Equal dependence of the high prevalence of health problems on age and family income in rural southern areas.

BACKGROUND: People who have periods of low family income are at risk for increased health problems in the future, even if they present a similar clinical picture before the reduction in family income. The association between low income and health status was studied in residents of an area with relatively low-average family income and with a historically unstable economy. METHODS: We surveyed a stratified, clustered sample of residents of Johnson County, Tennessee, using a structured interview. The responses were analyzed in conjunction with national and regional data (National Health Interview Survey). RESULTS: Residents of the geographic area under study had a markedly higher prevalence of self-reported health problems than either the national average or rural areas in the southeast United States. The higher prevalence was accounted for by the combination of age and family income, which had equal effects on health status, but not by age differences alone. CONCLUSIONS: Family income and economic development are critically important to improving community health. Sensible capitation rates in managed care arrangements can be obtained only if the income distribution of an insured population is considered along with their age, sex, and physical health status.

Effect of a transient, geographically localised economic recovery on community health and income studied with longitudinal household cohort interview method.

STUDY OBJECTIVE: The main purpose of the study was to determine whether the health or economic status of a cohort of residents in an economically troubled geographical area changed between 1990 and 1993. DESIGN: Longitudinal, single cohort, interview survey method with the key variables of health status and economic status. Quasi-experimental pre-post design with economic rebound as the intervention. SETTING: A relatively low income geographical area in a rural, mountainous region before and after an economic rebound. In 1990, the local economy and health care system collapsed because of the closure of a series of manufacturing plants; outward migration from the area peaked. Between 1990 and 1993, new industries opened, and state and private community assistance programmes intervened, resulting in an economic rebound, migration into the area, and marked growth of the health service sector. PARTICIPANTS: A 2% sample of residents of households, using a combination of random, stratified, and clustered sampling. Residents included in the study had lived within the area throughout the 1990-1993 period of the study. MAIN RESULTS: Stable, non-migrating residents had a statistically significant 7% reduction in health status between 1990 and 1993, as measured by a composite of subjective and objective measures. The non-migrating residents also had a significant decrease in average household income ($14,700 in 1990 and $12,400 in 1993 in constant 1990 dollars) during the strong economic expansion, and therefore did not participate in or receive direct economic benefit from the expansion. There was a rapid population increase during the expansion, attributable to inward migrants who were younger and healthier than existing residents. The decline in health for the non-migrating residents was tentatively attributed to either direct or indirect effects of the decline in family income. CONCLUSIONS: Local economic development accompanied by expanded health care services availability can leave existing area residents poorer and less healthy, and this problem may be masked by an abundance of healthier, wealthier inward migrants.

Culture, illness, and the biopsychosocial model.

Family medicine has appropriated the biopsychosocial model as a conceptualization of the systemic interrelationships among the biological, the psychological, and the social in health and illness. For all its strengths, it is questionable whether this model adequately depicts the centrality of culture to the human experience of illness. Culture (as meaning system) is not an optional factor that only sometimes influences health and illness; it is prerequisite for all meaningful human experience, including that of being ill. A more adequate model of the relationship between culture and illness would demonstrate the preeminence of culture in the experience of illness among all people, not just members of "exotic" cultures; would view healers as well as patients as dwellers in culture; would incorporate the role of culture as meaning system in linking body, mind, and world; and would promote the significance of the cultural context as a resource for research and therapy.

Classifying basic research designs.

Considerable confusion over terminology for classifying basic types of research design in family medicine stems from the rich variety of substantive topics studied by family medicine researchers, differences in research terminology among the disciplines that family medicine research draws from, and lack of uniform research design terminology within these disciplines themselves. Many research design textbooks themselves fail to specify the dimensions on which research designs are classified or the logic underlying the classification systems proposed. This paper describes a typology based on three dimensions that may be used to characterize the basic design qualities of any study. These dimensions are: 1) the nature of the research objective (exploratory, descriptive, or analytic); 2) the time frame under investigation (retrospective, cross-sectional, or prospective); and 3) whether the investigator intervenes in the events under study (observational or interventional). This three-dimensional typology may be helpful for teaching basic research design concepts, for contemplating research design decisions in planning a study, and as a basis for further consideration of a more detailed, uniform research design classification system.

Family physicians and generic drugs: a study of recognition, information sources, prescribing attitudes, and practices.

A survey of a national sample of family physicians was undertaken to investigate several aspects of attitudes and prescribing patterns related to generic drugs. Questionnaires were returned by 317 of 501 eligible respondents for a response rate of 63.3 percent. Of the respondents, 62.5 percent said they had enough confidence in generic drugs to prescribe them in their practices, but only 26.9 percent said they actually prescribed mostly generics. Respondents were also asked to indicate the relative importance of several potential sources of information on new drugs and to test their ability to recognize a list of generic and trade name drugs. Several associations were identified between physicians' sources of drug information and generic drug recognition, attitudes, and prescription patterns. The habit of prescribing mostly generic drugs, for example, was found to be more common among family physicians who were residency trained, who relied least on drug company representatives, and who were regular readers of the New England Journal of Medicine. The ability to recognize all ten generic names was found to be highest among these same groups of physicians and also among those who relied least on journal advertisements and those who were regular readers of The Medical Letter.

Variations in physician utilization patterns in a capitation payment IPA-HMO.

