Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal

Background: Internet-based interactive websites for patient communication (patient portals) may improve communication between patients and their clinics and physicians.Objective: The aim of the study was to assess the impact of a patient portal on patients' satisfaction with access to their clinic and clinical care. Another aim was to analyze the content and volume of email messages and telephone calls from patients to their clinic.Methods: This was a randomized controlled trial with 606 patients from an academic internal medicine practice. The intervention '' porta '' group used a patient portal to send secure messages directly to their physicians and to request appointments, prescription refills, and referrals. The control group received usual care. We assessed patient satisfaction at the end of the 6-month trial period and compared the content of telephone and portal communications.Results: Portal group patients reported improved communication with the clinic (portal: 77/174 [44%] '' a little better '' or '' a lot better;'' control: 18/146 [12%]; chi(2) = 38.8, df = 1, P < .00 1) and higher satisfaction with overall care (portal: 103/174 [59%] '' very good '' or '' excellent;'' control: 78/162 [48%]; chi(2) = 4. 1, df = 1, P = .04). Portal group patients also reported higher satisfaction with each of the portal's services. Physicians received 1 portal message per day for every 250 portal patients. Total telephone call volume was not affected. Patients were more likely to send informational and psychosocial messages by portal than by phone. Of all surveyed patients, 162/341 (48%) were willing to pay for online correspondence with their physician. Of those willing to pay, the median amount cited was US $2 per message.Conclusions: Portal group patients demonstrated increased satisfaction with communication and overall care. Patients in the portal group particularly valued the portal's convenience, reduced communication barriers, and direct physician responses. More online messages from patients contained informational and psychosocial content compared to telephone calls, which may enhance the patient-physician relationship.

OBJECTIVE:To determine whether a brief previsit questionnaire about referral concerns can improve primary care provider (PCP) recognition of patient concerns and satisfaction with care.DESIGN:Sequential prospective study in the internal medicine clinic of an academic medical center providing primary care to patients enrolled in a gatekeeper-model managed care plan.PARTICIPANTS AND METHODS:Twelve faculty internists serving as PCPs for 1495 consecutive patient visits. Patients were given a previsit questionnaire asking about referral need and rationale and a postvisit questionnaire asking about discussion of referral concern and visit satisfaction. Providers were given a postvisit questionnaire asking whether a referral was discussed and made and about visit satisfaction. In the control phase, patient previsit questionnaires remained confidential, whereas in the intervention phase PCPs were shown the previsit questionnaires at the time of encounter.RESULTS:The intervention significantly increased PCP referral recognition from 61% to 81% (P < .001) and was associated with increased visit satisfaction (P = .05). Satisfaction of PCPs with the referral discussion, overall rate of referral, and visit duration were not affected by the intervention.CONCLUSIONS:Using a brief previsit questionnaire about patient referral concerns increases PCP recognition of such concerns. The intervention does not adversely affect PCP satisfaction with the referral discussion or the overall referral rate and may enhance patient visit satisfaction.

OBJECTIVE:We wanted to characterize patient accompaniment to medical encounters and to explore the rationale and influence of the companion on the primary care medical encounter.STUDY DESIGN:This was a descriptive study.POPULATION:Academic general internal medicine physicians, patients, and patient companions participated.OUTCOMES MEASURED:We measured the frequency of waiting and examination room companions, the reasons for accompaniment, the influence on the encounter, and the overall helpfulness of the companion as assessed by patients and companions. We also determined the physicianamprsquos assessment of the companionamprsquos influence, helpfulness, and behavior during the encounter.RESULTS:Companions were in the examination room for 16% of visits; 93% were family members. The rationales for waiting and examination room companions were to help with transportation, provide emotional support, and provide company. Examination room companions helped communicate concerns to the physician, remember the physicianamprsquos advice, make decisions, and communicate their own concerns to the physician. Patients believed that examination room companions influenced 75% of medical encounters, mainly by improving communication between physician and patient. Physicians agreed that examination room companions favorably influenced physician and patient understanding (60% and 46% of encounters, respectively). Patients indicated that waiting and examination room companions were very helpful for 71% and 83% of visits, respectively.CONCLUSIONS:Companions frequently accompany patients to their primary care medical encounters. They are often family members, and they assume important roles in enhancing patient and physician understanding.

