Internal medicine residents reject "longer and gentler" training.

BACKGROUND: Increasing complexity of medical care, coupled with limits on resident work hours, has prompted consideration of extending Internal Medicine training. It is unclear whether further hour reductions and extension of training beyond the current duration of 3 years would be accepted by trainees. OBJECTIVE: We aimed to determine if further work-hour reductions and extension of training would be accepted by trainees and whether resident burnout affects their opinions. DESIGN: A postal survey was sent to all 143 Internal Medicine residents at the University of Colorado School of Medicine in May 2004. MEASUREMENTS: The survey contained questions related to opinions on work-hour limits using a 5-point Likert scale ranging from strongly agree to strongly disagree. Burnout was measured using the Maslach Burnout Inventory, organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment, with burnout defined as high EE or DP. RESULTS: Seventy-four percent (106/143) of residents returned the survey. The vast majority (84%) of residents disagreed or strongly disagreed with extending training to 4 or 5 years. Burnout residents were less averse to extending training (strongly agree or agree, 18.9% vs 4.3%, P = .04). The majority of residents (68.9%) disagreed or strongly disagreed with establishing a 60-hour/week limit. Residents who met the criteria for burnout were more likely to agree that a 60-hour limit would be better than an 80-hour limit (strongly agree or agree, 22% vs 8%, P = .02). CONCLUSIONS: In this program, most Internal Medicine residents are strongly opposed to extending their training to 4 or 5 years and would prefer the current 80 hours/week cap. A longer, less intense pace of Internal Medicine training seems to be less attractive in the eyes of current trainees.

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

Hispanic versus white, non-Hispanic physician medical practices in Colorado.

The purpose of the study was to extend the scope of earlier research on minority physicians attending to the needs of the poor and their own ethnicity by contrasting practice characteristics of Hispanic doctors in Colorado with those of their white, non-Hispanic counterparts. It was found that Hispanic physicians spent more hours per week in direct patient care, were more likely to have a primary care specialty, and were less often specialty board certified than white, non-Hispanic doctors. Hispanic generalists established practices in areas in which the percentages of the population that were (1) below poverty level, (2) Hispanic, (3) Hispanic and below poverty level, and (4) white, non-Hispanic, and below poverty level were greater than in areas in which white, non-Hispanic primary care physicians practiced. These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs.

Multi-method assessment of access to primary medical care in rural Colorado.

The objectives of this study include conducting an analysis of access to primary medical care in rural Colorado through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analyses examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads that might result from every rural Coloradoan's exclusive use of the nearest generalist physician as a regular source of care. Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files (Census of Population and Housing, 1990), the authors calculated distance to the nearest primary care physician for residents of each of the 1,317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. Straight-line mileage to primary medical care was modest for rural Coloradoans--a median distance of 2.5 miles. Almost two-thirds (65 percent) of the population resided within 5 miles, and virtually all residents (99 percent) were within 30 miles of a generalist physician. However, had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries depict access to primary medical care and corresponding consumer difficulty more fully than in previous studies. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas.

Considering school health program screening services as a cost offset: a comparison of existing reimbursements in one state.

This paper reports results of an analysis of the approximate costs of Colorado school health program screening activities during the 1993/94 school year had they been conducted elsewhere in the public or private sectors. School nurses and health aides performed 1,161,779 screening procedures during the year, an average of 1.93 per child enrolled in school districts throughout the state. Charges for Current Procedures Terminology (CPT) codes, which correspond to school health program screening activities, were used to approximate market value. Conservative assumptions were made regarding provider skill and time requirements as well as student service utilization profiles. The general dimension of the contribution of school health screening activities was found to be impressive.

Trends in a national sample of sexually abusive youths.

