Patients' trust and the quality of physicians

Patients are uncertain of physicians' quality but learn about the quality of particular physicians through experience in treatment. Patients come to trust physicians who have served them well. This paper explores the economic consequences of patients' learning and trust within a model of the market for physicians' services. In a market equilibrium, there are too many incompetent physicians in practice. Surprisingly, even the more competent physicians have an interest in preventing patients from judging quality except through experience. As we show, all physicians, including the most competent, may oppose steps to inform patients of physicians' quality.     

The supply of physicians' services

This paper presents a model of the supply of physicians' services based upon the assumption that physicians are price-taking utility maximizers. Assuming physicians' services are produced using physicians' labor and purchased inputs, the paper shows that the impact of changes in final product or input prices on the supply of physicians' services depends on the physicians' labor-leisure choice and on the degree of substitutability between physicians' labor and purchased inputs. The empirical results presented indicate that the physicians' labor supply curve is backward-bending, but that the supply curve of physicians' services is positively sloped.     

Nonverbal response patterns in physician-patient interactions: A functional analysis

In this paper, we examined physician-patient interactions in terms of the communicative functions accomplished during these encounters. Specifically, the nonverbal communicative exchanges of 38 physician-patient interactions in a family practice clinic were investigated. Two distinctive communicative patterns characterized these interactions. First, physicians nonverbally exerted greater dominance and control by employing longer speaking turns, more social touch, and more pauses while speaking than did the patients. Secondly, physicians and patients tended to reciprocate nonverbal behaviors signalling affiliation including gaze, response latencies, body orientations, and gestures. Consistent with previous research, there was a strong positive relationship between patients' satisfaction with health care and perceptions of the physicians' affiliativeness. Although there were few significant effects, physicians perceived less affiliative tended to be more vocally and gesturally active relative to the patients' nonverbal behavior styles. Finally, there were positive relationships between patients' perceptions of physicians' dominance and the physicians' use of task touch, and the extent to which physicians produced more interruptions and maintained more indirect body orientations relative to the patients' performances of these behaviors. The results are discussed in terms of the communicative functions of nonverbal behavior in physician-patient interactions and of patients' preferences for physicians' nonverbal expressiveness.The authors wish to thank Joe Cappella, Howard Waitzkin, Martha Davis, and William B. Stiles for their helpful comments on previous drafts of this paper.     

Physician case-by-case assignment and participation in Medicare

The prospect of budget cuts in Medicare is likely to result in less generous reimbursements from Medicare and thus affects physicians' willingness to accept Medicare patients with the reduced payments. This study examines physicians' decisions about case-by-case assignment and participation in Medicare in relation to Medicare reimbursement generosity. A two-part model is applied to a database from a national survey of physicians. The results indicate that reimbursement generosity from private insurance relative to that from Medicare negatively affects physicians' assignment rates, implying that the elderly's access to health care and/or the financial burden is likely to be jeopardized by further reductions in Medicare reimbursements.     

Free enterprise, professional ideology, and self-interest: an analysis of resistance by Canadian physicians to universal health insurance

Under Canada's universal health care system, physicians are remunerated through government-run health insurance plans; a private market for physicians' services is virtually nonexistent. A proposal to ban the practice of extra-billing, whereby some physicians billed patients for amounts over and above insured rates, met with physicians' opposition. The particular constellation of legislative, social, and political events that followed the proposed ban presented a unique opportunity to explore the nature of the medical profession's resistance to encroachment on professional autonomy. The results of this survey of physicians in four specialties (N = 313) in metropolitan Toronto suggest that resistance to universal health insurance is complex; it involves a prevailing social ideology among physicians, which happens to be antiwelfare and conservative generally, entangled with economic self-interest and a specific set of beliefs about medical practice and physicians' rights and privileges.     

Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms"

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256 physicians who viewed 1 of 16 video vignettes with different patient-actors presenting the same symptoms of coronary heart disease. Physician participants completed a structured interview and provided a narrative about their decision-making processes. Quantitative analysis showed that diagnostic uncertainty reduces the likelihood that physicians will order tests and medications appropriate for an urgent cardiac condition in particular. Qualitative analysis revealed that a subset of physicians applied knowledge that women have "atypical symptoms" as a generalization, which engendered uncertainty for some. Findings are discussed in relation to social-psychological processes that underlie clinical decision making and the social framing of medical knowledge.     

THE DIFFUSION OF MEDICAL TECHNOLOGY: SOCIAL NETWORK ANALYSIS AND POLICY RESEARCH

The purpose of this article is to demonstrate how social network analysis can be used to provide information for policy decisions pertaining to physicians' adoption and utilization of new medical technology. Interviews and hospital records were used to obtain data on refenals, consultations, discussions, and on-call coverage; utilization of a computer-based hospital information system; and personal and practice characteristics from 24 physicians who belong to a private group practice. The results of a block-model analysis suggest that the physician's relative position in the network is an important determinant of his/her participation in the diffusion process. A number of policy implications related to the introduction of new medical technology into practice settings are discussed.     

Considering social ergonomics: the effects of HIT on interpersonal relationships between patients and clinicians

This study explored physicians' interactions with EHRs to understand the qualities that contribute to patient satisfaction with their use of the technologies and patient satisfaction with physician. Video-taped observations of 100 medical consultations were used to distinguish interaction patterns between physicians and EHRs. Quantified observational methods were used to contribute to ecological validity. Ten primary care physicians and 100 patients from five clinics participated in the study. Visits were videotaped and coded using an objective coding methodology to understand how physicians interacted with electronic health records. Results indicate, a variety of EHR interaction styles may be effective in providing patient-centered care.     

