Independent practice association physician groups in California.

We surveyed independent practice association (IPA) physician groups in California about their approaches to staffing, physician payment, and governance. Most IPAs desired more primary care physicians but not more specialists. Capitation was the major mode of remuneration for primary care physicians in 77 percent of IPAs, and for specialists in 30 percent of IPAs. Most IPAs also used financial incentives related to use of referral or ancillary services. Boards of directors were dominated by physicians, but governance tended to be centralized rather than highly democratic. We found that IPAs mirror many of the broader trends in physician staffing and physician payment that exist in managed care organizations.

Health care reform and medical education: forces toward generalism.

The transformation of U.S. health care is driven by underlying principles. The tensions between what exists now and what will emerge over the next 15 years pervade health care delivery and financing, the doctor-patient relationship, the provider-payer relationship, and the atmosphere within educational institutions for the health professions. The institutions that early on develop the capacity to forge and sustain strategic partnerships will be well positioned to take advantage of the opportunities of a rapidly changing system, but those that do not will risk being isolated without the diversity of resources needed to make meaningful contributions to health care. The tensions also drive major changes in the way health professionals are educated, trained, and deployed. Health care reforms will dramatically change the culture of the medical school in areas of patient care, research, and education programs. These institutions face external pressures to change and internal barriers to change, not the least of which are the lack of sustained leadership and collective vision. Academic medical centers must take active steps now to assess their strengths and weaknesses objectively, look realistically at options, and construct new, mutually beneficial partnerships that will be the keys to success.

"Bimodal" medical schools: excelling in research and primary care.

The authors studied four "bimodal" medical schools--those ranked in the top 20% by the Association of American Medical Colleges both in production of primary care physicians and in receiving research grants from the National Institutes of Health. A descriptive, anthropologic method was used to describe the cultures of these schools and to determine common factors in their success. The four schools are at the University of Washington, the University of North Carolina, the University of California, San Francisco, and the University of California, San Diego. These common factors ranged from characteristics of the schools to characteristics of their external environments. All four are part of large, state-supported universities. They are relatively new schools in areas of the country that have blossomed in biotechnology, aerospace, and computer industries. The schools' missions, admission committees, and educational programs reflect their dual role: to meet the health care needs of their states and to advance basic science knowledge in medicine. Each state has a strong Academy of Family Practice, and the medical schools have been in the forefront of residency training in this specialty. Federal- and state-funded Area Health Education Centers and private foundations have provided seed money for educational programs in community and rural settings that attract medical students to primary care. Research-intensive medical schools can encourage students to enter primary care specialties if they have strong primary care leaders and programs and if they support medical education programs outside the academic, tertiary-care center. A culture of mutual respect and commitment to community service is also essential to achieving this bimodal success.

Insights into medical students' career choices based on third- and fourth-year students' focus-group discussions.

PURPOSE: To identify previously unrecognized factors influencing medical students' career choices and to better characterize the effects of educational experiences, role models, and educational debt on career decisions. METHOD: Fifty-two third- and fourth-year students were recruited from three California medical schools to participate in focus-group discussions. The students were assembled into 12 groups of about four classmates from the same school, each facilitated by a medical student from another school. Focus-group discussions were audiotaped and qualitatively analyzed using content analysis. RESULTS: The students' perceptions of their abilities to influence patients' outcomes and to cope with a large knowledge base differentiated those interested in primary care fields from those attracted to procedure-oriented specialties. Negative role models, based on the students' assessments of interpersonal interactions and career satisfaction, were particularly influential in closing doors to certain fields. Many of the women reported an absence of role models. Most of the students denied any effect of debt or potential income on career choice; while many cited their small debts, some of the women alluded to the anticipation of being in dual-income families. CONCLUSION: Students' career decisions are complex, dynamic, and individualized processes. The use of qualitative measures helps bolster understanding of these processes by identifying new factors (such as mastery of knowledge) and by further characterizing known factors (such as role models and financial considerations). A comprehensive and valid understanding of students' career-decision making is necessary to develop successful strategies to sustain and encourage the choice of primary care careers.

