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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_422"
                     title="Nurses Often Silent About Workplace Violence (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/tb/18335?impressionId=1265715240512"
                     
      The physical and verbal abuse nurses face on the job often goes unreported, according to an Australian survey.&lt;br&gt;
&lt;br&gt;Over the prior year, 52% of nurses in one community hospital said they had been physically assaulted and 69% reported being threatened with violence, according to Rose Chapman, PhD, of the University of Western Australia in Perth, and colleagues.&lt;br&gt;
&lt;br&gt;Verbal abuse was almost universal, being reported by 92% of respondents, the researchers wrote in the February issue of the &lt;em&gt;Journal of Clinical Nursing&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;However, only half mentioned the incidents to senior staff or co-workers, and just 16% filed an official report.&lt;br&gt;
&lt;br&gt;&quot;The reasons for not reporting are many and may include lack of time and management support and the belief that being attacked is &apos;just part of the job,&apos;&quot; they wrote.&lt;br&gt;
&lt;br&gt;The same is true in the U.S., where assaults and under-reporting appear just as common as suggested in the Australian survey, commented Kathleen M. McPhaul, PhD, RN, MPH, of the University of Maryland School of Nursing in Baltimore, who has been involved in such research in the U.S.&lt;br&gt;
&lt;br&gt;A culture change would likely be needed to make a real difference for nurses, Chapman&apos;s group suggested.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Hospitals would have to ensure that nurses have necessary support, education, encouragement, and time to complete official reports. Nurses who report abuse should get positive feedback from all levels of nursing, they said.&lt;/p&gt;
&lt;p&gt;&quot;If administrators and governments are serious in their intention to reduce workplace violence and provide staff with safe work environments, they should be seen to act on all reported [incidents],&quot; which is rare today, Chapman&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;However, currently there&apos;s no strong lever or incentive to address this kind of workplace abuse since hospitals focus mainly on patient safety as part of accreditation, and national and state workplace safety organizations have little mechanism for monitoring such incidents, McPhaul noted.&lt;/p&gt;
&lt;p&gt;The researchers&apos; survey was intended to reach all 332 nurses working at one nontertiary hospital across all departments  --  emergency, medical, surgical, maternity, pediatric, and mental health.&lt;/p&gt;
&lt;p&gt;The 113 nurses who responded were mainly women in their early 40s who worked part time.&lt;/p&gt;
&lt;p&gt;Among them, about three-quarters reported at least one incident of workplace violence over the preceding 12 months  --  25% said it occurred weekly, 27% said monthly, and for 25% it was rarer, at once every six months. &lt;ul&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Fully 30% of the nurses said they had been involved in an episode involving a weapon  --  often hospital equipment and more rarely a knife or gun.&lt;/p&gt;
&lt;p&gt;The number of total incidents was lowest among nurse midwives, with a mean of 1.67 per year.&lt;/p&gt;
&lt;p&gt;Not surprisingly, the rate was highest among emergency department and mental health staff, who reported an average of 46.43 and 40.39 episodes over 12 months.&lt;/p&gt;
&lt;p&gt;One reason behind the high risk in these two departments may be the &quot;shift to a community-based approach to mental health care and a reduction in mental health beds&quot; such that the same psychiatric patients that assault mental health department nurses are mainstreamed to the emergency department as their point of entry to the hospital, the researchers said.&lt;/p&gt;
&lt;p&gt;However, more years of experience or higher educational qualification didn&apos;t appear to protect nurses. Senior nurse unit managers and clinical nurse specialists actually reported more physical assaults than less senior nurses.&lt;/p&gt;
&lt;p&gt;Age and gender didn&apos;t predict occurrence or type of incident either.&lt;/p&gt;
&lt;p&gt;When nurses did report workplace violence or verbal abuse, it was most often to their immediate manager (29%), other senior nursing staff (14.5%), or to their friends and colleagues (6%).&lt;/p&gt;
&lt;p&gt;Overall, 30% of nurses who responded to the survey gave as their reason for not reporting that workplace violence happens all the time and is simply part of the job.&lt;/p&gt;
&lt;p&gt;Even among those who did make a report of some sort, half said they thought hospital management failed to act on it.&lt;/p&gt;
&lt;p&gt;In fact, when the researchers audited hospital records, they found that 42 official incident reports had been filed by nurses over the prior one year period, nearly always involving injuries.&lt;/p&gt;
