THE WESTERN JOURNAL OF MEDICINE

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tients over 65 years of age by 33%, for children under five years of age by 34%. Distinctive Features About Their Practices The questionnaire asked about the types and frequency of tasks performed by physician assistants. "Regular" tasks were performed one or more times per month. Physician assistants were also asked to compare their frequency of providing services with the frequency of service provided by the principal physician supervisor. Figure 1 summarizes responses of particular interest. Discussion California physician assistants have entered training from a variety of backgrounds. Most already have a baccalaureate degree. Clinical training, then, builds upon diverse sets of knowledge, skills, and social experiences. Of special note, in view of California's growing minority populations, is the large representation of ethnic minorities in the profession. The fact that most use another language with some of their patients, many with fluency, suggests that physician assistants are likely contributing to improved access to care for underserved minority patients. It is quite possible that such care may be culturally attuned to minority concerns as well. Physician assistants are realizing goals set out for the profession by the state legislature in that most graduates practice in California and work with physicians in the primary care specialties. They also frequently work in settings such as community clinics and county systems that care for the medically disenfranchised. Their self-reported involvement with patients on Medi-Cal and those without reimbursement for care suggests that they are playing substantial roles with the medically underserved. Role delegation between physician assistants and physicians varies greatly among practices. The data summarized in Figure 1 suggest that physician assistants commonly complement as well as extend the services provided by their physician supervisors/colleagues. VIRGINIA KLINER FOWKES, MHS Director, Primary Care Associate Program

DAVID McKAY, MD, MPH Clinical Associate Professor Division of Family and Community Medicine Stanford University School of Medicine 703 Welch Rd, Suite G-1 Palo Alto, CA 94304

Family Physicians and Obstetrics TO THE EDITOR: The article by Pyskoty and colleagues, "Malpractice Litigation as a Factor in Choosing a Medical Specialty," in the March 1990 issue1 was an important contribution to our understanding of the process that may affect some of the current physician maldistribution in the health care system. Studies suggest that less than 11% of University of Illinois students choose family practice each year.2 Having recently examined several of the Chicago programs, I found that family medicine is a relative "blind spot" for many of the medical schools there. In the high risk-low risk dichotomy, family practice was placed in the low risk group. Training in obstetrics remains as one of the important parts for accreditation of a family practice program by the Residency Review Committee. The American Academy of Family Physicians 1989 Congress of Delegates reaffirmed the place of family physicians in the delivery of obstetrical services.3 This is particularly important for rural and underserved groups. Projected cost for

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liability insurance affects specialty choice by discouraging medical students who fear legal and financial risk. This effect is unique for the specialty of family practice, which covers many areas of subspecialty endeavor, including obstetrics. Our studies and others' have documented the dramatic effect of liability insurance on family practice.4-6 Tragically, students' perception of insurance costs are frequently inaccurate or misleading, or both. Some students routinely overestimated family practice insurance costs by 200% to 400%. There is an unfortunate influence on specialty choice.4'5 As family physician role models disappear from training environments and the technical imperative marches on, cesarean section rates are almost 25% nationally. The American College of Obstetrics and Gynecology has declared that a physician cannot perform induction of labor without cesarean section capability. These events, which are at least partially attributable to the liability insurance environment, uniquely affect the specialty of family practice.7 In the same issue of the journal, Midtling and co-authors point out the systematic underfunding of family medicine residencies.8 Ironically, training for obstetrical skills is a labor-intensive task. Pyskoty and colleagues' study is an interesting one with an excellent discussion. In terms of one of the primary care specialties, family practice, the high risk-low risk dichotomy is misleading. Insurance concerns and the role of obstetrics within the specialty are powerful forces that partly contribute to the crisis in rural and underserved health care. Wm. MacMILLAN RODNEY, MD Professor and Chair Department ofFamily Medicine University of Tennessee

College of Medicine 1121 Union Ave Memphis, TN 38104

REFERENCES

1. Pyskoty CE, Byrne TE, Charles SC, et al: Malpractice litigation as a factor in choosing a medical specialty. West J Med 1990; 152:309-312 2. Schmittling G, Graham R, Tsou C: Entry of US medical school graduates into family practice residencies: 1989-1990 and 9-year summary. Fai Med 1990; 22:130-136 3. Rodney WM: A personal reflection from the AAFP Task Force on Obstetrics. Tenn Fam Phys 1990; 1:4-5 4. Rodney WM: The class of '85: OB malpractice fee phobia among medical students. West J Med 1986; 144:90-91 5. Rodney WM, Sanderson L: Effect of perceived malpractice insurance costs on the family practice career goals of medical students. Fam Med 1988; 20:418421 6. Rosenblatt RA, Wright CL: Rising malpractice premiums and obstetric practice patterns: The impact on family physicians in Washington State. West J l ed 1987; 146:246-248 7. Weiss BD: The effect of malpractice insurance costs on family physicians' hospital practices. J Fam Pract 1986; 23:55-58 8. Midtling JE, Barnett PG, Blossom HJ, et al: The future of family practice training in California. West J Med 1990; 152:317-321 *

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Dr Charles Responds To THE EDITOR: I appreciate very much Dr Rodney's thoughtful comments on our article.1 The reference to our high and low risk dichotomy with family practice included as low risk is of interest. As readers may have noted in our article, this designation was based on the rate classification used by the Illinois State Medical

Inter-Insurance Exchange, which is the physician-owned insurer associated with the Illinois State Medical Society. How many of those family practitioners in the low risk insurer classification actually engage in obstetrical care is unknown to us. Based on our knowledge of students at the University of Illinois at Chicago, our students perceive family practice primarily as an outpatient discipline and would

Family physicians and obstetrics.

THE WESTERN JOURNAL OF MEDICINE 9 SEPTEMBER 1990 o * 153 153 9 * tients over 65 years of age by 33%, for children under five years of age by...
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