PURPOSE: Ambulatory case Presentations occur typically in conference rooms, and attending physicians often have little contact with patients. The purpose of this study was to examine the effects of two different ambulatory case presentation formats that involve attending physicians more directly.SUBJECTS AND METHODS: We conducted two randomized controlled trials in a community-based ambulatory internal medicine clinic. Participants comprised 393 adult patients, 40 house officers, and 14 attending physicians. In the first trial, patient encounters were assigned randomly to either exclusive house officer-attending physician conference room discussion or to house officer-at tending physician conference room discussion plus attending physician-patient interaction. In the second trial, patient encounters were assigned randomly to either exclusive house officer-at tending physician conference room discussion or to exclusive house officer-at tending physician discussion in the examining room with the patient present. Patient satisfaction; attending physician contributions to teaching, diagnosis, and therapy; and house officer comfort and autonomy were assessed.RESULTS: Patient visit satisfaction and house officer assessment of attending physician teaching, diagnosis, and therapy were similar in the control and intervention groups of both trials. Patients involved in examination room discussions thought they were more comfortable with the discussion (mean +/- SD, 4.3 +/- 0.9 vs. 3.4 +/- 0.9 on a one- to five-point Likert scale, P <0.001) and more often indicated a preference to listen to the discussion in the future than did the control group (86% [71/83] vs. 63% [52/83], P <0.001). Some house officers (11% [9/83]) but no attending physicians (0/83, P <0.001) were made uncomfortable by examination room presentations, and some house officers (11% [9/83]) thought that examination room presentations diminished their autonomy.CONCLUSION: Patients perceive that ambulatory examination room presentations are beneficial, whereas some house officers perceive that examination room presentations are associated with discomfort and diminished autonomy. (C)2002 by Excerpta Medica, Inc.

Background: The residency recruitment and selection process is a critical one for residency programs and medical students. In 1999, internal medicine programs conducted the residency match on the Web for the first time using the Electronic Residency Application Service (ERAS).Purpose: The authors wished to study the impact of this change on house staff recruitment and quality of match.Method: A Web-based survey with e-mail, paper and fax reminders was sent to all 407 internal medicine residency programs after the 1999 match.Results: Eighty-six percent of reporting programs found the screening of applicants easier The overall number of applicants varied greatly (48% of programs reported more applicants; 32% reported fewer). The quality of final match was rated the same as previous years by 47%, better by 38%, and worse by 15%.Conclusions: The transition to ERAS was successful in internal medicine. However, there are several areas that were identified that will improve the ERAS process as it evolves.

Background. Medical students found to be deficient in communication and interview skills pose a difficult remediation challenge. There is no standard way to address such deficiencies. The authors describe the development and implementation of an intensive remedial curriculum.Description: A 2nd-year student found deficient in communication skills was held back for a year and paired with a clinical preceptor for intensive skills training, including a weekly precepted clinic, structured readings, standardized patient (SP) exercises, communications workshops, and end-of-year standardized clinical evaluations.Evaluation: The student's self-assessment and the preceptor's assessments of communication skill gradually improved over the year The student improved through a progression of SP exercises focusing on specific communication skills. The student passed a final evaluation exercise with an excellent rating from the SP and the preceptor.Conclusions: This multistrategy approach to improve communication skills can be applied to other students and in other institutions. Based on the Bayer Institute communication workshops and integrated coaching techniques, the material forms a framework to help deficient students to become proficient in communication and interviewing skills.

BACKGROUNDTime management in ambulatory patient visits is increasingly critical. Do patients who perceive a longer visit with internists report increased satisfaction?METHODSProspective survey of 1486 consecutively encountered ambulatory visits to 16 primary care physicians (PCPs) in an academic primary care clinic. Patients were queried regarding demographics, health status, perception of time spent before and after ambulatory visits, whether the physician appeared rushed, and visit satisfaction. Physicians were queried regarding time spent, estimated patient satisfaction, and whether they felt rushed.RESULTSIn 69% of 1486 consecutive visits, patient previsit expectation of visit duration was 20 minutes or less. Patient and PCP postvisit estimates of time spent significantly exceeded patient previsit time expectation. Patients who estimated that they spent more time than expected with the PCP were significantly more satisfied with the visit. When patient postvisit estimate of time spent was less than the previsit expectation, visit satisfaction was significantly lower independent of time spent. Patient worry about health and lower self-perceived health status were significantly associated with patient expectation for longer visits. Primary care physicians felt rushed in 10% of encounters. Although PCPs estimated patient satisfaction was significantly lower when they felt rushed, patient satisfaction was identical when PCPs did and did not feel rushed. Patients indicated that PCPs appeared rushed in 3% of encounters, but this perception did not affect patient satisfaction.CONCLUSIONPerceived ambulatory visit duration and meeting or exceeding patient expectation of time needed to be spent with the physician are determinants of patient satisfaction in an ambulatory internal medicine practice.