&lt;p&gt;In 95% of the cases, the only action taken by the hospital was making staff in the area aware of the incident. No other actions had been documented.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the voluntary nature and limited scope of the study may have limited generalizability, although the occurrence of violence against nurses is likely similar across developed countries.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers provided no information on conflicts of interest.&lt;/p&gt;&lt;p&gt;McPhaul reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_287"
                     title="COLUMN: Outliers: The Story of Success"
                     score="0.004"
                     href="http://www.medpagetoday.com/Columns/18148?impressionId=1265715240512"
                     
      &lt;p&gt;Popular author Malcolm Gladwell has become something of a fixture on the healthcare speaking circuit and it&apos;s easy to understand why. Taken collectively, his books go further than most in explaining the factors that influence and facilitate societal change.&lt;/p&gt;
&lt;p&gt;In his groundbreaking book, &lt;em&gt;The Tipping Point&lt;/em&gt;, Gladwell challenged  --  and eventually changed  --  the way we understand the world. He contends that one imaginative person applying a well-placed lever can move the world.&lt;/p&gt;
&lt;p&gt;His second book, &lt;em&gt;Blink&lt;/em&gt;, examined the power of intuition and its influence on our thinking. One concept that particularly struck me was the idea of &quot;thin slicing&quot;  --  filtering the few factors that matter from an overwhelming number of variables. In the context of medical malpractice, Gladwell advises readers to &quot;thin slice&quot; new physicians, trusting their intuition if they sense a physician is not listening to them.&lt;/p&gt;
&lt;p&gt;Gladwell has done it again! His newest book, &lt;em&gt;Outliers&lt;/em&gt;, is destined to transform the way we understand success.&lt;/p&gt;
&lt;p&gt;In &lt;em&gt;Outliers&lt;/em&gt;, Gladwell explains the extraordinary success of the Beatles and Bill Gates in the context of generation, family, culture, and class. The lives of these Outliers  --  people whose achievements fall outside normal experience  --  actually follow a peculiar and unexpected logic, suggesting that context and background matter a great deal.&lt;/p&gt;
&lt;p&gt;How does this apply to healthcare? The answer is in a chapter entitled, &quot;The Ethnic Theory of Plane Crashes.&quot;&lt;/p&gt;
&lt;p&gt;In the late 1990s, Korean Air was internationally admonished following a series of dramatic cockpit failures and subsequent crashes. Multiple investigations led to the same conclusion: poor cockpit communication, rooted in deep cultural barriers, led to circumstances that became deadly.&lt;/p&gt;
&lt;p&gt;The chapter discusses three important messages regarding communication: mitigation, crew resource management (CRM), and a concept known as the power distance index (PDI).&lt;/p&gt;
&lt;p&gt;Mitigation is a term used by linguists to describe an attempt to downplay or sugarcoat the meaning of what is being said. According to Gladwell, &quot;We mitigate when we&apos;re being polite, when we are ashamed or embarrassed, and when we are being deferential to authority.&quot;&lt;/p&gt;
&lt;p&gt;Although mitigation may be appropriate or even desirable in some situations, it can be disastrous in a cockpit on a stormy night, or an operating room or trauma bay. For the past 15 years, combating mitigation has been a major crusade in commercial aviation.&lt;/p&gt;
&lt;p&gt;Gladwell contends that the unprecedented decline in airline accidents in recent years is attributable, in part, to this war on mitigation.&lt;/p&gt;
&lt;p&gt;CRM training is designed to teach junior crew members how to communicate clearly and assertively in order to reduce dangerous mitigation. Airlines teach copilots how to challenge the pilot if he or she thinks something is going awry.&lt;/p&gt;
&lt;p&gt;For example, the copilot might begin with &quot;Captain, I&apos;m concerned about...,&quot; then proceed to &quot;Captain, I&apos;m uncomfortable with...,&quot; and if the Captain still doesn&apos;t respond, &quot;Captain, I believe this situation is unsafe.&quot;&lt;/p&gt;
&lt;p&gt;Today, CRM is also playing a major role in efforts to improve healthcare quality and safety.&lt;/p&gt;
&lt;p&gt;One staunch proponent is John Nance, a decorated Vietnam pilot, attorney, and author of &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt;, a clever book depicting a fictional hospital wherein the tenets of CRM have been completely internalized by the administrative leadership, medical staff, and all front-line caretakers.&lt;/p&gt;
&lt;p&gt;The third key communication concept outlined in &lt;em&gt;Outliers&lt;/em&gt;, PDI, is one aspect of a model developed by Dutch psychologist, Geert Hofstede. It is rooted in cross-cultural psychology and concerns attitudes toward hierarchy, especially those relating to how much a particular culture values and respects authority.&lt;/p&gt;
