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Primary healthcare is recognized as a team-based activity. Traditionally, a primary care team is considered to be a group of individuals that work together to satisfy patients’ needs for primary care services. Past studies show wide variation in the scope and structure of teams across primary care organizations, indicating ambiguity in the definition of primary care teams. In addition, it remains unclear why certain healthcare professionals are included/excluded from another professional’s “team”. This study explored the question: “How do healthcare professionals in primary care clinics define who is on their team?” Qualitative content analysis was performed on interview data from clinicians and staff in eight primary care clinics regarding team definitions. All participants acknowledged the importance of working in a team, yet they had very different perspectives on how their teams were defined. Multiple themes emerged including borrowing the expertise of another professional, sharing of patient panel, and policy requirements. This study can inform healthcare professionals and administrators, as well as health IT designers, consultants, architects and researchers interested in primary care teams and how they function in a clinic environment.

We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient–practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient–practitioner (or team)-EHR triad.

There is an inherent tension between standardization and customization of care delivery processes. The challenge for health care systems is to achieve the right balance. At its best, standardized work can create efficiencies that generate the additional time needed for personalized care. Similarly, at its best, customization allows the people within a system to accommodate the needs, preferences, and circumstances of the unique individuals and local communities they serve. We provide examples and offer principles to decide when standardization offers the most successful path and when customization may be preferred. We believe that, in sum, the balance has shifted too far toward standardization and that a rebalancing toward customization will benefit patients, clinicians, and the health care system.

Dr. Ben-Tzion (Bentzi) Karsh was a mentor, collaborator, colleague, and friend who profoundly impacted the fields of human factors and ergonomics (HFE), medical informatics, patient safety, and primary care, among others. In this paper we honor his contributions by reflecting on his scholarship, impact, and legacy in three ways: first, through an updated simplified bibliometric analysis in 2020, highlighting the breadth of his scholarly impact from the perspective of the number and types of communities and collaborators with which and whom he engaged; second, through targeted reflections on the history and impact of Dr. Karsh's most cited works, commenting on the particular ways they impacted our academic community; and lastly, through quotes from collaborators and mentees, illustrating Dr. Karsh's long-lasting impact on his contemporaries and students.

Primary health care is a complex, highly personal, and non-linear process. Care is often sub-optimal and professional burnout is high. Interventions intended to improve the situation have largely failed. This is due to a lack of a deep understanding of primary health care. Human Factors approaches and methods will aid in understanding the cognitive, social and technical needs of these specialties, and in designing and testing proposed innovations. In 2012, Ben-Tzion Karsh, Ph.D., conceived a transdisciplinary conference to frame the opportunities for research human factors and industrial engineering in primary care. In 2013, this conference brought together experts in primary care and human factors to outline areas where human factors methods can be applied. The results of this expert consensus panel highlighted four major research areas: Cognitive and social needs, patient engagement, care of community, and integration of care. Work in these areas can inform the design, implementation, and evaluation of innovations in Primary Care. We provide descriptions of these research areas, highlight examples and give suggestions for future research.

Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX).We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL.Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect.CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.

Objective To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries. Methods Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania. Results In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased. In Guatemala, sustained reductions in overall maternal mortality and mortality from postpartum hemorrhage (PPH) were recorded after ALSO implementation. In Honduras, there was a significant decrease in episiotomy rates, and increases in active management of the third stage of labor (AMTSL), vacuum-assisted delivery, and reported comfort managing obstetric emergencies. In Tanzania, the frequency of PPH and severe PPH decreased after training, while management improved. Conclusion In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training.

While health information technology (HIT) efforts are beginning to yield measurable clinical benefits, more is needed to meet the needs of patients and clinicians. Primary care researchers are uniquely positioned to inform the evidence-based design and use of technology. Research strategies to ensure success include engaging patient and clinician stakeholders, working with existing practice-based research networks, and using established methods from other fields such as human factors engineering and implementation science. Policies are needed to help support primary care researchers in evaluating and implementing HIT into everyday practice, including expanded research funding, strengthened partnerships with vendors, open access to information systems, and support for the Primary Care Extension Program. Through these efforts, the goal of improved outcomes through HIT can be achieved.

