Monitor

Goodbye medicine
Nearly half of physicians age 50 or older say they plan to leave medicine in the next one to three years, according to a new survey from Merritt, Hawkins & Associates. Thirty-eight percent plan to retire, and 12 percent plan to seek jobs in non-medical fields. Managed care and Medicare/Medicaid regulations were cited as their biggest professional frustrations; patient relationships were their greatest source of satisfaction.

Health care spending spree
National health care spending reached $1.1 trillion in 1998, an increase of 5.6 percent between 1997 and 1998, according to the Health Care Financing Administration (HCFA). The increase follows a period of sub-5-percent increases, which had been relatively good news for the industry. But the Employee Benefits Research Institute is suggesting that HCFA's calculations are too low. One example cited is that HCFA does not consider tax revenues spent on health care deductions. One thing both groups can agree on is that health care spending is once again on the rise.

State medical boards take on medical directors
A fast-growing number of state medical boards are seeking legislative or regulatory changes that will give them authority over health plan medical directors. The Texas Board of Medical Examiners is trying to become the second such entity to discipline a medical director for a preauthorization decision, but a lawsuit filed by United Healthcare on behalf of its medical director has stalled the board's efforts. At issue is whether the choice to pay for a treatment is a benefits determination or a medical necessity decision.

Flu shots from the PharmD
Patients in Massachusetts will soon be able to get flu shots from pharmacists participating in the state's pilot program designed to increase public access to immunizations, reports the Aug. 23 Boston Herald. The Massachusetts Medical Society has criticized the move, saying it will compromise patient safety in the case of adverse reactions and will establish a dangerous precedent allowing pharmacists to administer medications. Supporters argue it will reduce congestion at the doctor's office, increase immunization rates and be more convenient for patients.

In Medicare we trust
When asked whom they trusted most to insure adults their age, 50- to 70-year-olds ranked Medicare higher than both employer-based health plans and private insurance purchased individually, according to a survey conducted by the Commonwealth Fund. The survey also found that Medicare beneficiaries ages 65 to 70 were more likely than adults ages 50 to 64 to be very confident in their ability to obtain medical care when needed and to be satisfied with the quality of that care.

New Medicare resources
If your patients need information on Medicare that your office cannot provide, direct them to the free brochures available at http://www.medicare.gov/health/Overview.asp. Brochure topics range from an overview of Medicare benefits to a guide for choosing treatments. Patients without Internet access may request the brochures by calling 800-633-4227.

False credentials
Resume-bluffing continues to be a problem in all professions, including the health care industry, and a new breed of credential-checking firms have emerged in response, according to the Aug. 14 Boston Globe. One such firm in Massachusetts handles about 4,500 credential checks per year -- half of which are for the health care industry -- and claims to find "significant misinformation" in about a quarter of the cases.

Teaching compassion

Fearing that compassion in medicine is "perilously close to extinction," thanks to time pressures and high-tech health care, medical schools across the country are adding compassion to their curriculum, reports the Aug. 22 New York Times. A 1999 survey conducted for the Association of American Medical Colleges found that 85 percent of patients choose physicians based on their communication skills and caring attitude; however, these skills have often been neglected in academia.

To teach compassion, medical schools are taking a variety of approaches:

• At Harvard, first-year medical students are assigned to patients with life-threatening illnesses and are expected to develop ongoing relationships with the patient and family. If the patient dies, the student is encouraged to attend the funeral and grieve with the family.
• Students learn cultural competency at the University of Kansas by participating in overseas programs that connect them with individuals of diverse backgrounds.
• At the University of New Mexico, a panel of parents teaches pediatric students how to deliver bad news.
• Students at the Medical University of South Carolina College of Medicine participate in interactive seminars about faith, mindfulness and the power and limitations of the healer.
• At Pennsylvania State University College of Medicine, fourth-year students are offered an elective course in which they keep a daily spiritual log and report on a patient who has used religion to address a medical problem.

At the heart of these tactics, the goal is an improved focus on the patient. "What we don't want to happen is for you to forget the human element, the patient's story," says Nancy Angoff, associate dean of student affairs at Yale Medical School, speaking to medical students.

Practice Pearls

Delivering feedback

Employees need feedback, both positive and constructive, to help them do their jobs better. To give praise more effectively to your staff, try the following:

• Be prompt. Compliment the staff member on a good deed when it happens or shortly thereafter.
• Be specific. Acknowledge exactly what the staff member did (e.g., effectively calming an irate patient).
• Jot it down. When a staff member does a good job, acknowledge it and then write a note and put it in the personnel file. That way, you won't forget about it when it comes time for an annual review.
• Offer praise publicly. When you praise a staff member in front of other staff, it multiplies the effect and may motivate others.

To deliver criticism more effectively, try these tips:

• Do it privately. Don't discuss mistakes or bad behavior in front of other staff members. It can embarrass and demoralize the entire staff.
• Be specific. Pinpoint the error or behavior you want to correct and provide a concrete example.
• Don't attack. Control your anger and criticize the act, not the person.
• Be fair. Give a staff member the opportunity to explain his or her actions. Don't assume you know all the details.

-- Tell your employees how they're doing. The Physician's Advisory. Conshohocken, Pa: Advisory Publications. June 2000:6.

Group visits

Group visits, in which physicians see several patients with common conditions at one time, can benefit physicians and patients alike if they are done right. Here's how:

• Identify the target population and primary purpose of the visits. For example, you may want to use group visits to provide education and self-management support to patients who have diabetes.
• Facilitate, rather than dominate, the group visit. It should provide patients with an opportunity to interact and raise their specific areas of concern.
• Complete medical charting during the session. This can be accomplished by including a "break" time, during which you and your nurse circulate among the patients and update individual records.
• Develop appropriate outcome measures to gauge whether the visits are effective. These may include cost, quality, access, satisfaction or efficiency measures.

-- Noffsinger EB, Scott JC. Practical tips for establishing successful group visit programs. Group Pract J. 2000;49(6):31-37.

AIDS awareness for all

The CDC reports that over 10 percent of all new AIDS cases in the United States occur in people over age 50. To help prevent new cases, clinicians need to challenge assumptions that older people do not engage in risky behavior and should conduct thorough sex and drug-use risk assessments with patients over 50. Offer these patients the same support and education you offer others, for their own benefit and for younger generations who look to this group for leadership.

-- Center for AIDS Prevention Studies, University of California-San Francisco AIDS Research Institute. What are HIV prevention needs of adults over 50? Available at: www.caps.ucsf.edu/over50.html.

Copyright © 2000 by the American Academy of Family Physicians.
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