Recruiting physicians for office-based research.

OBJECTIVES: Research conducted in community outpatient offices can provide insight into the common experiences of patients and physicians. However, recruiting physicians to participate in office-based research is challenging and few descriptions of methods that have been used to successfully recruit random samples of physicians are available. This article describes recruitment strategies utilized in a project that achieved high rates of participation from community-based primary care physicians and surgeons. METHODS: Recruitment methods included the use of advisory boards to identify potential barriers to participation, use of respected members of the medical community as recruiters, and obtaining endorsements from physician organizations and prominent members of the medical community. RESULTS: Overall, 81% of physicians contacted from a sample frame agreed to participate in the project. Participating physicians most frequently reported that they participated because the project could provide them with feedback about their interviewing style. CONCLUSIONS: The recruitment methods described here can be generalized to other types of investigations.

Room for improvement.

Abstract In small studies lesbians report avoiding health care because of difficulty communicating with providers. This study examines lesbians' perceptions of communication with medical and alternative primary care providers using a statewide self-administered survey of members of a lesbian community organization. Univariate and bivariate statistics were used to analyze lesbians' perceptions of communication with their primary care provider about sexual orientation, difficult issues, and health issues important to lesbians. Of 324 respondents, 31% received primary care from alternative providers and 90% are "out" to one or more providers. Respondents who were "out" to their primary care provider were more likely to seek health and preventive care (p ≤ .05), more likely to have ever had a Pap smear (p ≤ .02), and more likely to be comfortable discussing sensitive issues (p ≤ .0001). Respondents rated alternative providers easier to communicate with than M.D.s (4.53 vs. 3.99, p ≤ .001). They reported being more open about sexual orientation (4.58 vs. 4.05, p ≤ .001) and more comfortable discussing difficult issues (4.08 vs. 3.61, p ≤ .001) with alternative providers. Respondents believe alternative providers understand lesbian health needs better than medical doctors (4.21 vs. 3.45, p ≤ .001). Lesbians appear to be motivated to disclose sexual orientation to their primary care providers and disclosure is associated with positive health behaviors. Medical doctors appear to need improvement in their skills in communicating with lesbians so that important medical and psychosocial information can be shared.

Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.

OBJECTIVE: To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons. DESIGN: Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician. SETTINGS: One hundred twenty-four physician offices in Oregon and Colorado. PARTICIPANTS: Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (> or =2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty. MAIN OUTCOME MEASURES: Audiotape analysis using the Roter Interaction Analysis System. RESULTS: Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons. CONCLUSIONS: Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups.

Health risk factors and health-seeking behavior in lesbians.

Lesbians may engage in behavior that places their health at risk and may delay health care and screening more than do their heterosexual counterparts. This article examines influences on lesbians' health risk factors and health-seeking behaviors. A statewide, self-administered survey of members of a lesbian community organization was performed. Univariate and bivariate analyses were calculated, and linear regression was used to examine models of health risks and health-seeking behavior. Of 324 respondents, 90% had disclosed sexual orientation to at least one provider, 22% reported seeking care without symptoms (preventive care), and 23% reported waiting until symptoms are at their worst or never seeking care. Young age, belief in the importance of lung cancer, difficulty of getting health care when needed, reliance on the partner for health support, and fewer male partners were all associated with greater health risk for lesbians. Difficulty obtaining health care, difficulty communicating with the primary care provider, discomfort in discussing depression, and degree of comfort in discussing menopause were all associated with a delay in seeking health care. Sensitive communication with lesbians and further identification of lesbians' specific barriers to care may improve health-seeking behavior and provide more opportunities for screening and risk factor counseling in this population.

A method to communicate patient preferences about medically indicated life-sustaining treatment in the out-of-hospital setting.

