Specialist versus primary care: not an easy question

The central focus in the debate to reform our nation's health care system is on cost, quality, and access. There is general agreement that there are too many specialists in the wrong places, which is said to contribute to the rising cost of health care. Physician profiling has supported the concept that some specialists are more costly than primary care physicians, although the severity of illness in patients treated by specialists may often be greater. Increasing the number of primary care providers may be a solution to reduce costs and will clearly improve access. The study reported in this article was carried out to examine the efficiency of primary care physicians and endocrinologists, a specialty that has been cited as one in which resource utilization is high, in caring for hospital inpatients with diabetic ketoacidosis.     

Spirituality and the care of patients at the end-of-life: an essential component of care

Spirituality is an essential component of the care of patients with serious illness and those that are dying. Dame Cicely Saunders developed the hospice movement based on the biopsychosocialspiritual model of care, in which all four dimensions are important in the care of patients. Of all the models of care, hospice and palliative care recognize the importance of spiritual issues in the care of patients and their families. The National Consensus Project Guidelines for Quality Palliative Care, in the United States, provides specific recommendations about all domains of care including the spiritual domain, which is recognized as a critical component of care (The National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org). Studies indicate that the majority of patients would like their spiritual issues addressed, yet find that their spiritual needs are not being met by the current system of care. Interestingly, spirituality is the one dimension that seems to get slightly less emphasis than the biopsychosocial dimensions of care. Some reasons may include the difficulty with definitions of spirituality for clinical and research purposes, the time constraints and financial burdens in the current healthcare system in the United States, and the lack of uniform training for all healthcare professionals. Yet, there are theoretical and ethical frameworks that support spiritual care as well as some educational models in spirituality and health that have been successful in medical education in the United States. Spirituality can be seen as the essential part of the humanity of all people. It is at its root, relational and thus forms the basis of the altruistic care healthcare professionals are committed to. Spirituality has to do with respecting the inherent value and dignity of all persons, regardless of their health status. It is the part of humans that seeks healing, particularly in the midst of suffering. Spiritual care models are based on an intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where healthcare professionals address spiritual issues with patients and their loved ones. Currently in the healthcare system, evidence-base models are the criteria for practice recommendations. Yet, spirituality may not be amenable entirely to strict evidence-base criteria. As hospice and palliative care continues to develop as a field, healthcare professionals are challenged to think of ways to advocate for and include the spiritual dimension of care.     

Certification: goals set, goals met.

When the American Board of Medical Management was founded by the American College of Physician Executives on January 1, 1989, it was understood that the process for formal recognition of medical management as a specialty of medicine would be rigorous. Understandably, particularly at a time when the medical profession and the health care delivery system are under increasing scrutiny by all third-party payers, the decision to expand medical specialization is made with great caution. But the process of recognition for medical management is now well under way. In an interview with Frank A. Riddick Jr., MD, FACPE, Chairman of the Board of Directors of ABMM, Physician Executive learned more about the specific goals of ABMM and about the degree to which those goals have been achieved.     

Physician manpower needs under managed care. How to determine the need for MDs by specialty

The concern in the last quarter century in the United States over the shortage of physicians has now been supplanted by the fear of an excess number of doctors, particularly among the subspecialists. This article outlines four methodologies to be used in parallel to determine by clinical specialty whether a predetermined population base has an inadequate, sufficient, or excess number of physicians. Based on various assumptions, physician-population ratios per 100,000 persons for 28 clinical disciplines are supplied. Possibly the most intriguing questions as a result of this study are whether a broad spectrum of HMOs will use general internists or family practitioners as their prime "gatekeepers;" and, whether, in the long-run, the fiscal incentives inherent in the managed care concept will result in a more frugal utilization of physician services.     

Hospital-sponsored networks. The rush to consolidate and the future of medical practice

As the medical delivery system undergoes fundamental change, there is a growing pressure on hospitals to form networks with physicians. The prime motivation for these entities is to preserve market share and fill beds. There is likewise intense pressure on physicians to join them, even if these networks do not serve their best interests, or the goal of fostering physician-centered practice. A transformation is under way, however, that may well place doctors again in the central role of guiding the new modes of medical practice in the United States.     

A guide to evaluating managed care companies

Managed care has gradually been replacing the traditional way in which doctors and patients interact. These changes are taking place at an increasing pace, which strongly suggests there will be a dramatic trend to managed care programs. It has become imperative to understand the business of medicine beyond the traditional "business manager" tasks of setting fees, analyzing tax consequences, and balancing the check book. Providers may be hard pressed to maintain the quality of care they feel comfortable giving as the regulations of managed care exert their pressures. A rational, systematic approach to evaluate managed care firms is presented in this article. Additional criteria will have to be added as new ideas for managed care evolve. Physicians and practices must make decisions concerning the level of their participation, depending on a variety of factors, some more sensible than others.     