Multiple reports from the Institute of Medicine and the National Academy of Engineering, (IOM 2001; Reid et al., 2005; Kaplan et al., 2013) have called for the use of human factors engineering (HFE) and systems engineering principles and methods/tools to improve health care delivery. Yet, the integration of engineers into health care settings and the education of clinicians and other health care professionals on human factors and systems engineering principles and methods/tools remain in its infancy. A recent editorial by Xiao and Fairbanks (2011), discusses a small, but growing presence of professionals who are “bilingual” in both human factors and medicine. Indeed, Carayon (2011) identified human factors as an innovation that will require diffusion into healthcare through the use of HFE methods and tools, increasing the health care professional knowledge of HFE, and the hiring HFEs in healthcare organizations. To achieve the goal of integration, there will be many “models” of healthcare – human factors collaborations, from experts working together from their different ‘silos’ to true bilingualism. SEIPS, the Systems Engineering Initiative for Patient Safety (Carayon et al., 2006), aims to integrate human factors and systems engineering with healthcare disciplines. Our panel of SEIPS-affiliated engineers and healthcare professionals represents many different types of collaborations across this spectrum and their work spans multiple healthcare settings and disciplines, including: ambulatory primary care, inpatient pediatrics, community pharmacy, and oncology.

PURPOSE Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non–face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODS We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from “event logging” records over a 3-year period for both direct patient care and non–face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. RESULTS Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). CONCLUSIONS Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.

Background Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit. Methods A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings. Results The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student. Conclusions The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.

Background: The wide-reaching, complex, understudied primary care environment presents hazards to patient safety. Elderly patients visit physician offices more often, with more problems, while taking more medications – increasing the complexity of the visit and the frequency of the hazards. Objective: Identify hazards in the primary care of elderly patients from the patient’s perspective. Methods: Fourteen elderly patients in three focus groups with questions developed from 70 hours of direct observation. Hazards were coded from participant responses and ‘what-if’ analyses to capture both explicit and implicit hazards. Results: Thematic hazard analysis resulted in eight emergent, overlapping hazard themes: 1) fragmentation of care; 2) problems with information transfer between healthcare professionals; 3) problems with patient communication and feedback; 4) problems with paper and electronic health records; 5) medication management and expense; 6) physical and memory limitations; 7) reliance on others; an...

