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Objective: To describe internal medicine patients' expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction., Design: Survey of patients and their physicians., Setting: The internal medicine practice of faculty and housestaff at a large academic center in Southern California., Patients: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85%) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases., Main Measurements: The patients' previsit reports of the elements of care they thought necessary for their physicians to provide; the patients' and physicians' postvisit reports of the elements of care actually provided; and the patients' satisfaction with care., Results: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients' own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain "necessary" elements of care was associated with lower visit satisfaction., Conclusion: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients' expectations are carefully elicited and dealt with the physician-patient relationship may be adversely affected.

Objective: To survey members of the American College of Physicians about their level of satisfaction and sources of dissatisfaction with practice, the extent to which their satisfaction is reflected in their counseling of students about careers in internal medicine, the prevalence of their concerns about patients' access to care, and their attitudes toward changes in the health care system., Design: A questionnaire survey of a random sample of members of the College., Participants: Members (2254) of the College were surveyed; 1446 (64%) responded and 1290 (57%) of the responses were usable., Measurements and Main Results: More than 80% of respondents were satisfied with their relationships with patients, professional challenges, and opportunities to interact with colleagues. Only about half were satisfied with their potential income, and most were dissatisfied with their autonomy or loss of control over clinical decision making. Major sources of concern were administrative burdens, the threat of malpractice litigation, loss of income, and loss of clinical autonomy. Forty percent of internists say that they discourage students from careers in internal medicine, and only 39% would once again pursue such a career. "Pain in the practice" seems generalized among internists: logistic regression analysis failed to show any specific groups who were most dissatisfied or concerned. With regard to access, 18% of internists had many patients without health care insurance; 69% had some patients without coverage; and the majority (61%) had some patients who lost their insurance because of changing jobs or location. Assuring universal access to care received the highest priority rating of a set of criteria for health care reform., Conclusions: There is growing dissatisfaction with the practice of internal medicine, primarily related to concerns over loss of clinical autonomy, the increase in administrative burdens, the potential loss of income, and the threat of malpractice litigation. Although physicians are concerned about patients' access to care, proposals to improve access should be examined for their effects on the major sources of physicians' dissatisfaction with practice.

Objectives: To determine the counseling practices of a group of internists in the areas of smoking, exercise, and alcohol and seat belt use, and to determine the associations among physicians' personal health habits and their counseling practices., Design: A random stratified sample of members and fellows of the American College of Physicians in 21 regions selected to represent all areas of the United States. Because of the relatively small proportion of women in this group, they were oversampled., Setting: Physicians' practices., Participants: One thousand three hundred and forty-nine internists (members or fellows of the College) returned questionnaires, for a response rate of 75%; 52% defined themselves as general internists., Interventions: A questionnaire was used to obtain information on internists' use of cigarettes, alcohol, and seat belts and their level of physical activity. Data were obtained on the indications used for counseling and the aggressiveness of counseling about each of these four habits., Measurements and Main Results: Bivariate and logistic regression analyses were used to compare the tendencies of internist subgroups both in using various indications for counseling and in the thoroughness of counseling. Generalists were more likely than specialists to counsel at least once all patients who were at risk and to be more aggressive in counseling. Ninety percent of respondents counseled all of their patients who smoked, but 64.5% never discussed the use of seat belts. Only 3.8% of these internists currently smoked cigarettes, 11.3% drank alcohol daily, 38.7% were extremely or quite active, and 87.3% used seat belts all or most of the time. Among men internists, for every habit except alcohol use, personal health practices were substantially associated with counseling patients; for example, nonsmoking internists were more likely to counsel smokers, and very physically active internists were more likely to counsel about exercise. Among women internists, being very physically active was associated with counseling more patients about exercise and alcohol use., Conclusions: The low level of self-reported counseling among these internists suggests that further emphasis on training in these skills is needed. The association between personal and professional practices suggests that medical schools and housestaff training programs should support health promotion activities for future internists.

To evaluate the care given by internists in group practices at 16 academic medical centers to patients who used minor tranquilizers or antidepressants, data were abstracted from medical records and compared with specific criteria for quality care.Of 1,532 continuing care patients, 18% used minor tranquilizers and 7% used antidepressants. Almost 90% of antidepressants were prescribed for depression and 50% of minor tranquilizers were prescribed for mental health problems. The group practice internists performed well on concrete aspects of care, such as avoiding giving minor tranquilizers intravenously or intramuscularly and scheduling follow-up visits. Relatively few patients, however, had an adequate treatment plan noted in the chart. About 25% of users of minor tranquilizers did not have an acceptable indication for the drug noted in the chart. Less than 10% of users of minor tranquilizers had a plan for discontinuing the drug use; yet, 35% had long-term regular use.