OBJECTIVE: To describe sociodemographic factors pertinent to sexually abusive youths, to define common characteristics of the offending behaviors and victims, and to identify issues relevant to treatment recommendations. METHOD: The Uniform Data Collection system (UDCS), developed by the National Adolescent Perpetrator Network, provided data from 90 contributors in 30 states on more than 1,600 juveniles referred to them for specialized evaluation and/or treatment following a sexual offense. The UDCS comprises four separate structured questionnaires that collect both factual information and clinical impressions. RESULTS: Physical and sexual abuse, neglect, and loss of a parental figure were common in these youths' histories. Twenty-two percent of the youths, who had been victims of sexual abuse, reported that the perpetrator of their own sexual abuse was female. The youths committed a wide range of sexual offenses, with twice as many of the referring offenses involving female victims than male victims. CONCLUSION: The discovery of sexually abusive youths across both urban and rural areas supports the need for comprehensive service delivery and a continuum of treatment services to be available in all communities.

A cluster analysis of detected and substantiated child maltreatment incidents in rural Colorado.

This paper reports the results of a cluster analysis of the incidents of detected and substantiated child maltreatment in 31 rural Colorado counties during the 5-year period (1986-1990). Mapping and statistical techniques employed revealed time-space clustering in the occurrence of child abuse and neglect in sparsely settled rural areas of the state. The study examined temporal-geographic patterns among all 830 confirmed incidents in the Colorado Child Abuse and Neglect Registry for counties of less than 10,000 population. These findings suggest that a first incident of abuse or neglect serves as a sentinel event, predicting a period of more frequent receipt and substantiation of maltreatment cases by child protection professionals in the county or community of occurrence. Clustering was apparent using 3-, 7-, 14-, 30-, and 60-day intervals of time; a scheme endorsed by the Centers for Disease Control for national study of the epidemicity of adolescent suicide. An agenda is proposed to review the appropriateness and adequacy of child protection policies and protocols in view of this phenomenon, and to pursue additional related research objectives.

A survival analysis of the revictimization of children: the case of Colorado.

This paper reports the results of a survival analysis of patterns of revictimization of children with records of confirmed cases of maltreatment in Colorado during the 4-year period 1986-1989. The study examined the cases of 24,507 children in that state's Child Abuse and Neglect Registry for evidence of their revictimization. Hazard rates for repeat offenses were highest immediately after the initial incident of abuse or neglect. Risk of revictimization was greater for younger children and for females, but those relationships were strongly mediated by the form of maltreatment. The rate of revictimization of physically neglected children exceeded that for other major types of maltreatment. Although abused and neglected children were most at risk immediately after their incident of abuse or neglect, they remained at greater risk of mistreatment for years thereafter.

Geographic benefit from decentralized medical education: student and preceptor practice patterns.

The performance of area health education center (AHEC)-stimulated programs and decentralized education for medicine is not well understood. The Statewide Education Activities for Rural Colorado's Health (SEARCH)/AHEC project at the University of Colorado School of Medicine was examined to determine if the program had an effect on the practice location of its graduates. Practice location and specialty of graduates of the University of Colorado School of Medicine (UCSOM) classes 1980-1985 were compared for students who had participated in decentralized SEARCH/AHEC experiences versus students who had not. The majority of the graduates were practicing out of state in 1990. Non-Colorado doctors were more often practicing in rural (non-metropolitan statistical area [MSA]) counties and in towns of fewer than 2,500, 5,000 and 10,000 residents, respectively. In addition, of the 251 active patient care physicians practicing in Colorado communities of fewer than 10,000 in non-MSA counties in 1986, those who precepted UCSOM students on SEARCH rotations were more likely to have remained in their same practice location in 1992 (77.8% versus 62.1% for those who had not precepted students). This analysis of both student and preceptor practice patterns documents the value of decentralized medical education in addressing the geographic and specialty maldistribution of physicians. These results have important policy implications for funding medical education programs.

The relationship of child protection worker attitudes to attrition from the field.

Child protection workers in 33 states and the District of Columbia participated in a survey conducted by the C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect to determine the attitudes and attributes of workers who terminate their careers in child protection. A year after the survey, telephone follow-up was done to identify respondents to the survey who had left the child protection field. Attributes and attitudes were then linked directly to whether workers had terminated or continued child protective service. Just 8.0% (15 of 187) of the workers had left the field. There were few differences between workers that departed and those whose services were retained. Both were generally dissatisfied with their profession at the time of the survey. The shrinking social service labor market and worker investment in the field are discussed as factors impeding turnover among child protection workers.