ECADES OF RESEARCH HAVEconfirmed that poor skills in patient communication are associated with lower levels of patient satisfaction, higher rates of complaints, an increased risk of malpractice claims, and poorer health outcomes. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Medical schools have responded by incorporating training in patient communication and clinical skills into the curriculum. However, these skills were not systematically evaluated, nor was a minimum level of proficiency required for medical licensure. 17 To address this problem, licensure reforms were undertaken in North America. 18 The Medical Council of Canada (MCC) (1993), 19 the Educational Commission for Foreign Medical Graduates (1998), 20 and most recently the United States Medical Licensing Examination (USMLE) ( 2004) 21 have all introduced a clinical skills examination (CSE)-a nationally standardized assessment of patient-physician communication, clinical history taking, and examination skills-as a requirement for licensure. All US and Canadian medical For editorial comment see p 1057.

Background: a physician' s personal and professional characteristics constitute only one, and not necessarily the most important, determining factor of clinical performance. our study assessed how physician, organizational and systemic factors affect family physicians' performance. Method: our study examined 532 family practitioners who were randomly selected for peer assessment by the College of Physicians and surgeons of ontario. a series of multivariate regression analyses examined the impact of physician factors (e.g., demographics, certification) on performance scores in five clinical areas: acute care, chronic conditions, continuity of care and referrals, well care and records. a second series of regressions examined the simultaneous effects of physician, organizational (e.g., practice volume, hours worked, solo practice) and systemic factors (e.g., northern practice location, community size, physician-to-population ratio). Results: our study had three key findings: (a) physician factors significantly influence performance but do not appear to be nearly as important as previously thought; (b) organizational and systemic factors have significant effects on performance after the effects of physician factors are controlled; and (c) physician, organizational and systemic factors have varying effects across different dimensions of clinical performance. Conclusions: We discuss the implications of our results for performance improvement and physician governance insofar as both need to consider the broader environmental context of medical practice.

Doctor scores on qualifying examinations are significant predictors of quality-of-care problems based on regulatory, practice-based peer assessment.

Eight nurse practitioners were interviewed to determine their perception of the quality of care provided to patients with multimorbidity at NPLCs. Interpretive description guided the analysis and themes were identified. Findings Three themes arose from the analysis, each of which has an impact on the quality of care. The level of patient vulnerability at the NPLCs was high resulting in the need to address social and financial issues before the care of chronic conditions. Dynamics within the interprofessional team impacted the quality of patient care, including NP recruitment and retention, leaves of absence and turnover in staff at the NPLCs had an effect on interprofessional team functioning and patient care. Finally, coordination of care at the NPLCs, such as length of appointments, determined the extent to which attention was given to individual clinical issues was a factor. Strategies to address social determinants of health and for recruitment and retention of NPs is essential for improved quality of care. Comprehensive orientation to the interprofessional team as well as flexibility in care processes may also have positive effects on the quality of care of patients with complex clinical issues.