Objective: With the introduction of the Electronic Residency Application Service (ERAS) for internal medicine programs in 1999, residency directors needed to use its categories of information. We examined which factors in the applicant's file were most useful to residency program directors in deciding about interview invitations and ranking candidates. Description: In conjunction with the Association of Program Directors in Internal Medicine (APDIM), we undertook a Web-based survey of all 407 program directors in internal medicine. An e-mail message containing a direct Internet link to the survey was distributed to all APDIM listserve members. The response rate was increased by personalized e-mails, letters, and faxed requests to the directors. We received 332 responses (81.5%). All data were down-loaded into SAS for analysis. On the survey, programs categorized themselves by type of program (university, community), size, and geographic location. They rated the usefulness of dean's letters, personal statements, transcripts, application forms, USMLE scores, and chairman's letters for making decisions about interview invitations and ranking applicants. Applicant interview was an additional variable for ranking applicants. In rating usefulness, respondents could choose highly, moderately, mildly, and not. Optional text boxes for comments were provided. The items rated highly or moderately useful for interview decisions were USMLE scores (94%), dean's letters (87%), transcripts and application forms (85%), chairman's letters (79%), and personal statements (61%). The items rated highly or moderately useful for ranking decisions were applicant interviews (96%), USMLE scores (93%), transcripts (83%), dean's letters (82%), chairman's letters (77%), application forms (74%), and personal statements (57%). Chi-square analysis by program type was done with the interview and ranking criteria. A logistic regression model was developed with program type as outcome, and three applicant-ranking criteria (transcripts, chairman's letters, and USMLE scores) using 322 observations. The overall p value (.0001) indicated that the predictors reliably distinguished between university and community programs. The university programs were 0.70 times as likely to rate transcripts more useful than community programs (−0.68, −0.057, confidence limits, p =.02); they also were 0.70 times as likely to rank the chairman's letter as useful (−.68, −.085, p =.01). However, community programs were 1.7 times as likely as university programs to rank USMLE scores as useful (0.22, 0.93, p =.001). Discussion: USMLE scores are consistently important since they allow programs to make objective comparisons between applicants. Community programs found these scores more useful than did university programs, which found transcripts and chairman's letters more useful. With ERAS, programs can filter pass/fail on USMLE, but filtering by score is not possible. While personal statements often reveal unique individual characteristics, they are seen as the least useful information and are harder to evaluate. The interview is an opportunity to assess personal characteristics and is critical for determining candidates' suitability. Comments revealed that while dean's letters are seen as useful, many programs start inviting candidates for interviews before the letters are released. In addition, the considerable variability in quality of these letters was noted, as was the redundancy between dean's and chairman's letters. This information about the way ERAS information is being used will be of interest to residency directors and applicants.

OBJECTIVE: To determine the frequency and determinants of provider nonrecognition of patients’ desires for specialist referral. DESIGN: Prospective study. SETTING: Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan. PARTICIPANTS: Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits. MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients’ referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P<.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P<.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered “not indicated” by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred. CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients’ referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire.

