. CONCLUSIONS: Internists and family physicians who work at least 10 hours per week in ambulatory care report making approximately three home health agency referrals per month and spending substantial amounts of time coordinating home health agency care. Despite reporting less availability of many home health agency services, rural physicians report greater involvement than non-rural physicians in the delivery of home care.

Communication between nurses and physicians in home care.

The increasing acuity of illness among home care patients and complexity of the in-home service network have created a greater need for frequent communication between the various members of the interdisciplinary home care team. This will likely become an increasingly important quality-of-care issue as home care continues to expand and to incorporate advances in technology.

Policy issues for physicians involved in home care.

The demand for home care services of all varieties will continue to grow in the next two decades, as will the need for well-informed physicians as members of the home health care team. It is hoped that an enlightened society will continue to develop reimbursement and regulatory structures that will foster a larger role for physicians in home care.

Factors associated with the frequency of house calls by primary care physicians.

OBJECTIVE: To evaluate factors associated with the frequency of house calls by primary care physicians. DESIGN: A cross-sectional design with a self-administered mailed survey. SITTING/PARTICIPANTS: 751 primary care physicians who care for Medicaid patients in Virginia. RESULTS: Among 389 physician respondents (52%), regular house callers (n = 216) were compared with occasional house callers (n = 162). Among physician characteristics, specialty and practice duration were associated with house call frequency. Regular house callers also more often cited chronic illness (67% vs. 20%, p less than 0.01) and terminal illness (67% vs. 40%, p less than 0.01) as indications for house calls, compared with occasional house callers. Use of visiting nurses to substitute for physician house calls was less often considered appropriate by frequent house callers (7% vs. 24%, p less than 0.01), and regular house callers were less likely to report being "too busy" to make house calls (71% vs. 29%, p less than 0.01). Multivariate analysis confirmed the association of these attitudes with house call frequency. CONCLUSION: These data suggest that specific attitudes among primary care physicians are associated with house call frequency.

The influence of physician specialty on housecalls.

Despite growing numbers of frail elderly, physicians make housecalls infrequently. We surveyed 1000 primary care physicians from Virginia regarding their attitudes and knowledge about housecalls, and 389 completed questionnaires (response rate, 52%): 185 family physicians, 36 general practitioners, 101 general internists, and 63 subspecialists. Despite similar proportions of homebound patients and practice demographics, family physicians (69%) and general practitioners (63%) were significantly more likely than either internists (53%) or subspecialists (37%) to make routine housecalls. Although all four groups thought the fee was rarely a motivation, internists and subspecialists suggested larger increases. Also, internists and subspecialists were less likely than family physicians or general practitioners to increase housecalls with increased payment. Internists and subspecialists also were more likely than family physicians or general practitioners to report that housecalls were often unnecessary, not "enjoyable," "inefficient," and unimportant. While improved reimbursement may lead to increased housecalls by family physicians, future strategies should include efforts to change internists' attitudes.