OBJECTIVE: Patient preferences for life-sustaining treatment are frequently unknown at critical moments, which often results in clinicians providing treatment that is not medically indicated and/or may not be consistent with patient desires. A consortium of Oregon health care professionals developed the Medical Treatment Coversheet (MTC) to standardize documentation of patient preferences in the out-of-hospital setting by having corresponding physician orders available at the patient's location. We describe a unique process of development, evaluation, and implementation of the MTC. DESIGN: First, we conducted focus groups of providers to help draft the MTC. Second, the accuracy of MTC interpretation was determined by cohorts of acute and long-term care providers by indicating their treatment approach to three hypothetical written scenarios. They responded to the same scenarios twice, with and without the MTC. Responses were compared with each other and with ideal responses (most medically appropriate and in agreement with patient preferences) as defined by an expert panel. Finally, we are instituting pilot projects and developing a plan for statewide voluntary implementation of the MTC. SETTING: Urban and rural long-term care facilities and emergency medical service systems in Oregon. PARTICIPANTS: Focus groups included 28 general internists practicing in urban and rural settings and five nurses working in a long-term care facility. In addition, 87 providers (19 primary care physicians, 20 emergency physicians, 26 paramedics, and 22 long-term care nurses) participated in the evaluation of the form by responding to hypothetical scenarios. Providers in long-term care facilities in both an urban and rural area helped with pilot implementation of the MTC. Use of the MTC in noninstitutional settings was not evaluated. MAIN OUTCOME MEASURES: Suggestions from focus groups were incorporated into the form. For the hypothetical scenario responses, ideal appropriateness scores were analyzed, with a total possible score of 30 for each acute care provider and 15 for each long-term care provider. Statistically significant differences were determined using a paired t test. We report the experience of providers who helped with the pilot implementation of the form. RESULTS: Focus groups would use the MTC and believed it would be useful for their patients. Comparing responses to the hypothetical scenarios without the MTC to those with the MTC, 37% of treatment decisions changed for acute care and 29% changed for long-term care providers. Changes were attributable overwhelmingly to withholding treatments consistent with patient preferences. Compared with the ideal, decisions were more appropriate for all specific treatments across all scenarios and clinician groups with the MTC, with one exception: some advanced emergency treatments were withheld inappropriately by 18% of acute care providers with the MTC, (chi-square = 15.94, P < .0001). For all scenarios combined, appropriateness scores increased significantly with the MTC for both acute care (16.4 to 22.3, P < .0001) and long-term care providers (8.8 to 12.2, P < .0001). Overall, providers helping with the pilot implementation were satisfied with the document, organizational endorsements, and available informational resources. CONCLUSION: We describe our process for development, initial evaluation, and implementation of the MTC. In clinical scenarios overall, the MTC improves the appropriateness of clinicians' decisions about life-sustaining treatments. We are planning statewide implementation of the MTC after appropriate education of clinicians.

Evaluating a patient satisfaction survey for maximum benefit.

BACKGROUND: Patient satisfaction surveys are now in use in some form at most hospitals and health care systems. Yet, it is unclear how well information collected meets the needs of all groups who might benefit from patient feedback. An evaluation was conducted at the Center for Outcomes Research, Sisters of Providence Health System (Portland, Ore), to determine the extent to which the survey, then almost three years in use, was satisfying its internal consumers and to guide redesign of the entire survey process. METHOD: The evaluation of the survey process was designed to address several questions: who uses the results (consumers); what are their objectives (goals); what results are useful (product); and what is done with the results (intervention utility). Techniques such as interviews, literature reviews, and supplemental data collection, were used to explore the needs of each consumer group. CONCLUSION: The evaluation has led to a number of changes in the patient satisfaction survey process. Large-scale patient satisfaction surveys result in large-scale costs and therefore must be beneficial to multiple users in multiple ways.

Internal medicine training in ambulatory gynecology. A house of staff survey.

OBJECTIVES: Practicing internists commonly provide gynecologic care, yet internists receive little formal training in ambulatory gynecology. To evaluate current residency training, we surveyed house staff perceptions of their training in gynecology. METHODS: Data were collected from house staff at five Portland, Ore, internal medicine training programs by questionnaire using a Likert scale about training in 24 gynecologic and five nongynecologic internal medicine problems. Responses were compared by level of training, institution, and gender. RESULTS: Responses were received from 195 (89%) of 221 residents. House staff reported less than adequate training in gynecology, particularly in the areas of family planning and medical complications of pregnancy, while reporting much superior training in the traditional medicine problems. CONCLUSIONS: House staff in internal medicine report little training in the diagnosis and treatment of gynecologic problems. Training in family planning may be particularly deficient. Residency programs must seek effective teaching strategies to address this deficiency.