Can doctors and administrators work together?

The working relationship between physicians and health care organizations has dramatically changed since the introduction of competitive factors. Fifer suggests that future doctors may have as many as five or six economic relationships with their associated health care system, in contrast to the singular role as admitting physician of the past. The physician will continue to admit patients, but may also belong to an HMO or some other joint venture (freestanding ambulatory care center, outpatient laboratory, etc.), be salaried part time for leadership roles, be a leader in some other parallel economic venture, etc. Physicians are already assuming multiple roles as health care providers, private entrepreneurs, and joint venture partners with hospitals. Hospitals and health care systems also continue to change through vertical and horizontal integration. Traditional clinical departments are becoming blended into product line entities, and a sophisticated executive team of market-oriented specialists now augments the traditional administrative leadership. So, from a tradition of predictable roles, relationships, and authority structures, we are now attempting to thrive and prosper with many new partners in an integrated, complex, and conflict-ridden set of interrelationships.     

Serving the public by serving the profession. Interview by Wes Curry.

With the formation this year of the American Board of Medical Management, the American College of Physician Executives took a giant step toward formal recognition of the medical management profession as a specialty of medicine. Much needs to be done, however, to make that dream a reality. Late last year, Physician Executive talked with Donald G. Langsley, MD, Executive Vice President of the American Board of Medical Specialties (ABMS), about the certification process for specialties of medicine and about the role of ABMS in ensuring high standards for the medical profession and for the practice of medicine.     

The old ways of doing medical business are passing

Doctors must realize that the ?us and them? labels have to be discarded. No longer do physicians wield the ultimate power. We've lost our patients to insurance companies and part of our medical knowledge rests with nonphysicians. Likewise, physicians must accept the reality that all doctors aren't going to be in the same practice setting: some will work for hospitals, some for insurance companies, some for HMOs, some for themselves. But we're all members of a great profession that has proven its ability to give high-quality care to our patients, and now more than ever with more attention paid to costs.     

Health care trends, Part I. The promise and perils of evidence-based medicine ... panel discussion.

Numerous studies have demonstrated that there are wide variations in the way physicians manage similar patients. This suggests that an evidence-based approach could lead to better outcomes with less cost. But practicing evidence-based medicine requires new skills, such as using computerized databases and applying the rules of evidence to primary and integrative studies in the medical literature. The progress of evidence-based medicine will depend in large measure on how quickly these new skills can be developed and integrated into the practice environment. Here's how six experts see the promise and the perils of evidence-based medicine, now and in the new millennium. Part 2 of the panel discussion will explore the new provider team, which includes nurses and, more recently, pharmacists, who are collaborating with physicians to provide disease management and drugs therapy management services.     

不确定性支持向量分类预警算法

支持向量分类从理论上可以保证好的预警外推能力。但历史警度的确定是一个十分棘手的问题。论文提出了不确定性支持向量分类预警方法。将支持向量分类预警问题转化为各个历史样本的惩罚系数的合理变化,从而大大减少了约束的个数,体现了专家决策在预警系统的作用。不仅实现了专家意见的综合,而且是对SVM理论本身的拓广。证明了模糊支持向量机是不确定性支持向量分类的特例,从而给出了模糊支持向量机的确切含义。数据试验表明,未确知支持向量分类预警方法具有一定的实际应用价值。     

Provider profiling: advancing to episodes of care

Judging by the interest expressed by managed care organizations, provider profiling has arrived. Surveys indicate that most organizations have adopted, or plan to adopt in the near future, a means to describe provider practice patterns. A further vote of confidence came from providers: In 1994, the American College of Physicians, the largest national specialty organization, issued a position paper supporting provider profiling and questioning the value of other approaches to utilization management, such as preauthorization of individual services. Also, an article and an editorial in the New England Journal of Medicine cautiously supported the concept of profiling. Provider profiling has great promise as a means to promote cost-effective care without the limitations of case-by-case preauthorization. The combination of a sophisticated episode of care methodology and a set of validated practice benchmarks offers the opportunity to perform true clinical profiling and to supply providers with data to review and alter practice patterns.     

MSO (medical services organizations)--the new new kid on the block?

In response to pressures on the practice of medicine, new practice management styles and organizations are being created to meet market demands. Managed care environments have encouraged the development of IPAs, closed panel HMOs, and other corporate structures to provide care for their patients. Early resistance of physicians to joining in administrative arrangements has now melted. Providers are beginning to adopt the philosophy of joining resources for survival and to improve market penetration. Physician executives must keep their minds open to the possibility that these provider-based organizations will occur even in the most unlikely places.     