“The reality of the growing dissatisfaction with the practice of medicine has reached a crisis level”(Weinstein and Wolfe 2007). This belief has led to the growing number of studies of physician job satisfaction (Breslau, Novack, and Wolf 1978; Pasternak, Tuttle, and Smith 1986; Schulz and Schulz 1988; Buciuniene, Blazeviciene, and Bliudziute 2005; Scott et al. 2006; Van Ham et al. 2006; Whalley et al. 2006; Keeton et al. 2007;). Job satisfaction studies are important because they have identified outcomes linked to satisfaction, such as turnover (Beasley et al. 2004; Misra-Hebert, Kay, and Stoller 2004; Landon et al. 2006; Joseph et al. 2007; Wright and Bonett 2007;), cutting back hours (Landon et al. 2006), mental health (Williams et al. 2002), quality of care (Grembowski et al. 2005), and burnout (Linzer et al. 2001). Satisfied physicians also appear to engender greater satisfaction, trust, and confidence in their patients (Grembowski et al. 2005). Satisfaction studies are also important because they have identified job and organizational predictors of satisfaction (Gaertner 1999; Freeborn 2001; Duffy and Richard 2006; Van Ham et al. 2006;) that can be changed to improve satisfaction, and they decrease the likelihood of subsequent bad outcomes such as burnout or turnover. While physician satisfaction continues to receive attention, physician commitment has received far less (Lakin 1998; Burns et al. 2001; Freeborn 2001;). Outside of health care, commitment and satisfaction are considered among the two most important employee attitudes because both lead to a variety of important behaviors such a performance, turnover, absenteeism, and helping behaviors (Currivan 1999; Meyer and Herscovitch 2001; Wagner 2007; Solinger, van Olffen, and Roe 2008;). But for some reason, commitment has been largely ignored in studies of physicians. Commitment has been defined in many ways, but a common theme is that commitment to something can be thought of as the force that binds a person to something, where the “something” is typically a behavior (e.g., “I am committed to providing better care”) or an entity (e.g., “I am committed to my practice”) (Meyer and Herscovitch 2001). Commitment has cognitive, emotional, and behavioral components (Solinger, van Olffen, and Roe 2008). Low commitment can lead to behaviors such as turnover, but high commitment can lead to helping behaviors directed to patients or colleagues (Solinger, van Olffen, and Roe 2008), making the study of physician commitment an important gap to fill. Another important gap in the literature on physician attitudes, in addition to the omission of commitment, is that studies have not examined satisfaction and commitment directed to the entities that physicians most associate themselves with: one's practice, one's workgroup (people with whom you take call), and one's employer, which we refer to as the physician's health care organization (HCO) or parent organization.1 Instead, existing research has typically only focused on the latter (Schulz, Girard, and Scheckler 1992; Burdi and Baker 1997; LePore and Tooker 2000; Linzer et al. 2000; Sturm 2001; Beasley et al. 2004, 2005). Results show that HMO employed and non-HMO physician satisfaction varies widely, as do the predictors of satisfaction. But these studies have not compared measures of satisfaction (or commitment) with entities that physicians affiliate. This is an important omission for at least two reasons: (a) satisfaction with or commitment toward these different entities may differentially predict outcomes such as turnover and job performance and (b) different variables may predict each type of satisfaction and commitment. If (a) and (b) are true, then current efforts to improve physician satisfaction and/or commitment may need to be redirected. This study is an attempt to fill that gap. The purpose of this study was to compare satisfaction and commitment scores among family physicians toward their practice, workgroup, and HCO and to determine what work factors predict the different types of satisfaction and commitment. The sample consisted of family medicine physicians employed by large multispecialty group practices, a group for whom this may be especially important in light of the low numbers of medical students intending to pursue a career in primary care (Hauer et al. 2008).

PURPOSE Family physicians in Wisconsin who are mainly employed by large health care organizations have voiced concerns regarding the quality of their work lives. We explored the quality of work life and its relationship to employment by health care organizations. METHODS We conducted a cross-sectional survey of the 1,482 active members of the Wisconsin Academy of Family Physicians in 2000. RESULTS A 47% overall response rate was obtained, and 584 respondents could be identifi ed as independent or employed by a health care organization. There were no differences in age or sex between the 2 groups. The independent physi- cians worked longer hours, were in smaller work groups, and had been in practice longer and in their current practice longer than the employed physicians. Inde- pendent physicians reported better working relationships, more satisfaction with family time, more infl uence over management decisions, better satisfaction with being a physician, better perceived quality of the care they provided, greater abil- ity to achieve professional goals, and lesser intention to leave the practice. CONCLUSIONS Independent physicians have signifi cantly more positive ratings of several aspects of the quality of their work life compared with physicians employed by health care organizations. Health care organizations need to address these issues if they are to have a satisfi ed and stable workforce.

The need for research that is applicable to the most common health problems is well recognized. Some of this research will be in the area of primary care, and family doctors must contribute to the research for it to be effective in improving care. Using a sample of key informants from 10 different countries, this paper explores the extent to which family doctors are involved in research in the various regions of the globe. We find great variability in the level of research being conducted by family doctors at academic institutions and in the development of the community research structures, such as practice based research networks. Despite the problems, family doctors are involved in research in every region assessed, and there is room for optimism that this role will be substantially expanded.

