In anticipation of an expected national shortage of primary care physicians, 24 medical students from the East Tennessee State University Quillen College of Medicine were selected through a snowball sample and participated in in-depth interviews. A major aim of the study was to explore the social and economic factors influencing students’ specialty choice and career interests. Students’ perceptions of “rural” environments, student debt, professional obligations, specialties, and preceptorship experiences were analyzed. Students’ gender heavily influenced their feelings about choosing a medical specialty, as did their stereotypes of physicians in particular medical fields. The thesis concludes with recommendations for challenging negative stereotypes about primary care professions and addressing patterns of inequality within the medical profession.

Indiana University-Purdue University Indianapolis (IUPUI) / Policy and natural shocks are exogenous factors, which may disrupt patients’ ability to access recommended health care. My dissertation investigates the effect of recent natural and policy shocks in health care provision on different patient outcomes. The first chapter studies the effect of the 2014 Ebola virus epidemic in West Africa on maternal health care utilization and infant health in Sierra Leone. The Epidemic resulted in the diversion of the limited health care resource away from other services to care for Ebola patients. It also led to maternal stress from fear of infection and community breakdown. The results show the outbreak led to significant decline in maternal health care utilization and infant birth weight. The second chapter examines whether physician practices that are vertically integrated with hospitals provide healthcare at higher costs than non-integrated practices in a Medicare patient population. The degree of integration is exogenously assigned to a patient following a geographical move. The study finds that switching to integrated practice increases health care utilization and spending. Although integration may increase quality of care, the increase in spending suggests the need for a continuing attention to policies and incentives that are associated with integration. Finally, the third chapter documents the impact of the recent changes in state medical and recreational cannabis access laws in the United States on health care utilization. The liberalization of access to cannabis may enable patients to substitute cannabis for another prescription and non-prescription health care services. The results show a significant decline in the utilization of emergency and outpatient services among patients with chronic pain for the states that legalized cannabis. The effect is mainly due to medical cannabis laws, whereas the effect of recreational cannabis is ambiguous. The three chapters, taken together, show that exogenous shocks, such as natural shocks and government policy, affect health care utilization and the health of individuals. Health policies should, therefore, target developing a resilient health care system that withstands natural shocks and promote policies that provide better treatment alternatives.

OBJECTIVES: Tools are needed for determining appropriate weights for complex performance assessment components in medical education. The feasibility of using judgmental policy capturing (JPC), a procedure to statistically describe the information processing strategies of experts, for this purpose was investigated. METHODS: Iterative JPC was used to determine appropriate weighting for the six core communication skill scores from a communications objective structured clinical examination (OSCE) for medical students using a panel of four communication skill experts. RESULTS: The mean regression weights from the panel indicated they placed less importance on information management (8.5%), moderate and nearly equal importance on rapport building (15.8%), agenda setting (15.4%), and addressing feelings (14.1%), and greater importance on active listening (20.1%) and reaching common ground with the patient (25.5%). DISCUSSION: JPC is an effective procedure for determining appropriate weights for complex clinical assessment components. The derived weights may be very different for those assessment components.

Research has shown that female physicians continue to earn less than their male counterparts. From both social justice and feminist perspectives, laws requiring equal pay should provide just income for females as compared to males. However, the literature continues to indicate that in general females earn less than males, a trend that is also true for physicians. Theoretically informed postulates are measured here with structural equation modeling to test the influence of the unique latent construct "specialization" on the income gap while controlling for demographic and contextual variables. The analysis tests the assumption that the influence of specialization is the same for females and males. If the influence of specialization and other variables differs by gender, gender bias in physician income may be conceptually implied. The study uses three waves of data from the Community Tracking Study Physician Survey (CTS). The study finds an income gap between females and males in three waves of the CTS. Gini coefficients show females continue to experience greater income inequality than males, with the Lorenz curves for males being closer to the equality lines. Using 1999 income data, there is a statistically significant income gap between female and male physicians when controlling for weeks worked. Information Technology (IT) use was found to be the most reliable construct measuring the unique latent variable specialization. Structural equation modeling showed indicators of specialization have an influence on the income gap. The variables in the CTS Physician Survey made for a poor construct that failed to measure specialization as a uni-dimensional construct. The variables that influence the income gap were different for females than for males. As policy makers revise or create better laws to protect income equality, gender differences must be taken into consideration.

The purpose of this research study is to examine the effect of public information sources on an individual's satisfaction with the search process undertaken to select a physician. A quasiexperimental research design was adopted to randomly divide the medical staff of a large central Florida medical group into control and intervention groups of approximately 77 physicians each. The intervention involved insertion of the website address to online physician report cards on to each intervention group physician’s profile in the physician directory on the medical group's website. After two months, data were collected consisting of all individuals who had scheduled first-time appointments with one of the medical group's physicians during the two-month intervention period. A random sample of patients was drawn from each group and sample members were mailed a 62-item questionnaire along with a cover letter, summary of the research and postage-paid reply envelope. A total of 706 questionnaires were mailed and 61 completed questionnaires were returned, an 8.64% response rate. Intent-to-treat analysis was conducted using independent-samples t-tests to compare the research study’s continuous variables' mean scores for control and intervention group participants. The analysis revealed no significant difference in scores for control and intervention groups with the exceptions that the control group was somewhat more committed to conducting a search and selecting a new physician. The control group said the physician's communications skills influenced their satisfaction with the search and selection of a new physician quite a lot while the intervention group said physician communication skills somewhat influenced their satisfaction with search and selection. iv Results of the covariance structure analysis demonstrated that information use and level of commitment to search and select a new physician independently predict search satisfaction. As information use and search commitment increase, a patient's satisfaction with the search increases as well. Furthermore, as information use increases, the variety of information sources relied upon or used also increases. The findings support the alternative hypothesis that the positive or direct effect of physician report cards is demonstrated in the time and cost of patient search for a physician for both intervention and control groups. One other alternative hypothesis was partially supported, i.e., the effect of household income is confirmed in patient search and satisfaction in selecting a physician. The alternative hypotheses that proposed that physician report cards are more likely to be used to search for a medical specialist and that physician experience, office location and accepted insurance effect patient search and selection of a physician were not tested. Two other alternative hypotheses were rejected. The research findings also indicated that predictors of health care information search satisfaction vary based upon the environment and contextual factors in which the search is conducted.