Professional competencies in the changing health care system: physicians' views on the importance and adequacy of formal training in medical school.

PURPOSE: To examine physicians' attitudes toward 16 competencies deemed essential to the effective practice of medicine in the changing health care system. METHOD: In early 1991 a telephone survey was conducted of 300 physicians from random samples selected as representative of the physician population in the continental United States. The physicians were categorized as general practitioners, surgery specialists, and other specialists, and as belonging to the graduation cohorts of 1960-1969, 1970-1979, and 1980-1989. The physicians were asked to rate (1) the importance of formal undergraduate training in each of 16 competencies and (2) the adequacy of their own undergraduate training in the competencies (these ratings are reported only for the 87 physicians in the 1980-1989 cohort). The competencies were derived from the skills, attitudes, and behaviors defined by the Pew Health Professions Commission as necessary for the nation's health care practitioners to meet society's evolving health care needs. RESULTS: Fifty percent or more of the physicians thought that 12 of the 16 competencies were "very important" to include in undergraduate training. Over 75% thought that it was "very important" to include the five competencies involving skills traditionally valued in medical practice: diagnosis and treatment, effective communication with patients, problem solving, lifelong learning, and counseling on medical ethics. More than 50% thought that undergraduate training was "very important" in some competencies that reflect the changing dynamics of medicine and care delivery over the past ten years: health promotion and preventive medicine, involvement of patient and family in care, management of large volumes of information, appropriate use of technology, working on a team with other professionals, and consideration of cost in clinical decision making. In rating their own training, over 50% felt well prepared (ratings of "excellent" or "good") in the five traditional competencies and, in addition, in their abilities to promote health, to manage large volumes of information, to work in teams, to understand and respond to diverse cultures, and to expand access to care. However, a majority felt that their training was only "fair" or "poor" regarding the involvement of patients and their families, evaluation of the appropriateness of costly technology, consideration of cost implications in their decision making, and understanding and supporting the community's role in health care. Forty percent or more felt poorly prepared to work in managed care settings or to accommodate increasing external scrutiny. CONCLUSION: The physicians validated the traditional strengths of medical schools, but revealed curricular weaknesses in the teaching of competencies proposed as important for the emerging health care system, especially in the managed care environment.

Academic deans' views on curriculum content in medical schools.

PURPOSE: To determine which of 33 topics academic deans identify as worthy of greater emphasis in medical curricula. Also, to assess the barriers to needed curricular changes. METHOD: In March 1996 a questionnaire was developed and mailed to the academic deans of all U.S. schools affiliated with the Association of American Medical Colleges (n = 126) and all schools associated with the American Association of Colleges of Osteopathy (n = 17). There were 46 questions in a five-point Likert-type format (1 = not at all, 5 = to a great extent) and one open-ended question. The deans were queried as to what extent each of 33 topics (1) was included in medical students' required learning experiences (current emphasis) and (2) should be included in medical students' required learning experiences (ideal emphasis). The deans were also asked to what extent they believed 12 different factors would be barriers to needed curriculum changes in their programs. Primary data analysis focused on simple comparisons of response means and frequencies. RESULTS: Two separate mailings resulted in the return of 100 questionnaires (70%): 85 from the allopathic schools (67%) and 15 from the osteopathic schools (88%). "Effective patient-provider relationships/communication," "outpatient/ambulatory care," and "health promotion/disease prevention" had the three highest mean ratings for ideal emphasis by the allopathic school deans. "Primary care," "professional values," and "use of electronic information systems" also had high mean rankings for ideal emphasis. "Primary care," "outpatient/ambulatory care," and "health promotion/disease prevention" had the three highest mean ratings for ideal emphasis by the osteopathic school deans. CONCLUSION: Changes in health care delivery and an increasing generalist orientation are influencing academic deans' perspectives on needed curriculum changes, and there appears to be considerable support for medical school curricula that will foster a broader, more humanistic role for physicians.