Health care utilization data, using measures such as rates of hospitalization, physician visits, and specialty referrals, were collected for individual provider offices in an Individual Practice Association-Health Maintenance Organization (IPA-HMO) that used a capitation payment system to reimburse its primary physicians. Variations in health care utilization patterns between IPA offices were identified and examined for possible associations with other characteristics of these medical practices. As on indirect test of the effectiveness of the HMO's incentive system, it was hypothesized that IPA offices with a larger number of HMO subscriber-patients and those with a longer duration of membership in the IPA would exhibit practice patterns that would conform most with the HMO's cost control objectives. Associations were found between health care utilization measures and characteristics such as the specialty of physicians, but size of HMO patient load and length of IPA membership did not have the predicted effect. The findings of this study serve to identify several questions that need to be addressed in further assessments of the performance of IPAs that follow this general model.

Characteristics of students preferring family practice/primary care careers.

Survey data from a large national sample of junior medical students were used to make several comparisons between students indicating a preference for family practice and students selecting other specialties. Comparisons were also made between students on the basis of their interest in primary care vs non-primary care fields. On the basis of measures of premedical school academic performance (undergraduate grade point average and Medical College Admission Test scores), students choosing family practice and those indicating a general preference for primary care were similar to students choosing other specialties or nonprimary care fields. Subjectively, students selecting primary care ranked themselves lower than other students in medical school academic performance. Students with a career interest in primary care also gave greater weight to the desire to help people as a career motivation, were more oriented toward considering the sociopsychological context of patients' problems, and were more likely to perceive a need for change to improve health care in the United States.

A comparison of the professional values and career orientations of male and female medical students: some unintended consequences of U.S. public policy.

During the 1970s, partly as a response to U.S. public policy which promoted the objective of equal opportunity for women, there was a dramatic increase in the proportion of women entering careers in medicine. Some observers have expressed the expectation that these women physicians will promote progressive changes in health care and that they will be more likely to emphasize "humanistic" aspects of treating patients. This paper presents data from a national survey of U.S. medical students which provides a comparison of several relevant characteristics of these male and female students. There are several important areas where significant differences are apparent. Women students are more likely to place greater importance on the desire to help people as a career motivation, for example, and are less likely to express satisfaction with the status quo in American health care. There are also significant male-female differences in career plans with respect to areas such as specialty choice and preference for practice setting. These findings are used to consider the question of the probable impact of increased numbers of women physicians on the future of American health care. Projections for the future are made more difficult because of important changes within the medical profession and in the context of health care organization, but it is clear that women physicians do represent some potential for progressive change in American medicine.

Priorities and practices of continuing medical education program directors.

A survey of program directors in continuing medical education (CME) was conducted to determine the priorities and practices of the persons who develop CME programs. Respondents from community hospitals, medical schools, specialty societies, state medical societies, and other organizations thought that the most important issues related to the measurement of educational needs and outcomes. A high degree of congruence between program directors' ideal priorities and those they thought were actually being attained in their organizations was notes. Differences between groups of CME providers were infrequent, but medical schools were significantly more concerned than other groups about funding and accountability; community hospitals, about needs assessment and training for program directors; and specialty societies, about methods for adult learning. The majority of directors thought that CME credits, recertification, and relicensure (but not reexamination) should be mandatory.

A comparative study of physicians' and nurses' conceptions of the role of the nurse practitioner.

Attempts to define the role of the nurse practitioner as a new health care provider raise questions about the traditional health care division of labor. In order to determine nurses' and physicians' conceptions of the NP's role, parallel surveys were conducted among registered nurses and primary care physicians in southeastern Pennsylvania (including Philadelphia). Respondents (679 nurses and 597 physicians) indicated their opinions on the issue of autonomy for NPs and on the issue of specific tasks appropriate to the NP's role. There were significant differences between nurses and physicians with respect to both of the issues under consideration, but there were also important differences within each of these groups. Nurses were more likely to assert that an NP might practice independently, and also had a higher conception of the NP's capabilities. Physicians who were interested in employing a nurse practitioner had opinions which were closest to those of nurses. These findings suggest that conflict between nurses and physicians might be minimal as long as the nurse practitioner movement remains relatively small, but that there may be latent conflict inherent in any large scale attempt to change the health care division of labor at the present time.

The effects of mandatory quality assurance: a review of hospital medical audit processes.

A study of 17 hospitals in the Greater Delaware Valley region was undertaken in order to determine if those hospitals which had participated in an early voluntary effort to initiate medical audit differed qualitatively or quantitatively from a matched group of hospitals which had not participated in the previous project. The study also provided the opportunity to analyze the current status of medical audit in a group of hospitals which varied significantly in size, location, and educational responsibilities. Data regarding audit administrative organization, number of audits performed, type of system used, quality of audit criteria, and utilization of audit findings were gathered and analyzed. For these variables, no discernible differences were found between hospitals which had participated in the early voluntary project and those which had not. Wide variations were found among the hospitals in the extent to which medical audit processes were formalized and implemented. There were also variations in the quality of criteria formulated by the hospitals, but they generally did not receive a high rating. The implications of audit findings were generally not followed up in an organized and appropriate manner. Many hospitals which had received PSRO delegated status were given a low rating by the reviewers. The implications of these findings are discussed.

A study of the demand for part-time residency programs.

A survey was conducted at the Medical College of Pennsylvania to measure the magnitude of demand for part-time residency programs and to assess the motivations underlying such interest. Responses from 206 females and 96 males (84 percent of all students) indicated that approximately 39 percent would probably or definitely apply to part-time residencies if they were available. As was expected, interest was greater among women and was greatest among women who were parents. At the same time, however, there was considerable interest which was not related to marital or parental status and which derived from a general dissatisfaction with the time demands of traditional graduate medical training. While there are many other factors to be considered, the demand for part-time residency programs probably far exceeds the supply of such programs and, with the continued expansion of the numbers of women physicians, will probably continue to grow.