Patterns of relating between physicians and medical assistants in small family medicine offices.

PURPOSE: The clinician-colleague relationship is a cornerstone of relationship-centered care (RCC); in small family medicine offices, the clinician-medical assistant (MA) relationship is especially important. We sought to better understand the relationship between MA roles and the clinician-MA relationship within the RCC framework. METHODS: We conducted an ethnographic study of 5 small family medicine offices (having <5 clinicians) in the Cincinnati Area Research and Improvement Group (CARInG) Network using interviews, surveys, and observations. We interviewed 19 MAs and supervisors and 11 clinicians (9 family physicians and 2 nurse practitioners) and observed 15 MAs in practice. Qualitative analysis used the editing style. RESULTS: MAs' roles in small family medicine offices were determined by MA career motivations and clinician-MA relationships. MA career motivations comprised interest in health care, easy training/workload, and customer service orientation. Clinician-MA relationships were influenced by how MAs and clinicians respond to their perceptions of MA clinical competence (illustrated predominantly by comparing MAs with nurses) and organizational structure. We propose a model, trust and verify, to describe the structure of the clinician-MA relationship. This model is informed by clinicians' roles in hiring and managing MAs and the social familiarity of MAs and clinicians. Within the RCC framework, these findings can be seen as previously undefined constraints and freedoms in what is known as the Complex Responsive Process of Relating between clinicians and MAs. CONCLUSIONS: Improved understanding of clinician-MA relationships will allow a better appreciation of how clinicians and MAs function in family medicine teams. Our findings may assist small offices undergoing practice transformation and guide future research to improve the education, training, and use of MAs in the family medicine setting.

The military veteran to physician assistant pathway: building the primary care workforce.

The physician assistant (PA) profession emerged to utilize the skills of returning Vietnam-era military medics and corpsmen to fortify deficits in the health care workforce. Today, the nation again faces projected health care workforce shortages and a significant armed forces drawdown. The authors describe national efforts to address both issues by facilitating veterans' entrance into civilian PA careers and leveraging their skills.More than 50,000 service personnel with military health care training were discharged between 2006 and 2010. These veterans' health care experience and maturity make them ideal candidates for civilian training as primary care providers. They trained and practiced in teams and functioned under minimal supervision to care for a broad range of patients. Military health care personnel are experienced in emergency medicine, urgent care, primary care, public health, and disaster medicine. However, the PA profession scarcely taps this valuable resource. Fewer than 4% of veterans with health care experience may ever apply for civilian PA training.The Health Resources and Services Administration (HRSA) implements two strategies to help prepare and graduate veterans from PA education programs. First, Primary Care Training and Enhancement (PCTE) grants help develop the primary care workforce. In 2012, HRSA introduced reserved review points for PCTE: Physician Assistant Training in Primary Care applicants with veteran-targeted activities, increasing their likelihood of receiving funding. Second, HRSA leads civilian and military stakeholder workgroups that are identifying recruitment and retention activities and curricula adaptations that maximize veterans' potential as PAs. Both strategies are described, and early outcomes are presented.

Women's understanding of different dosing instructions for a liquid pediatric medication.

INTRODUCTION: Dosing errors by caregivers are common and often are directly attributed to poorly designed instructions. The purpose of this study was to assess whether instruction wording--that is, implicit versus explicit dosage intervals--was associated with participants' ability to describe and correctly measure a dose of a commonly prescribed liquid pediatric prescription medication. METHODS: English-speaking women (N = 193) of child-bearing age were recruited to participate in this study from an outpatient residency clinic in the southeastern United States. Based on a priori randomization, each participant was presented with one of two medication bottles that were identical except for the instructions: (1) "shake liquid well and give (child's name) 6 ML by mouth every 12 hours" ("implicit" dosage interval)," or (2) "shake liquid well and give (child's name) 6 ML by mouth at 7 AM and 7 PM" ("explicit" dosage interval). Participants completed a structured interview to assess sociodemographic characteristics, health literacy skills, ability to describe and demonstrate the dosage of the liquid medication, and preferences for label format. RESULTS: Seventy-two participants (37.3%) were able to correctly describe how they would give the medicine to a child during a 24-hour period, while 145 women (75.1%) were able to correctly demonstrate how they would give one dose of the medication. Approximately one third of participants (32.1%) were able to correctly describe and measure a dose of the medication. Slightly more than half of participants (n = 103, 53.4%) indicated that they would prefer instructions with "explicit" dosage intervals. DISCUSSION: This study suggests that few people can accurately describe how liquid medications are to be administered, while more people can demonstrate the correct dose to be administered.