Characteristics, importance, and implications of comprehensive drug therapy management.

Ideas and opinions about comprehensive drug therapy management (CDTM) were gathered from an expert panel representing health care practitioners, educators, and consumers. A qualitative method of inquiry, the Delphi technique, was used to aggregate opinions of an expert panel of health care professionals, health care educators, and consumer representatives. The 66 experts who agreed to participate in the study consisted of 10 from pharmacy education, 10 from pharmacy professional associations, 20 from managed care, 19 from primary care, and 7 consumers (public members of health care regulatory and governing boards). Each participant was sent a questionnaire designed to evaluate a preliminary definition of CDTM and gather opinions on related topics. A second questionnaire was sent to the participants to determine the extent of their agreement with each statement generated by the first questionnaire. A third questionnaire was sent, asking participants to reconsider their ratings in light of the group's responses and to choose the most important elements. The response rates were 83% for the first questionnaire, 70% for the second, and 76% for the third. The panel reached a high level of agreement on a definition of CDTM. Panel members also identified many critical aspects of CDTM, including what makes it worthwhile, barriers to and facilitators of engaging in CDTM, key participants, ways in which responsibility for CDTM may be shared, and the competencies needed for CDTM. An expert panel of health care leaders and future leaders, within and outside the pharmacy profession, reached a high level of agreement on a definition of CDTM and identified many critical aspects of this concept.

Estimates of the effects of a statewide sealant initiative on dentists' knowledge and attitudes.

The effects of a statewide initiative promoting the use of dental sealants were evaluated by assessing dentists' knowledge and attitudes before the initiative and 18 months later. Immediate changes also were determined for participants in continuing education (CE) sessions, a principal component of the initiative. Results of these assessments indicate that minor improvements in knowledge and attitudes occurred, that the effects were stronger but still modest for those dentists who participated in CE sessions, and that respondents believed the initiative had resulted in increased use of sealants. This evaluation highlights the need for controlled assessments of the effectiveness of future promotional campaigns.

Public attitudes toward dentists: a U.S. household survey.

This article reports on research that assessed public attitudes toward dentists and the dental profession and compared them to dentists' own attitudes about their roles. Enhanced knowledge of patients' perceptions can help practicing dentists gain a better understanding of public perceptions of themselves and of dentistry as a profession, as well as enhance their relationships with patients.

Responses of baccalaureate and graduate programs to the emergence of choice in nursing accreditation.

Specialized accreditation in nursing is a widely recognized and respected hallmark of program quality. The advent of a second specialized accrediting agency for baccalaureate and higher degree programs in nursing prompted a survey of these programs to determine their choice of nursing accreditation agency, factors influencing their choice, their perceptions of the value added by nursing accreditation, and the difficulties encountered with the accreditation process. These study variables and the relationships between choice of accrediting agency and types of degree-granting nursing education programs offered by the institution, agency membership in the National League of Nursing (NLN) or the American Association of Colleges of Nursing (AACN), expected date of next accreditation visit, geographic region, public versus private status, and type of institution (Carnegie classification) were analyzed. Findings revealed that nearly a quarter (24%) of respondents intend to continue with the NLN Accrediting Commission (NLNAC), whereas 30% indicated they have already switched to the Commission on Collegiate Nursing Education (CCNE) or intend to do so prior to their next accreditation cycle. However, nearly a quarter (24%) of respondents said they plan to be accredited by both agencies for the immediate future, and 21% indicated they are still undecided. Study findings suggest an end to single-source accreditation, and the beginning of a new market-oriented approach.

Curriculum trends in nurse practitioner programs: current and ideal.

