The Permanente journal最新文献

{"title":"Why Have All the Doctors Gone? Insights Into Early Clinical Departure Among Physicians in the United States: A National Survey.","authors":"Sea Chen, Lindsey Carlasare, Roger Brown, Michael Tutty","doi":"10.7812/TPP/25.219","DOIUrl":"https://doi.org/10.7812/TPP/25.219","url":null,"abstract":"<p><strong>Introduction: </strong>This national survey of clinically inactive physicians was conducted to identify the factors driving early exit from the clinical physician workforce in the United States, aiming to evaluate characteristics and motivations for leaving early.</p><p><strong>Methods: </strong>A sample of clinically inactive physicians drawn from American Medical Association Physician Professional Data™ completed a survey between May and June 2024, with questions assessing demographics, education, clinical training, and reasons for leaving clinical practice. In addition to standard descriptive statistics, gender differences were also explored.</p><p><strong>Results: </strong>Among the 971 respondents included in the analysis, the majority (63.9%) identified as women, the mean age was 45.8 years, and 11.0% had never practiced after graduate medical education. The physicians who left practice reported \"hassle factor\" (44.7%) and \"too stressful\" (44.5%) as prime motivators for their departure. Physicians who were women were more likely than men to have exited due to needing to care for family members (7.9% vs 0.6%, <i>P</i> < .001) or children (21.3% vs 4.2%, <i>P</i> < .001). The mean age of physicians who left clinical practice was 48.1 years, 9 years younger than observed in a similar cohort in 2008.</p><p><strong>Discussion: </strong>This study suggests that physicians who have left practice early have had shorter clinical careers than in the past. Interventions to reduce \"hassle factor\" and workplace stress may address the motivations for leaving practice.</p><p><strong>Conclusion: </strong>Understanding early attrition from clinical practice may improve interventions in sustaining the physician workforce. Specifically, further study is needed for women physicians who were fully trained but never entered clinical practice, as these groups will likely contribute an outsized effect on the magnitude of the workforce shortage.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-13"},"PeriodicalIF":0.0,"publicationDate":"2026-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147843166","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Immediate Nerve and Tendon Transfers After Wide Resection of a Radial Nerve Malignant Peripheral Nerve Sheath Tumor: A Case Report and Surgical Technique.","authors":"Joanne Zhou, Sai Shreya Kambham, Andrew Fang, Christopher Frey, Michael MacAvoy","doi":"10.7812/TPP/25.199","DOIUrl":"https://doi.org/10.7812/TPP/25.199","url":null,"abstract":"<p><p>The authors have reported on immediate nerve and tendon transfers postresection of a radial nerve-based malignant peripheral nerve sheath tumor in a 15-year-old female with neurofibromatosis. The median nerve branch to flexor carpi radialis was transferred to the posterior interosseous nerve, the median nerve branch to flexor digitorum superficialis was transferred to the nerve to extensor carpi radialis brevis, and the pronator teres tendon was transferred to the extensor carpi radialis brevis tendon, with 3-year outcomes reported. Tumor excision, tendon, and nerve transfer yielded negative margins and remission. Functional wrist/finger extension appeared at 6 months and increased until 3 years of follow-up.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-6"},"PeriodicalIF":0.0,"publicationDate":"2026-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147843159","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Awareness and Confidence in Accreditation Council for Graduate Medical Education Competencies: A Cross-Sectional Study of Postgraduate Trainees in Qatar.","authors":"Maya Aldeeb, Ibrahim A Khalil, Mohammed Al-Abdulla, Mohamed Elgassim, Marina Dawood, Hisham Elhiday, Shireen Suliman","doi":"10.7812/TPP/25.236","DOIUrl":"https://doi.org/10.7812/TPP/25.236","url":null,"abstract":"<p><strong>Background: </strong>Competency-based medical education, structured around the 6 core competencies of the Accreditation Council for Graduate Medical Education (ACGME), underpins postgraduate training in ACGME-International (ACGME-I)- accredited institutions. Despite its central role, limited evidence exists regarding trainees' awareness, confidence, and educational preferences related to these competencies, particularly in the Middle East. This study aimed to assess postgraduate trainees' awareness and confidence across the 6 ACGME competencies and to explore their orientation preferences at Hamad Medical Corporation, Qatar's largest ACGME-I-accredited academic center.</p><p><strong>Methods: </strong>A cross-sectional electronic survey was distributed to all postgraduate trainees at Hamad Medical Corporation. The questionnaire assessed self-reported awareness and confidence across the 6 ACGME Core Competencies, perceived emphasis during training, and preferred formats and frequency of competency-based orientation.</p><p><strong>Results: </strong>A total of 255 trainees completed the survey. Overall confidence was high across most competency domains, particularly in medical knowledge, interpersonal and communication skills, and professionalism. Systems-based practice and practice-based learning and improvement were the least familiar and least emphasized domains. Trainees who previously received structured competency orientation reported significantly higher confidence across all domains (<i>P</i> < .01). Patient care (66.7%) and medical knowledge (63.9%) were perceived as highly emphasized competencies, whereas systems-based practice was least emphasized (39.2%). Most trainees (76.5%) expressed interest in competency-focused orientation, favoring annual sessions delivered through online or blended learning formats.