The number of problems managed concurrently by family physicians during patient encounters has not been fully explored despite the implications for quality assessment, guideline implementation, education, research, administration, and funding. Our study objective was to determine the number of problems physicians report managing at each visit and compare that with the number reflected in the chart and the bill.Twenty-nine members of the Wisconsin Research Network reported on encounters with 572 patients using a physician problem log. The patient chart notes and the diagnoses submitted for billing from the encounters were compared with the information in these logs.The physicians reported managing an average of 3.05 problems per encounter and recorded 2.82 in the chart and 1.97 on the bill. For all patients, 37% of encounters addressed more than 3 problems, and 18% addressed more than 4. For patients older than 65 years, there was an average of 3.88 problems at each visit, and for diabetic patients there was an average of 4.60. There was evidence for the selective omission of mental health and substance problems from the diagnoses used for billing.Family medicine involves the concurrent care of multiple problems, which billing data do not adequately reflect. Our findings suggest a mismatch between family medicine and current approaches to quality assessment, guideline implementation, education, research, administration, and funding. Activities in all these areas need to address the physician's task of prioritizing and integrating care for multiple problems concurrently.

The purpose of this paper is to examine the differences between the preferences of physicians and clinical assistants for the design of a statewide medical error reporting system. The study employed a series of separate focus groups composed of physicians and clinical assistants. The focus groups covered a wide range of relevant topics based on the previous literature on error reporting both in and outside of healthcare. Focus group transcripts were subject to a content analysis resulting in a total of 86 major and minor themes. While physicians and clinical assistants shared similar preferences and beliefs surrounding error reporting such as its educational potential and fear of punitive repercussions, they differed as well. Some of the differences uncovered included the rules and regulations governing the use of the system, the medium of reporting, and aspects of the organization that may affect reporting levels. The design implications for considering these issues are discussed.

Objective While the use of electronic health records (EHRs) in primary care has increased dramatically, its potential benefits need to be considered in light of potential negative impacts on physician–patient interactions and the increase in physician cognitive workload. This study aims to understand work system factors contributing to physicians' use of the EHR as a communication tool during primary-care encounters. Methods We interviewed 14 primary care physicians on their use of EHRs as a communication tool in patient visits. A qualitative content analysis guided by the work system model identified factors influencing physicians' decisions to share or not share the computer screen with their patients. Results The analysis revealed 26 factors that influenced physicians' decisions to share the screen, most related to the "task" (reviewing lab records), "tools and technology" (using algorithm calculators for risk prediction), or "individual" (patient interest) elements of the work system. The analysis revealed 15 factors that influenced physicians' decisions not to share the screen, most related to the "individual" (patient's acute pain), "organization" (insufficient time), or "task" (documenting embarrassing information) elements of the work system. Conclusion Eleven physicians made individual decisions to share or not to share the screen in a particular visit based on work-system related factors. Three doctors always shared the screen, based on the idea that it is polite and builds trust. However, several physicians also reported that it was time consuming and caused unnecessary distractions. Understanding these factors is essential to effective EHR redesign and training for improving physician–patient communication.

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Coronary artery disease (CAD) is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (NSTEMI) are very common manifestations of this disease. These life-threatening disorders are a major cause of emergency medical care and hospitalizations in the United States. In 1996, the National Center for Health Statistics reported 1 433 000 hospitalizations for UA or NSTEMI. In recognition of the importance of the management of this common entity and of the rapid advances in the management of this condition, the need to revise guidelines published by the Agency for Health Care Policy and Research (AHCPR) and the National Heart, Lung and Blood Institute in 1994 was evident. This Task Force therefore formed the current committee to develop guidelines for the management of UA and NSTEMI. The present guidelines supersede the 1994 guidelines. The customary ACC/AHA classifications I, II, and III summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective . Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data …

Preamble......971 I. Introduction ......972 A. Organization of Committee and Evidence Review......972 B. Purpose of These Guidelines......973 C. Overview of the Acute Coronary Syndrome......973 1. Definition of Terms......973 2. Pathogenesis of UA/NSTEMI ......974 3. Presentations of

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Purpose: The purpose of this article is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda. Methods: We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety. Results: Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, and its consequences, and we discuss possible solutions and suggest a research agenda that may lead to methods to reduce the problem. Conclusions: Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying, and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.

Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit.A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings.The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student.The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.

A total of 684 primary care physicians in Wisconsin participated in a survey designed to explore their experiences of consulting with and referring patients to mental health care professionals. The respondents indicated that they had only moderate access to mental health care professionals, and even less access when a patient was covered by Medicare or Medicaid or had no insurance. Physicians in group practices that included at least one mental health professional reported having better access to care than those in practices that did not include mental health services. Perceived access to mental health care services was not related to community size or to a managed care setting.

BackgroundHealth care systems are changing around the world; family doctors need to adapt and prepare for future challenges.AimTo consider the present status of family doctors, anticipated changes in health care systems, the challenges these will bring and possible solutions.Collection of informationCollaborative enquiry amongst members of the International Federation for Primary Care Research Networks (IFPCRN). Six strategic questions were addressed by 37 contributors from 23 countries. Responses were collated and contributors invited to further comment on the interim report.FindingsPresent status: Despite wide variability, common problems relate to delivery systems, funding and policy, lack of evidence-based medical practice, education and research. Role of family doctors: There is wide variability in roles and often poor interaction with other caregivers. Anticipated changes: An expansion of the family physician model is anticipated, alongside shortages of family doctors in the face of increased health care needs, increased complexity of problems and the shift to ambulatory care. Advances in information technology may be useful. Anticipated challenges and proposed actions: Address quality issues. This requires audit and quality assurance, promoting adaptability, promoting group practices and teamwork, coordinating care, incorporating information technology and ensuring ethical relationships with industry. Improve education and continuing professional development: Improved education and continuing professional development are needed, as are measures to prevent burnout and retain the workforce. Develop a robust research enterprise: Research in primary care is needed to develop relevant guidelines. Improve support for family doctors: Providing excellent patient care is essential for improved status and support. Achieving this requires engagement with policy makers, academic institutions and the public.ConclusionsWhile there is great variability across different countries, common themes relate to present status, anticipated changes in health systems and the responses needed from family medicine.

Public reports ranking physician competence and quality often yield conflicting results and create confusion.Bivariate Pearson correlation analyses were performed to compare states' rankings of physician discipline and physician quality, as reported by the Medicare program and National Practitioner Data Bank. Medical boards were surveyed on their rates of complaints against physicians and ratio of actions to complaints.For all states, there was a poor to negative correlation between state rankings of disciplinary rates and quality, as well as rates of complaints against physicians. As an example, Wisconsin ranked 50th out of the 50 states plus the District of Columbia (where 1 is most desirable and 51 is worst) in rates of "serious" licensure sanctions, but did well when ranked by Medicare quality (eighth out of 51) and the rate of NPDB adverse reports (second out of 51). Wisconsin had a low rate of complaints per physician, ranking second out of 35 responding states, and a high ratio of actions to complaints, ranking fourth out of 35.Conflicting conclusions among public reports on physician discipline and quality raise questions about their methods and validity. State rankings of physician discipline and quality should be viewed with caution.

Background:The Advanced Life Support in Obstetrics (ALSO®) program is a highly structured, evidence-based, two-day course designed to provide healthcare professionals with the knowledge and skills to manage the emergency conditions that can occur during childbirth.Objectives:To document the number of ALSO®-trained clinicians and instructors in the United States and internationally and to promote ALSO® training among prehospital and disaster medicine professionals.Methods:Records maintained by the American Academy of Family Physicians (AAFP) for each country where ALSO® is taught were reviewed for: (1) the years and locations of the ALSO® courses; (2) the number of ALSO®-trained caregivers; and (3) the number of ALSO® instructors.Results:Between 1991 and 2005, 54,071 ALSO®-trained caregivers and 2,251 instructors have completed provider and instructor ALSO® courses in 25 countries. Of these, 17,755 caregivers and 1,220 instructors are from outside the United States.Conclusion:The ALSO® program is a popular, multi-disciplinary course for preparing maternity caregivers to manage obstetric emergencies. Limited evidence suggests it can be effective and efficient in enhancing the knowledge and skills of prehospital and disaster medicine clinicians. Hong Kong provides a model in which emergency physicians have taken the lead in promoting the ALSO® course. As the ALSO® program expands, additional research is needed to assess its impact on educational and health outcomes.