The purpose of this study was to ascertain the extent to which nurse practitioner (NP) education programs are addressing curriculum topics related to practice competencies needed for the next century as recommended by the Pew Health Professions Commission and other professional organizations, including the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties. The study was part of a comprehensive survey of 11 health professions education programs. NP program directors indicated greatest dissatisfaction with curriculum coverage of "use of electronic information systems" and "business management of practice." The three most important curriculum topics identified by respondents were "primary care," "health promotion/disease prevention," and "effective patient-provider relationships/communication," identical to the three topics rated most important by all groups combined. The most significant barriers to change identified by the respondents included "an already crowded curriculum" and "limited availability of clinical learning sites." Findings show that NP program directors perceive that they are doing an effective job addressing most of the 33 curriculum topics, but they also recognize a need to continue to improve their curricula in response to the ever-changing health care environment. Barriers to achieving the desired curricular improvements, however, may be significant. Recommendations for overcoming these barriers to change are offered.

Developing BSN leaders for the future: the Fuld Leadership Initiative for Nursing Education (LINE).

The Helene Fuld Leadership Initiative in Nursing Education (LINE) program was designed to enhance beginning leadership competencies of baccalaureate nursing students. Given the increasing need for strong and effective leadership throughout the health care system, and the demands new graduates encounter as they move into practice, the LINE program is built on the premise that leadership skills must be instilled at the undergraduate level. The program achieves its goal through an intensive 5-day institute focused on assessing and developing the leadership competencies of nurse educators and their clinical partners to enable them to be effective agents of curriculum change in their home institutions. The institute also assists participants to redesign their baccalaureate nursing (BSN) curricula to ensure that students learn to: (1) work effectively within and across complex, integrated organizational and institutional boundaries; (2) think and act from the perspective of a system; and (3) communicate, negotiate, lead, and facilitate change within health care organizations. D. Goleman's (1998) framework of emotional intelligence, which addresses both personal competence (managing oneself) and social competence (handling one's relationships with others) provides the framework for operationalizing leadership in the BSN curriculum. To date, 26 BSN programs and their clinical partners have participated in the LINE program, which has the potential to influence the beginning leadership development of more than 2,400 BSN students. Program outcomes reveal that education-practice collaboration, professional networking, individual leadership development of nurse educators and their clinical partners as change agents, and the integration of leadership experiences at all levels of the BSN curriculum are important in developing beginning leadership competencies in BSN students.

Attitudes of dentists toward emerging competencies for health care practitioners.

Dentists' attitudes about the importance of formal training in a variety of skills were assessed as a part of the Pew Health Professions Commission initiative to help health professional schools prepare for the future. Through a telephone survey with a 54 percent participation rate, attitudes of a national sample of practitioners were determined concerning the importance of training in 16 competencies that reflect skills, attitudes, and behaviors identified by the commission. Most respondents indicated that competency in treating and preventing disease, practicing ethically, communicating with patients, applying problem solving techniques, and continuing to learn were very important. Conversely, less than half of dentists indicated that competency in managing information, responding to cultural diversity, supporting community agencies, and working in managed care settings were very important. The opinions of graduates since 1980 about their own training in the competencies tended to mirror their ratings of importance. These results demonstrate the continuing need for dental educators to consider prevailing opinion of practicing professionals as a part of any evaluation or planning effort.

Academic deans' perceptions of current and ideal curriculum emphases.

This study assessed the current and ideal for dental curriculum emphasis of thirty-three curriculum topic areas and evaluated barriers to curriculum change. A forty-six item survey was mailed to the academic deans of all U.S. dental schools with an 86 percent e response rate (n = 57). The means of their responses for current curricular emphasis and ideal emphasis on the thirty-three topic areas were compared. "Health promotion/disease prevention," "primary care," and "effective patient-provider relationships/communication" were the three topic areas rated most highly (for ideal emphasis) by the academic deans. "Case management," "outpatient/ambulatory care," and "continuous quality improvement" also received high mean scores for ideal emphasis. The most significant barrier to curriculum reform was "an already crowded curriculum." The academic deans reasserted the traditional emphasis in dentistry on primary care. There also appears to be considerable support for educational programs that will foster better patient relationships and greater quality assurance and control.