&lt;p&gt;In cultures with low PDI, power holders try to underplay their power. In cultures with high PDI, the leader&apos;s authority is unassailable.&lt;/p&gt;
&lt;p&gt;Gladwell relates the impact of Hofstede&apos;s findings on aviation industry research. Their battle over mitigated speech and teamwork was actually an attempt to reduce power distance in the cockpit! He notes that Hofstede&apos;s work &quot;suggested something that had not occurred to anyone in the aviation world; that the task of convincing first officers to assert themselves was going to depend ... on their culture&apos;s power distance rating.&quot;&lt;/p&gt;
&lt;p&gt;So, what does PDI have to do with healthcare? I think that lowering the PDI  --  by means as simple as introducing one another and referring to one another by first names  --  can be helpful in improving communication on patient rounds, the intensive care unit, and elsewhere in the hospital setting.&lt;/p&gt;
&lt;p&gt;Surely, this may be provocative and threatening to the status quo. It might not work everywhere, but solid ethnographic research has concluded that when things go awry in a cockpit it is much easier to address a captain by his first name than by his title.&lt;/p&gt;
&lt;p&gt;I am not suggesting that we must suddenly become buddies on rounds, but knowing who is who and taking a moment to recognize everyone&apos;s role on the team would go a long way to improving communication  --  and, perhaps, clinical outcomes.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;Gladwell&apos;s books, and their provocative messages regarding how we think, challenge many of the tightly held, seemingly scientific aspects of our clinical decision-making at the bedside.&lt;/p&gt;
&lt;p&gt;But irrespective of varying reactions to &lt;em&gt;Outliers&lt;/em&gt;, I believe it would enhance our individual and collective ability to improve communication if we knew a little bit more about CRM and PDI.&lt;/p&gt;
&lt;p&gt;Maybe &lt;em&gt;Outliers&lt;/em&gt; and &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt; should be required reading for every medical student and house officer as a part of the training experience.&lt;/p&gt;
&lt;p&gt;Could the way we address one another have an impact on clinical outcomes? If this is the case  --  and I believe it is  --  we should learn how to communicate appropriately in a simulated training environment so that it becomes routine in the hurly burly of everyday work.&lt;/p&gt;
&lt;p&gt;Gladwell asks why it is so difficult to acknowledge the fact that each of us comes from a culture with its own distinctive mix of strengths and weaknesses, tendencies, and predispositions. &quot;Who we are cannot be separated from where we are from  --  and when we ignore that fact, planes crash.&quot;&lt;/p&gt;
&lt;p&gt;And patients die.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Want More on Health Policy?&lt;/strong&gt; &lt;a href=&quot;http://nashhealthpolicy.blogspot.com/&quot; mce_href=&quot;http://nashhealthpolicy.blogspot.com/&quot; target=&quot;_blank&quot;&gt;Read David Nash&apos;s blog&lt;/a&gt;.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_228"
                     title="Nurses Should Have a Bigger Leadership Role in Healthcare"
                     score="-0"
                     href="http://www.medpagetoday.com/PracticeManagement/StaffingScheduling/tb/18080?impressionId=1265715240512"
                     
      &lt;p&gt;Opinion leaders across a wide variety of groups think nurses should have more influence in health policy, planning, and management, according to a new Gallup survey.&lt;/p&gt;
&lt;p&gt;Although nurses are viewed as being the most valued source of health information behind physicians, survey respondents rank them as the least likely of healthcare stakeholders  --  including patients  --  to have a great deal of influence in healthcare reform over the next 10 years.&lt;/p&gt;
&lt;p&gt;This despite the fact that among the 1,504 thought leaders in academia, insurance, health services, government, industry, and the corporate world polled, 51% said nurses are very important in reducing medical errors and improving patient safety, and 50% said they are very influential in improving the quality of patient care.&lt;/p&gt;
&lt;p&gt;The major barriers to increased nurse influence, nearly 70% of respondents said, are perceptions that they are lower on the totem pole than physicians when it comes to decision-making and revenue generation.&lt;/p&gt;
&lt;p&gt;When asked what could be done to ensure that nurses take on more leadership responsibility, the first priority, respondents said, was that they make their voices heard  --  56% had said that nursing lacks a single voice in speaking on national issues. More than half of respondents also noted that there was a lack of opportunities for nurses to advance into leadership positions.&lt;/p&gt;