The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.

Most family physicians in Wisconsin are employed by large health care organizations. Because of its impact on physician recruitment, retention, commitment to the organization, and patient care, the quality of physician work life is an important problem.A survey was designed based on a literature review and augmented by focus group data. It was sent to all 1482 members of the Wisconsin Academy of Family Physicians in 2000.Overall response rate was 47%. Three hundred ninety-seven of the respondents were employed by 18 different health care organizations having 10 or more respondents. There were significant differences among Wisconsin's health care organizations in terms of physicians' satisfaction with their organization. There was a strong significant negative correlation between satisfaction with one's organization and turnover intention and a strong positive correlation between satisfaction with one's organization and ability to achieve one's professional goals. There were also significant, though less strong, correlations between satisfaction with one's organization and satisfaction with being a physician and perceived quality of care delivered.Some of Wisconsin's health care organizations are doing better than others at working with their family physicians to maximize these physicians' satisfaction with the organization, reduce the likelihood of turnover, and enable them to reach their professional goals.

Background: We evaluated the frequency, nature, and importance of the changes in patient care that occurred as a result of differences in outpatient radiograph readings for cases in which the primary care clinician, hypothetically, would not request a second reading by a radiologist. Methods: During 4 months, 1393 pairs of radiographic readings were collected from 9 volunteer primary care practices with 86 clinicians and a second reading by one of 42 radiologists. For 553, hypothetically, the clinician would not request a consultation from a radiologist. Review analysis of the 553 pairs revealed 100 (18.1%) radiographs in which the radiologist’s reading did not agree with the clinician’s reading. Data from the original visit and subsequent related care were abstracted from patient charts and reviewed. Changes in clinical care resulting from the radiologist’s reading were identified. Results: The radiologists’ second reading of these 553 sets of radiographs resulted in 14 (2.5% of 553 and 14% of 100) cases of one or more changes in care. We found 38 documented or presumed changes in care and zero substantial changes in care. Conclusions: Primary care clinicians are able to identify radiographs for which a second reading by a radiologist will not result in substantial changes in care.

State and federal initiatives to develop medical error reporting systems are being proposed. For these to lead to an effective error reporting system to improve primary care, the needs of primary care professionals must be understood.This study was based on the answers to key questions directed at primary care physicians and clinical assistants. A series of focus groups was held to determine what elements need to be included in the design of a medical error reporting system for ambulatory care.Participants addressed the purposes of an error reporting system, the barriers and motivators to the use of a system, the types of events that should be reported, how the reporting should be done, and how the data should be analyzed and used. During the sessions, 87 different themes emerged that were distilled down to the general principles and operating design elements deemed most important.The participating physicians and clinical assistants supported a primary care medical error reporting system designed to provide useful information to improve health care. The system should not be punitive.

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of unstable angina and non–ST-segment elevation myocardial infarction (UA/NSTEMI) were published in September 2000.1 Since then, a number of clinical trials and observational studies have been published or presented that, when taken together, alter significantly the recommendations made in that document. Therefore, the ACC/AHA Committee on the Management of Patients With Unstable Angina, with the concurrence of the ACC/AHA Task Force on Practice Guidelines, revised these guidelines. These revisions were prepared in December 2001, reviewed and approved, and then published on the ACC World Wide Web site (www.acc.org) and AHA World Wide Web site (www.americanheart.org) on March 15, 2002. The present article describes these revisions and provides further updates in this rapidly moving field. Minor clarifications in the wording of three recommendations that now appear differently from those that were previously published on the ACC and AHA Web sites are noted in footnotes. The ACC/AHA classifications I, II, and III are used to summarize indications as follows: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of …