Domains of medical practice: physicians' assessment of the role of physician extenders

The relationship between physicians and physician extender occupations is considered in light of the stratification of medical care workers. Professional dominance between various medical occupations and professional competition among physicians are considered. Data from a national sample of physicians taken in 1981 are used to determine 1) under what conditions physicians are likely to consider the employment of physician extenders helpful for improving quality of care and 2) which characteristics and available resources are associated with the belief that the employment of physician extenders will improve medical care. Of four different service populations considered, physicians are most likely to think that the use of physician extenders to care for the urban poor will aid care and are least likely to think that their employment will improve care for obstetrics and pediatrics cases. The results indicate that physicians' beliefs regarding the employment of physician extenders are dependent on the clientele as well as on the relative position of the two occupational groups in the hierarchy of medical care occupations.     

College students' use of widely advertised medications

The authors describe college and university students' use of widely advertised pharmaceutical products. Four hundred seventy-one students from three institutions completed self-administered questionnaires that addressed the use of advertised medications, attention to magazine ads for medications, communications with physicians about medications, and the conditions the medications address. Results indicated that the majority of the students used at least one of the advertised products. Most students did not discuss the pharmaceutical products with their physicians or discuss the conditions for which they reported they were taking the drugs.     

Changing economic conditions and their effects on professional autonomy: An analysis of family practitioners and oncologists

This study examines the effects of dimensions of the social structure on professional autonomy. Little support exists for arguments suggesting professional dominance or professional-bureaucratic confrontation. The study supports a theory of social change that places physicians in their historical, political, and economic context. There are four important findings. First, the degree of autonomy varies across physician specializations, and the social structure affects the autonomy of family practitioners and oncologists in different ways. Second, the Federal Drug Administration constrains the responsibility autonomy of both oncologists and family practitioners, and the innovative autonomy of family practitioners. Third, bureaucracy either has no effect or enhances physicians' autonomy. The fourth, and most consistent, finding demonstrates that profit-seeking corporations external to the work setting constrain physicians' autonomy. Findings suggest that researchers should give more attention to shifts in the loci of power and the effects of organizations external to the work setting, especially corporations, on professions.An earlier draft of this paper was presented at the American Sociological Association annual meeting, Miami, Florida, August 1993.     

A nursing-centered treatment team in inpatient medical psychiatry

1. Nurses have the most extensive direct contact with their patients, yet in the traditional physician-centered model, they are often excluded from decision making. We have developed a new model of patient care with the nurse as the primary therapist and contact person, as well as the individual who cares for each patient's physical needs. 2. Out team approach improves efficiency, integration of care, and staff unity, which can be especially helpful for patients with personality disorders. 3. Patients appreciate the approach and are better able to increase focus on treatment when the physicians are not present in the ward.     

Sensitivity to bodily nonverbal communication as a factor in practitioner-patient rapport

The relationship between physicians' nonverbal sensitivity and the satisfaction of their patients was tested in two field studies. In the first study, 40 physicians were given a film test of nonverbal sensitivity (the PONS test) and were evaluated by their patients. The second study was a replication using 31 additional physicians. Most noteworthy for research in therapeutic interaction, the present studies contained three methodological advances: (1) the use of actual patients' ratings of satisfaction with treatment, (2) the extension of research from psychological to medical settings, and (3) the use of a standardized test of nonverbal decoding skill. Physicians' skill at reading the emotion conveyed through the nonverbal channel of body movement was found to be significantly correlated with their interpersonal success with patients in the clinical setting.The authors would like to thank Donald Dickson, M.D., Mary Ann Spadaro, M.D., Louise M. Prince, John L. Helmuth, Jr., Helene M. Murphy, and the physicians and patients who participated in the research. Study I was supported by a Peter B. Livingston Fellowship from the Massachusetts Mental Health Center and Study II by a W. K. Kellogg Fellowship from the Hospital Research and Educational Trust, both to the senior author.     

College Students' Use of Widely Advertised Medications

Abstract

The authors describe college and university students' use of widely advertised pharmaceutical products. Four hundred seventy-one students from three institutions completed self-administered questionnaires that addressed the use of advertised medications, attention to magazine ads for medications, communications with physicians about medications, and the conditions the medications address. Results indicated that the majority of the students used at least one of the advertised products. Most students did not discuss the pharmaceutical products with their physicians or discuss the conditions for which they reported they were taking the drugs.     

The labour market absorption of CIS immigrants to Israel: 1989-1994

The labour market absorption in the 1990s of some 600,000 immigrants from the ex-USSR has, on the whole, been a major success. The rate of unemployment among immigrants who came in 1990 has converged on the rate of unemployment for native Israelis. However, concern has been focused on the low rates of occupational retention and the waste of human capital that this implies. We use three micro data sets to investigate the absorption dynamics of CIS immigrants in the Israeli labour market in the 1990s.
Our findings suggest that the employment absorption process is steady, if slow. The Labour Force Survey suggests that "academics" experience positive duration dependence during the first four years in Israel. Vocational training did not appear to promote employment absorption. However, Hebrew training has a beneficial effect on employment absorption. We caution against the interpretation of occupational mismatch as being identical with the waste of human capital. It takes a long time until owners of human capital can fully adapt it to their new milieu.