&lt;p&gt;The survey, conducted by Gallup for the Robert Wood Johnson Foundation, examined professional views of nursing, nursing leadership, the future of the industry, and potential barriers to leadership roles for nurses among various healthcare-related groups. It included responses from opinion leaders in academia (276), health services (253), government (253), industry (253), insurance (237), and the corporate world (232).&lt;/p&gt;
&lt;p&gt;Nine out of 10 said nurses should have more influence in increasing the quality of care and reducing medical errors.&lt;/p&gt;
&lt;p&gt;About 85% said they wanted nurses to have more influence in promoting wellness and preventive care, improving efficiency and cost, coordinating care through the healthcare system, and adjusting care to meet an aging population.&lt;/p&gt;
&lt;p&gt;Additionally, 72% thought increased nurse influence would help the healthcare system adapt to the growing change in ethnic, racial, and cultural diversity in patient populations.&lt;/p&gt;
&lt;p&gt;The opinion leaders were also asked whether they feel there is a nursing shortage in the U.S. Just over 80% said Yes and of those, only 2% said it was not a serious problem.&lt;/p&gt;
&lt;p&gt;To blame for the shortage? Respondents cited a stressful/poor work environment (44% see that as a very important reason), not enough openings in nursing schools (40%), and too many nurses leaving the profession (37%). Only 22% cited low pay as very instrumental in causing the shortage.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_157"
                     title="COLUMN: Re-engineering Made Easy"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Columns/17986?impressionId=1265715240512"
                     
      &lt;p&gt;Re-engineering was a catch-phrase in the business world not long ago, and it has crept into the medical &quot;business&quot; too. But what does it really mean to &quot;re-engineer your practice&quot;?&lt;/p&gt;
&lt;p&gt;According to Michael Hammer and James Champy, authors of the seminal book about re-engineering, it is &quot;the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service, and speed.&quot;&lt;/p&gt;
&lt;p&gt;The principles of re-engineering are:&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Combine tasks&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Empower employees&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Perform process steps in a natural order&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Design processes to be flexible&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Minimize checks and controls&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Implement hybrid centralized/decentralized operations&lt;/p&gt;
&lt;p&gt;&amp;#8226;	Manage customers (read patients) through a single point of contact&lt;/p&gt;
&lt;p&gt;How do you apply those principles to your practice? Here&apos;s where we make it easy with an example that happens over and over in different specialties across the country.&lt;/p&gt;
&lt;p&gt;Example:&lt;/p&gt;
&lt;p&gt;&lt;em&gt;Tim, a patient in an internal medicine practice, has a prescription that is due to expire about two weeks before his scheduled annual exam. On a Monday, a couple days before it expires, he calls the medical office to get his prescription reissued. About two hours later, he gets a call from the pharmacist explaining that the pharmacy doesn&apos;t have his medication in stock, but it will be arriving the next day and it will cost about $60. &lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;Tim is puzzled by this because in the past he paid only his $10 prescription copay for the medication. The pharmacist explains that the prescription that the doctor&apos;s office transmitted is not for a generic. Tim is even more puzzled because all his previous prescriptions were written for generics. &lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;So, Tim calls the practice for a second time (by now, it is midafternoon) to get the prescription written as the generic he was trying to refill.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;On Tuesday morning Tim goes to the pharmacy but they claim they have received nothing from the medical practice. So Tim calls the practice while he&apos;s at the pharmacy. He explains the situation as an extension of the previous afternoon&apos;s call.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt; But the secretary who answered the call is not the person Tim spoke with yesterday. She is confused about which medication is generic but promises to have the prescription rewritten to fill with the generic and transmit that to the pharmacy. Doing so will probably take a couple of hours she tells Tim, who leaves the pharmacy knowing he&apos;ll have to make yet another trip and vows to call before going.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;So, one &quot;simple&quot; medication reissue request generated three unique phone calls from the patient to the practice, a call from the pharmacist to the patient, and two trips to the pharmacy by the patient.&lt;/p&gt;