A positive physician-patient relationship is crucial for high quality and effective health care. Yet, cultural and language differences between providers and patients often challenge the establishment of effective physician-patient relationships. These challenges are especially evident in provider-refugee-patient interactions in which patients have experienced loss, torture, and trauma. Understanding of what constitutes a positive doctor-patient relationship is fundamental to diagnosis and treatment and is crucial for the delivery of quality care for diverse patient populations, including refugees. This qualitative, phenomenological case-study focuses on physician-reported experiences caring for refugees in order to identify what experiential factors contribute to effective therapeutic relationships.

Introduction: Medication errors are a major cause of illness and hospitalization of patients throughout the world. This study examines the situation regarding medication errors in the Armed Forces Hospital, Kuwait since no literature exists of any such studies for this country. Several types of potential errors were studied by physicians, nurses and pharmacists. Their attitudes to the commission of errors and possible consequences were surveyed using questionnaires. Additionally, patient medical records were reviewed for possible errors arising from such actions such as the co-administration of interacting drugs. Methods: This study included direct observations of physicians during the prescribing process, pharmacists while they dispensed medications and nurses as they distributed and administered drugs to patients. Data were collected and compiled on Microsoft Excel spreadsheet and analyses were performed using SPSS. Where applicable, results were reported as counts and/ or percentages of error rates. Nurses, pharmacists and physicians survey questionnaires: From the 200 staff sent questionnaires a total of 149 respondents comprising nurses (52.3%), physicians (32.2%) and pharmacists (16.1%) returned the questionnaires a total response rate of 74.5%. All responses were analyzed and compared item-by-item to see if there were any significant differences between the three groups for each questionnaire item. All three groups were most in agreement about their perception of hospital administration as making patient safety a top priority with regard to communicating with staff and taking action when medication errors were reported (all means 3.0 and p > 0.05). Pharmacists were most assured of administration support when an error was reported whereas nurses were least likely to see the administration as being supportive ( p < 0.001), and were more afraid of the negative consequences associated with reporting of medication errors (p = 0.026). Although nurses were generally less likely to perceive themselves as being able to communicate freely regarding reporting of errors compared to pharmacists there was no significant difference between the two groups. Both however were significantly different from physicians (p< 0.001). Physicians had the most favorable response to perceiving new technology as helping to create a safer environment for patients and to the full utilization of such technologies within the institution in order to help prevent medical errors. Scenario response - Responses to two scenarios outlining possible consequences, should a staff member commit a medication error, tended to be very similar among the three groups and followed the same general trend in which the later the error was discovered and the more grievous the patient harm, the more severe would be the consequences to the staff member. Interestingly, physicians saw themselves as less likely to suffer consequences and nurses saw themselves as more likely to suffer consequences should they have committed a medication error. All three groups were more likely to see themselves as facing dismissal from their job if the patient were to die. RESULTS OF ALL THREE OBSERVATIONS: Result of Nursing observations: For 1124 doses studied, 194 resulted in some form of error. The error rate was 17.2% and the accuracy was 82.8%. The commonest errors in a descending order were: wrong time, wrong drug, omission, wrong strength/ dose, wrong route, wrong instruction and wrong technique. No wrong drug form was actually administered in the observational period. These were the total number of errors observed for the entire month period of the study. IV Result of Pharmacist observations: A total of 2472 doses were observed during the one month period. Observations were done for 3 hours per day each day that the study was carried out. The study showed that there were 118 errors detected which were in the following categories respectively: 52 no instructions, 28 wrong drug/unordered, 21 wrong strength/dose, ignored/omission 13, shortage of medication 3 and expired date 1. Result of Prescribers in Chart review for drug-drug interactions: The analysis of the drug-drug interactions showed that out of a total of 1000 prescriptions, 124 had drug-drug interactions. None were found to fall into the highest severity rating i.e. 4 (contraindicated). Only twenty-one interactions were rated 3 (major), 87 interactions were rated moderate and 15 interactions were rated minor according the modified Micromedex scale. Patient education: All health care such as physician, pharmacist, and nurses have a responsibility to educate patient about their medication use and their health conditions to protecting them from any error can occur by wrong using drugs. Conclusion This study has contributed to the field of medication errors by providing data for a Middle Eastern country for the very first time. The views and opinions of the nurses, pharmacists and physicians should be considered to enhance the systems to minimize any errors in the future.

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