Administrative fellowships in emergency medicine

Physicians today need to be effective managers, as well as clinicians. In previous years, physicians gained managerial experience either through on-the-job training, degree programs, or continuing medical education courses. The specialty of emergency medicine began its first administrative fellowship in 1990 in California. Currently, three administrative fellowships exist nationally in emergency medicine. This article will describe the purpose of the fellowships and their curricula. Each fellowship has a different emphasis, with the goal to educate physicians who are interested in developing administrative skills to manage emergency departments or management groups or accept roles in hospital leadership. The existence of these fellowships will ideally influence the establishment of administrative fellowships in other specialties.     

Generalists or specialists--who does it better?

Managed care companies encourage primary care physicians to limit referrals to specialists and provide as much of the needed services themselves. As a result, generalist and specialist physicians are now in direct competition with one another. Is the care provided by generalist and specialist physicians different in terms of quality and cost? The authors reviewed the literature over the past five years and found 21 articles comparing the care between specialists and generalists. They realized asking who does it better, the generalists or the specialists, is the wrong question to explore. Physicians must come together to design systems of care that maximize the long-term health of patients and deliver care in a coordinated and efficient manner. The emphasis should be on creating value for the consumer across the continuum of providers and through time. Competition between generalists and specialists in a fragmented system only serves to further weaken the position of physicians in the health care industry.     

Preparing to tack: when physicians change careers

Because of the progressive health care revolution that gives all the power to the managed care insurance companies, the usurpation of physician autonomy, and the replacement of the physician-patient relationship with HMO policies, doctors are looking at other career choices. Many doctors have never considered life after medicine and have made no plans for that time in their future. Despite their ample education, some doctors say, "I don't know how to do anything else. I am trapped in this system, and I can't get out. If I knew what else I could do, I would definitely change careers." Many doctors feel that it is too late in their lives to make such a change. However, it is becoming more and more acceptable to switch or modify a medical career. A number of physicians have switched careers successfully without disgrace and have discovered that there is indeed a life after the first career choice. It isn't always easy, but it can be done.     

Suggestions for management training of residents

In addition to having medical expertise, physicians must possess managerial skills to deal with the ever-changing business environment of the practice of medicine. This article addresses the need for management training of physicians and calls for management training during residency and medical school. It also describes one residency program's efforts to provide comprehensive management training to its residents in pathology.     

The importance of end-of-life care in nursing home settings is not diminished by a disaster

The emphasis in disaster situations is on preserving life, and this goal is both appropriate and laudable. There is a risk, however, that the needs of people who are dying can become lost when there is a sudden surge of people needing acute intervention. There are significant ethical considerations inherent in society's prioritization of care needs across the acute, rehabilitative, and palliative spectrum in general, let alone in a disaster situation. These ethical conundrums are not the focus of this article. Rather, we anchor our discussion on the assumption that care needs are equally valid, and our purpose is to explore the issues that impact the provision of quality end-of-life care in nursing home settings for those who require this care when a disaster occurs. Nursing home residents, in particular, are at heightened risk for experiencing negative disaster-related outcomes due to compromised physical or mental health that requires skilled nursing care. Moreover, within the already vulnerable nursing home population are many people who are receiving palliative end-of-life services when a disaster strikes. Education and training in end-of-life services for nursing home staff, disaster emergency responders, and other lay people is vital to build capacity for adapting the delivery of these services in disaster situations in the interest of equity and human rights. Given the present lack of guidance in the literature as to what end-of-life care looks like when adapted to the context of disaster response, there is also a pressing need for research to inform this discussion. The purpose of this article is to draw attention to this topic and highlight some of the critical issues, gaps, and opportunities.     

Changes in the practice of medicine

In constructing this report, the author interviewed physicians to ask them how the practice of medicine has changed and what changes bother them most. She also talked to physician executives to find out how they were managing an increasingly disgruntled group of doctors. Four changes in the professional environment that physicians face dominated these conversations--lowered income, loss of control, the threat of litigation, and greatly increased paperwork. This article is a summary of comments in these four areas.     

The Piñata syndrome

The Pi?ata Syndrome is manifested by physician lounge grumbling and griping; sniping at medical and administrative leadership; resistance to examining best practices; refusal to hold colleagues responsible for their behavior, and general melancholy. This disease is characterized by grousing physicians who do not enjoy the practice of medicine and if self treated will leave medicine. It is accompanied by patients who receive inappropriate care and caring. The treatment, which can result in an excellent prognosis, is self-administered and must be vigorously pursued to avoid chronic Pi?ata Syndrome, a professional death.