&lt;p&gt;It is painfully obvious that we created the problem in the practice when we mishandled the initial request. Less obvious is how to re-engineer to avoid such a situation  --  how to rethink our process so that we achieve a dramatic improvement in the cost of our operation and the service to our patient.&lt;/p&gt;
&lt;p&gt;We need to stop and ask why we are getting that initial call to reissue the medication in the first place. A radical redesign of our process would be coordinating prescription expirations with follow-up appointments!&lt;/p&gt;
&lt;p&gt;In other words, Tim must be given an appointment for his annual exam that occurs before the date his prescription will expire! That&apos;s the natural order to perform medication reissues, that&apos;s re-engineering and it&apos;s that easy!&lt;/p&gt;
&lt;p&gt;So, how do you get started in your practice?&lt;/p&gt;
&lt;p&gt;Look at the re-work and duplicative activities and the waste that occurs each day. Do you get prescription re-issue requests like Tim&apos;s? Start with all appointments from this day forward and be sure that you order a follow-up appointment that falls at least two weeks before the expiration of the prescription order you&apos;re writing. If you write a 90-day prescription, order a follow-up appointment for 10 weeks from today instead of 12 weeks or three months.&lt;/p&gt;
&lt;p&gt;Look at other incoming telephone calls and examine why patients are calling  --  30% to 40% of incoming calls are from patients seen in the office in the preceding two weeks.&lt;/p&gt;
&lt;p&gt;Do patients have questions that should have been addressed during their appointment? Would a referral to a Web site with patient education material provided at the appointment reduce those calls?&lt;/p&gt;
&lt;p&gt;Are patients calling to learn about test results? Look to re-engineer the process for notifying patients about their tests and eliminate those calls.&lt;/p&gt;
&lt;p&gt;Manage all the calls through a single point of contact  --  a centralized call center. The size of your call center will vary depending on the size of your practice. A one- or two-physician practice may get by with only one person, while a practice with 20 providers may need three to five FTEs to staff the call center.&lt;/p&gt;
&lt;p&gt;Rethinking the way you handle prescriptions and refill calls can cut down on the number of times patients phone the practice, and that can save significant dollars  --  each incoming call costs the practice just under $10, on average.&lt;/p&gt;
&lt;p&gt;In the case of our hypothetical patient Tim, better timing on prescription refills or his office visit would have saved $30 and a lot of aggravation.&lt;/p&gt;
&lt;p&gt;Re-engineering is as easy as looking at the processes that you do every day over and over and rethinking how to improve them. Take time out to rethink and you&apos;ll have made re-engineering easy!&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20090101_19_406"
                     title="Clinic Work Environment May Affect Minority Health Disparities"
                     score="-0.005"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/tb/12811?impressionId=1265715240512"
                     
      MAYWOOD, Ill., Feb. 9 -- Primary care clinics with a high percentage of minority patients present a more challenging work environment for physicians, which might explain some healthcare disparities, researchers here said.
              &lt;p&gt; 
              &lt;p&gt;Physicians at these clinics reported less access to medical supplies (&lt;em&gt;P&lt;/em&gt;&lt;0.001) and referral specialists (&lt;em&gt;P&lt;/em&gt;&lt;0.005) than those at clinics serving fewer minority patients, Anita Varkey, M.D., of Loyola University Medical Center, and colleagues found.
              &lt;p&gt; 
              &lt;p&gt;They were also more likely to report seeing patients who were medically and psychosocially complex (&lt;em&gt;P&lt;/em&gt;&lt;0.001), they reported in the Feb. 9 issue of &lt;em&gt;Archives of Internal Medicine&lt;/em&gt;.
              &lt;p&gt; 
              &lt;p&gt;&quot;[The resource] deficiencies may contribute to physician stress and time pressure,&quot; the researchers said.
              &lt;p&gt; 
              &lt;p&gt;&quot;The combination of time pressure, insufficient resources, and complex patients likely constitutes a &apos;perfect storm&apos; that contributes to the challenges that physicians face in providing quality care to large proportions of minority patients,&quot; they said.
              &lt;p&gt; 
              &lt;p&gt;Minority patients have worse outcomes from numerous diseases and conditions, the researchers said, some of which are attributable to differences in quality of care stemming from healthcare access and patient and physician factors.
              &lt;p&gt; 
              &lt;p&gt;But few studies have examined the effect of workplace environment on healthcare disparities, they said.
