Correlates of between-surgeon variation in breast cancer treatments.

BACKGROUND: Determinants of between-surgeon variation in breast cancer treatment utilization are not well understood. OBJECTIVES: The objectives of this study were to evaluate variation in receipt of surgical treatment (ie, mastectomy or breast-conserving surgery with or without radiation) for women with stage I, II, or III breast cancer and receipt of breast reconstruction attributable to surgeons, and to assess factors associated with this between-surgeon variation. METHODS: We surveyed all attending surgeons (n = 456) of a population-based sample of patients with breast cancer diagnosed in Detroit and Los Angeles during 2002 (n = 1844). Our analytic dataset linked data from 1477 patients with that of 311 surgeons. We used random-effects modeling to account for the multilevel dataset and evaluated 2 outcomes: 1) primary surgical treatment (mastectomy vs. BCS); and 2) receipt of reconstruction before being surveyed (yes vs. no). Independent variables included patient-related factors (clinical and demographic), surgeon-related factors (breast procedure volume, practice setting, and demographics), surgeon treatment recommendation, and referral propensity. RESULTS: Surgeons explain some variation in use of both mastectomy and reconstruction (9.9% and 26%, respectively). Patient clinical factors and surgeon volume together explain approximately one-third of the between-surgeon variation in mastectomy. Patient factors and surgeon demographics explain approximately 60% of between-surgeon variation in reconstruction, and surgeon referral propensity explains an additional 15%. CONCLUSION: Our findings suggest that similar patients may get different treatment depending on their surgeon. Broader dissemination of guidelines coupled with increasing patient access to consultations before definitive surgery may reduce between-surgeon variation. Contributing factors such as patient-physician communication should be explored.

Validation of a global measure of faculty's clinical teaching performance.

PURPOSE: To validate the University of Michigan Global Rating Scale (GRS), a single-item, five-point global measure of faculty members' clinical teaching performances previously shown to be reliable. METHOD: In June 1998, 98 senior medical residents (98% of seniors) from four academic institutions completed the GRS for all teaching faculty at their institutions. Each resident also completed the 26-item Stanford Faculty Development questionnaire (SFDP26) for ten faculty with whom he or she had had teaching contact during residency. The SFDP26 is a validated instrument that measures seven specific aspects of clinical teaching (e.g., communication of goals, feedback). RESULTS: The mean GRS score (SE) was 3.83 (.07). There was no difference in mean GRS or SFDP26 subscale scores across institutions. In a random-effects model that controlled for interrater reliability, correlation coefficients comparing the mean GRS scores and the mean scores for the individual SFDP26 subscales ranged from.86 to.98. CONCLUSIONS: The GRS correlates highly with measures of seven specific aspects of teaching effectiveness among senior medical residents. The GRS is a simple, readily administered measure of faculty's teaching performances that can be used by residency programs as part of an incentive or reward program, to identify teachers as potential candidates for faculty development, or for consideration in promotion decisions.