Many observers have been concerned about a mismatch between the knowledge, skills, and professional values of newly trained physicians and the requirements of current and future medical practice. We surveyed and interviewed Kaiser Permanente's clinical department chiefs for internal medicine, pediatrics, general surgery, and obstetrics/ gynecology to ascertain their views of the perceived gaps in the readiness of newly trained physicians. Nearly half of those surveyed reported deficiencies among new physicians in managing routine conditions or performing simple procedures often encountered in office-based practice. A third of the chiefs noted deficiencies in coordinating care for patients. Filling these and other training gaps will require changes at many levelsfrom residency programs to Medicare reimbursement policies-to better prepare new physicians for the challenges of working in a health care system evolving to emphasize accountability, quality outcomes, cost control, and information technology.
The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.
We present a model of hypothesized relationships between physician satisfaction, physician well-being and the quality of care, in addition to a review of relevant literature. The model suggests that physicians who are stressed, burned out, depressed, and/or have poor self-care are more likely to be dissatisfied, and vice-versa. Both poor physician well-being and physician dissatisfaction are hypothesized to lead to diminished physician concentration, effort, empathy, and professionalism. This results in misdiagnoses and other medical errors, a higher rate of inappropriate referrals and prescriptions, lower patient satisfaction and adherence to physician recommendations, and worse physician performance in areas not observed by others. Research to date largely supports the model, but high quality studies are few. Research should include studies that are prospective, larger, and have a stronger analytic design, ideally including difference in differences analyses comparing quality of care for patients of physicians who become dissatisfied to those who remain satisfied, and vice versa.
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