OBJECTIVETo test the hypothesis that there is substantial use of a practitioner of alternative/complementary medicine by patients traditionally considered to be underserved.DESIGNCross-sectional, self-administered survey study.SETTINGSThree university hospital-affiliated general ambulatory clinics serving patients of different socioeconomic status and racial origin.SUBJECTSFive hundred and thirty-six (93% of those attending) consecutive clinic attendees.OUTCOME MEASURESPast use and desired future use of one or more practitioners of five modalities of alternative/complementary medicine and willingness to pay for these modalities out-of-pocket.RESULTSPast usage and desired future usage of one or more practitioners of alternative/complementary medicine was comparable at the three clinic sites despite wide differences in socioeconomic status and willingness/ability to pay out-of-pocket for these services. Multivariable analyses revealed lower self-rated health status and female gender (both p < 0.006) but not income, race, age or education as independent, significant predictors of use of a practitioner of alternative/complementary medicine.CONCLUSIONUsage of alternative/complementary medicine is not confined to any well-circumscribed socioeconomic group and is common in patients often considered to be underserved. Self-assessed lower health status is significantly and independently associated with use of a practitioner of alternative/complementary care.

OBJECTIVE:To describe patient desire and reasons for specialist referrals in a gatekeeper-model managed care plan.STUDY DESIGN:Cross-sectional prospective study.PATIENTS AND METHODS:We developed a patient questionnaire to gather demographic data and to gauge patients' desire for specialist referral and their reasons for seeking such referral. The survey was administered at 2 sites--an ambulatory care facility of a university hospital and an internal medicine clinic in a suburban ambulatory care site. Patients asked to complete the questionnaire at the university hospital site were enrolled in a gatekeeper-model managed care plan (called CU Gold); those seen at the internal medicine clinic were enrolled in a group-model health maintenance organization. Patients were asked to complete the 1-page questionnaire in the waiting room before being seen by their primary care physician.RESULTS:Among the 860 CU Gold patients who met the inclusion criteria during the 3-month study period (September to December 1997), 112 (13%) reported a definite desire to see a specialist and 274 (32%) indicated a possible desire to see a specialist at the time of their primary care visit. Compared with the CU Gold patients, significantly fewer patients in the health maintenance organization indicated a definite desire to see a specialist (3% versus 13%), but a similar percentage expressed a possible desire to see a specialist (30% versus 32%). The difference in definite desire for referral between the 2 groups could not be explained by patient or primary care physician characteristics. The principal health concerns for which patients sought referral were musculoskeletal, genitourinary or gynecologic, or dermatologic problems. Need for reassurance (cited by 67% of patients), seeing a specialist before (56%), and believing the primary care physician lacked expertise (49%) were the primary reasons patients sought referral. Seventy-four percent of patients referred by their primary care provider and 54% of those not referred agreed it was a good idea to see their primary care physician first before seeing a specialist.CONCLUSIONS:Patients have a significant desire for specialist referral, driven by their need for reassurance, previous specialist referral, and belief that their primary care physician does not have the requisite expertise. Patients' expectations for referral varied significantly, depending on the healthcare system (academic primary care clinic or health maintenance organization) in which they were enrolled.

OBJECTIVE: To determine the frequency and determinants of provider nonrecognition of patients’ desires for specialist referral. DESIGN: Prospective study. SETTING: Internal medicine clinic in an academic medical center providing primary care to patients enrolled in a managed care plan. PARTICIPANTS: Twelve faculty internists serving as primary care providers (PCPs) for 856 patient visits. MEASUREMENTS AND MAIN RESULTS: Patients were given previsit and postvisit questionnaires asking about referral desire and visit satisfaction. Providers, blinded to patients’ referral desire, were asked after the visit whether a referral was discussed, who initiated the referral discussion, and whether the referral was indicated. Providers failed to discuss referral with 27% of patients who indicated a definite desire for referral and with 56% of patients, who indicated a possible desire for referral. There was significant variability in provider recognition of patient referral desire. Recognition is defined as the provider indicating that a referral was discussed when the patient marked a definite or possible desire for referral. Provider recognition improved significantly (P<.05), when the patient had more than one referral desire, if the patient or a family member was a health care worker and when the patient noted a definite desire versus a possible desire for referral. Patients were more likely (P<.05) to initiate a referral discussion when they had seen the PCP previously and had more than one referral desire. Of patient-initiated referral requests, 14% were considered “not indicated” by PCPs. Satisfaction with care did not differ in patients with a referral desire that were referred and those that were nor referred. CONCLUSIONS: These PCPs frequently failed to explicitly recognize patients’ referral desires. Patients were more likely to initiate discussions of a referral desire when they saw their usual PCP and had more than a single referral desire.