              &lt;p&gt; 
              &lt;p&gt;To explore the issue, the researchers surveyed clinic managers, physicians, and patients who had hypertension, diabetes, or congestive heart failure from 96 primary care clinics in New York City and the upper Midwest as part of the Minimizing Error, Maximizing Outcome (MEMO) study.
              &lt;p&gt; 
              &lt;p&gt;The multicenter sample included 388 primary care physicians and 1,701 of their patients.
              &lt;p&gt; 
              &lt;p&gt;At 27 clinics, at least 30% of the patients were from minority racial or ethnic groups (range 30% to 95%).
              &lt;p&gt; 
              &lt;p&gt;Patients at these clinics were more likely to have less than a high school education and to report a lower medical literacy, and were more likely to report being depressed (&lt;em&gt;P&lt;/em&gt;&lt;0.001 for all). 
              &lt;p&gt; 
              &lt;p&gt;Compared with physicians from clinics that cared for a low percentage of minority patients, those from clinics that saw a high percentage of minority patients reported:
              &lt;p&gt; 
              &lt;ul&gt;
                &lt;li&gt;Less access to medical supplies (&lt;em&gt;P&lt;/em&gt;&lt;0.001)
                &lt;li&gt;Less access to referral specialists (&lt;em&gt;P&lt;/em&gt;&lt;0.005)
                &lt;li&gt;Fewer examination rooms per physician (&lt;em&gt;P&lt;/em&gt;=0.002)
                &lt;li&gt;Poorer access to pharmacy services (&lt;em&gt;P&lt;/em&gt;=0.03)
                &lt;li&gt;Limited written educational materials for patients with hypertension (&lt;em&gt;P&lt;/em&gt;=0.03) and congestive heart failure (&lt;em&gt;P&lt;/em&gt;=0.01)
              &lt;/ul&gt;
              &lt;p&gt; 
              &lt;p&gt;In addition, they reported a higher percentage of patients covered by Medicaid (20% versus 8%, &lt;em&gt;P&lt;/em&gt;&lt;0.001), uninsured patients (32% versus 13%, &lt;em&gt;P&lt;/em&gt;=0.048), patients who did not speak English (27.1% versus 3.4%, &lt;em&gt;P&lt;/em&gt;=0.004), patients with chronic pain (24.1% versus 12.9%), and patients with substance abuse problems (15.1% versus 10.1%, &lt;em&gt;P&lt;/em&gt;=0.005).
              &lt;p&gt; 
              &lt;p&gt;They were more likely to report having a chaotic work environment (OR 4.0, 95% CI 2.0 to 7.9, &lt;em&gt;P&lt;/em&gt;=0.003), and less likely to report having high work control (OR 0.2, 95% CI 0.1 to 0.5, &lt;em&gt;P&lt;/em&gt;=0.003) and high job satisfaction (OR 0.4, 95% CI 0.2 to 0.7, &lt;em&gt;P&lt;/em&gt;=0.01).
              &lt;p&gt; 
              &lt;p&gt;&quot;These adverse work environments may contribute to healthcare disparities by increasing the risk of provider biases and by stereotyping of minority patients, especially in settings where medical complexity and clinical uncertainty compete with time pressure,&quot; the researchers said.
              &lt;p&gt; 
              &lt;p&gt;&quot;Current efforts, such as provider-specific interventions to increase cultural competence and sensitivity, may not fully address these deeper systemic work environment issues,&quot; they said.
              &lt;p&gt; 
              &lt;p&gt;They said that national strategies that address healthcare disparities should consider the work environment as a potential &quot;target for interventions to reduce physician burnout, increase work control, and reduce clinic chaos.&quot;
              &lt;p&gt; 
              &lt;p&gt;The authors acknowledged several limitations of the study, including the limited generalizability to other parts of the country or to non-primary care settings, the use of self-reported data, the lack of information on how physician-related factors affect care, the low rates of participation and enrollment (60% and 56% respectively), and the potential for geography to explain the findings.
              &lt;p&gt; 
              &lt;p&gt; 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;The study was supported by grants from the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation. One of Dr. Varkey&apos;s co-authors is a Robert Wood Johnson Foundation Harold Amos Faculty Development Scholar.
              &lt;p&gt; 
              &lt;p&gt;The authors made no financial disclosures.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
         
    </recommendedItem>
</recommendedContent>