Clinical work intensity among physician specialties: how might we assess it? What do we find?

BACKGROUND: The level of work intensity associated with patient encounters has implications for quality of care, patient safety, practice management, and reimbursement. The utility of available instruments for clinical work intensity assessment is unknown. OBJECTIVE: We assessed, in the clinical setting, the performance of existing measures of work intensity that are valid for nonclinical contexts. RESEARCH DESIGN: A cross-sectional, multimeasure design involving work intensity assessments for the last patient encounter and for an entire half-day clinic session. SUBJECTS: A convenience sample of 14 providers from the following 4 specialties: family medicine, general internal medicine, neurology, and surgery. MEASURES: Perceived clinical work intensity was measured by the following 3 instruments: National Aeronautic and Space Administration-Task Load Index, Subjective Workload Assessment Technique, and Multiple Resources Questionnaire; stress was measured by the Dundee Stress State Questionnaire. Convergent validity was assessed by correlation among the instruments. RESULTS: For the last patient encounter, there was a moderate to high correlation between the work intensity instruments' scores (Pearson's r ranged from 0.41 to 0.73) and low to moderate correlation with the distress subscale of the Dundee Stress State Questionnaire (Pearson's r ranged from -0.11 to 0.46), reflecting their stress dimension. Provider personality was associated with reported levels of work intensity and stress. Similar results were obtained when the entire clinic session was the unit of reference. CONCLUSION: Existing measures of work intensity and stress appear to be valid for use in the clinical setting to generate evidence on perceived intensity and stress experienced by providers in the performance of medical services.

Temporal and subjective work demands in office-based patient care: an exploration of the dimensions of physician work intensity.

BACKGROUND: Physician work intensity (WI) during office-based patient care affects quality of care and patient safety as well as physician job-satisfaction and reimbursement. Existing, brief work intensity measures have been used in physician studies, but their validity in clinical settings has not been established. OBJECTIVES: Document and describe subjective and temporal WI dimensions for physicians in office-based clinical settings. Examine these in relation to the measurement procedures and dimensions of the SWAT and NASA-TLX intensity measures. DESIGN: A focused ethnographic study using interviews and direct observations. PARTICIPANTS: Five family physicians, 5 general internists, 5 neurologists, and 4 surgeons. METHODS: Through interviews, each physician was asked to describe low and high intensity work responsibilities, patients, and events. To document time and task allotments, physicians were observed during a routine workday. Notes and transcripts were analyzed using the editing method in which categories are obtained from the data. RESULTS: WI factors identified by physicians matched dimensions assessed by standard, generic instruments of work intensity. Physicians also reported WI factors outside of the direct patient encounter. Across specialties, physician time spent in direct contact with patients averaged 61% for office-based services. CONCLUSIONS: Brief work intensity measures such as the SWAT and NASA-TLX can be used to assess WI in the office-based clinical setting. However, because these measures define the physician work "task" in terms of effort in the presence of the patient (ie, intraservice time), substantial physician effort dedicated to pre- and postservice activities is not captured.

Building the research culture of family medicine with fellowship training.

BACKGROUND AND OBJECTIVES: The future of family medicine is closely tied to the strength of family medicine research. Physicians with fellowship training have been shown to be more productive researchers than those without fellowship training. This study's objectives are to (1) identify fellowship programs available to family physicians, (2) explore how family medicine fellows are taught research skills, and (3) identify obstacles to enhancing research training in fellowships. METHODS: Fellowship programs available to family physicians were identified by Internet searches and confirmed by telephone or e-mail. Directors of identified fellowships received a 33-item survey exploring research training provided by their program. Descriptive statistics were used to evaluate the quantitative data. Survey comments were analyzed qualitatively to identify themes. RESULTS: We confirmed that 247 of 328 identified research fellowships are available to family physicians. Survey response rate from those 247 fellowships was 65%. Fellowships with and without a research focus are providing research training. They are threatened, however, by weak research infrastructure, inadequate funding, and attitudinal biases against family medicine research. CONCLUSIONS: There are many fellowship and research training opportunities for family physicians. But in many programs, research training is tenuous, and support for researchers is low. We recommend expanding research advocacy efforts within family medicine, Congress, and funding institutions.