In response to two written clinical vignettes describing patients with commonly seen somatic and psychologic complaints, 146 physicians from internal medicine, family medicine, and psychiatry recorded the tests and initial treatments they would order. As with the problems and diagnoses suggested by the physicians, enormous variation was seen in all specialties. The number and to some extent the nature of tests, procedures, and initial treatments ordered varied by specialty and within specialty subgroups (i.e., housestaff, full-time academic, and volunteer clinical faculty members). Physician test ordering responses to one vignette was highly correlated with responses to the second vignette, suggesting that test ordering among physicians is partly based on personal habits and characteristics and not alone on the patient's signs and symptoms.

A sample of 146 physicians from internal medicine, family medicine, and psychiatry responded to two written clinical vignettes describing patients with combinations of commonly seen somatic and psychologic complaints. The physicians included housestaff of all levels of training, full-time academic faculty, and community-based clinical faculty. Enormous variation was seen in all specialties in the numbers and types of problems and diagnoses suggested by the physicians. Aside from one or two areas, there were few differences among the specialties or by level of training with regard to the numbers or types of problems identified and tentative diagnoses recorded. The variability within specialty groups was greater than among the groups. Physician behavior in response to one vignette was highly correlated with responses to the second vignette.

The present study explored the relationship between satisfaction with life in general among 211 practicing internists and characteristics of their work, health, and life styles. Using a forced stepwise multiple regression analysis, 67% of the total variance in life satisfaction was accounted for by study variables. More satisfied physicians were more likely to be older, married, engaged in sexual intercourse more often, argued with or emotionally withdrew from family or friends less often, had fewer health problems, were less anxious and depressed, and experienced less job stress and more job satisfaction. Characteristics of the work setting, type of work activity (teaching, research, or patient care), number of patients seen, or hours worked per week were unrelated to satisfaction with life. The findings point to the importance of studying family life, mental health, and social relations in addition to work-related variables in order to understand and assess the quality of life among physicians.

As part of an assessment of interests and needs for continuing medical education among academic general internists, a 20 per cent random sample of the 1985 physician membership of SREPCIM was asked to describe how they divided their time among basic work activities (patient care, teaching, housestaff supervision, administration, and research), how they perceived the importance of specific skills related to those basic activities, and how interested they were in participating in a faculty development program in order to improve those skills. Although respondents reported a great diversity of work roles, attitudes, and values, there was a strong and consistent tendency to value and want to improve upon only those skills related to basic activities in which physicians were already spending more time. Also, physicians who spent more time in direct patient care were significantly less likely to value classroom teaching or research, less likely to be doing teaching or research, and less motivated to improve their skills in those activities. Likewise, faculty who spent more time doing research were less interested in improving their patient care skills. The implications of these findings for meeting current and future manpower needs of divisions of general internal medicine are discussed.

To understand the educational needs of faculty general internists in academic hospital environments, surveys of general internal medicine division chiefs, department of medicine chairmen, and members of the Society for Research and Education in Primary Care Internal Medicine were undertaken. Results indicated considerable interest in faculty development activities among all physicians sampled. Division chiefs and department chairmen viewed such activities as feasible, potentially effective, and were willing to assume considerable responsibility in providing educational opportunities to their faculty. Although some physicians viewed self-learning as a potentially effective educational method, the vast majority preferred learning in a small group taught by an expert. Specific content areas for faculty development were assessed, as were the skills thought to be essential for personal job satisfaction, academic promotion, and organizational effectiveness.

As part of an assessment of interests and needs for continuing medical education among academic general internists, a 20 per cent random sample of the 1985 physician membership of SREPCIM was asked to describe how they divided their time among basic work activities (patient care, teaching, housestaff supervision, administration, and research), how they perceived the importance of specific skills related to those basic activities, and how interested they were in participating in a faculty development program in order to improve those skills. Although respondents reported a great diversity of work roles, attitudes, and values, there was a strong and consistent tendency to value and want to improve upon only those skills related to basic activities in which physicians were already spending more time. Also, physicians who spent more time in direct patient care were significantly less likely to value classroom teaching or research, less likely to be doing teaching or research, and less motivated to improve their skills in those activities. Likewise, faculty who spent more time doing research were less interested in improving their patient care skills. The implications of these findings for meeting current and future manpower needs of divisions of general internal medicine are discussed. [ABSTRACT FROM AUTHOR]

Objective: To describe internal medicine patients' expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction.Design: Survey of patients and their physicians.Setting: The internal medicine practice of faculty and housestaff at a large academic center in Southern California.Patients: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85%) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases.Main Measurements: The patients' previsit reports of the elements of care they thought necessary for their physicians to provide; the patients' and physicians' postvisit reports of the elements of care actually provided; and the patients' satisfaction with care.Results: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients' own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain "necessary" elements of care was associated with lower visit satisfaction.Conclusion: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients' expectations are carefully elicited and dealt with the physician-patient relationship may be adversely affected. [ABSTRACT FROM AUTHOR]