</p><p><strong>Conclusion: </strong>Postgraduate trainees demonstrate strong overall awareness of ACGME-I competencies; however, notable gaps persist in systems-based practice and practice-based learning and improvement. Structured, recurring competency orientation is associated with higher trainee confidence.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-7"},"PeriodicalIF":0.0,"publicationDate":"2026-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147843207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors Associated With Mortality in Appalachian Nursing Homes During the COVID-19 Pandemic.","authors":"Erica Gigas, Baiming Zou, Lorinda A Coombs, Patricia Schmidt, Margaret Chamberlain Wilmoth, Saif Khairat","doi":"10.7812/TPP/25.220","DOIUrl":"https://doi.org/10.7812/TPP/25.220","url":null,"abstract":"<p><strong>Introduction: </strong>Disasters, including the recent COVID-19 pandemic, have disproportionately impacted nursing homes (NHs). NH residents experienced higher mortality during the pandemic, but not all NH were affected equally. Appalachia has a history of reduced health compared to the general United States. Therefore, this study is focused on NHs in Appalachia during the COVID-19 pandemic.</p><p><strong>Purpose: </strong>This study aimed to investigate how the neighborhood and NH characteristics are associated with mortality in Appalachian NHs during the COVID-19 pandemic.</p><p><strong>Methods: </strong>Using publicly available datasets, including NH, patient, and county-level characteristics, the authors' investigated how the these factors impacted COVID-19 death, COVID-19 death rate, and total NH deaths by adopting negative binomial regression outcomes and multiple linear regression models.</p><p><strong>Results: </strong>A total of 1259 NHs in Appalachia were included in the analysis. Deaths from COVID-19 were positively associated with the number of NH beds, share of White residents, and resident age. Centers for Medicare & Medicaid Services 5-star quality rating was negatively associated with COVID-19 deaths. On the other hand, although number of beds, acuity index, share of White residents, average age, and share of White residents in the community were positively associated with total deaths, lower county education levels and county income were negatively associated with total deaths.</p><p><strong>Discussion and implications: </strong>NH and county characteristics associated with NH deaths varied from prior literature that included the general United States. Policymakers and NH leaders responsible for NHs in Appalachia should be sensitive to regional differences when making decisions and resource allocations.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2026-04-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147781864","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Proactive Engagement of Patients With Advanced Chronic Kidney Disease to Reduce Clinical Complications: The Kaiser Permanente Northern California Experience.","authors":"Sijie Zheng, Jingrong Yang, Rishi Parikh, Jignesh Patel, Leonid N Pravoverov, Thida C Tan, Alan S Go","doi":"10.7812/TPP/25.191","DOIUrl":"https://doi.org/10.7812/TPP/25.191","url":null,"abstract":"<p><strong>Introduction: </strong>Chronic kidney disease (CKD) affected > 35 million US adults in 2023. Effective therapies exist to reduce CKD progression and risk of cardiovascular events. However, whether population-level management strategies are effective is not known. The authors evaluated a program that proactively identified and referred high-risk patients to a structured CKD management approach aimed at improving guideline-direct care.</p><p><strong>Methods: </strong>Within a large, integrated health care delivery system, the authors enrolled adults with high-risk CKD identified from electronic health records between June 2021 and March 2022 who were not receiving nephrology care into a structured CKD management program based on a multidisciplinary, nephrologist-led model of care. These patients were compared to a matched cohort of high-risk patients with CKD receiving usual care. The authors evaluated feasibility and differences in targeted process measures over a 3-month follow-up period.</p><p><strong>Results: </strong>Among 120 eligible patients with CKD enrolled in the program and 120 matched patients with CKD receiving usual care, mean (standard deviation) age was 73.9 (8.4) years, 57.8% were women, and demographic characteristics and comorbidity burden were well matched. Despite the COVID-19 pandemic, implementing the structured CKD management program was feasible. During the 3-month follow-up period, those enrolled in the CKD management program experienced a higher rate of estimated glomerular filtration (58% vs 43%, <i>P</i> = .02) and urinary protein (38% vs 11%, <i>P</i> < .0001) testing.</p><p><strong>Conclusion: </strong>Proactive referral to structured CKD management was feasible and led to increased short-term surveillance of kidney function. Future studies should assess whether engagement at earlier stages of CKD and longer systematic care and follow-up can improve outcomes and inform broader implementation of population-level CKD management strategies.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-10"},"PeriodicalIF":0.0,"publicationDate":"2026-04-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147781939","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Leveraging Clinical Registries and Electronic Health Systems to Advance Value-Based Medicine Across Specialties.","authors":"Elizabeth W Paxton, Jessica Harris, Kanu Okike, Ronald A Navarro, Nithin C Reddy, Robert W Chang, Mark Sedrak, Rouzbeh Mostaedi, Kern H Guppy, Gregory B Maletis, Heather Prentice","doi":"10.7812/TPP/25.184","DOIUrl":"https://doi.org/10.7812/TPP/25.184","url":null,"abstract":"<p><p>Value-based medicine provides the potential framework for addressing the escalating costs of health care in the United States. Value includes patient outcomes and cost, and improving quality and/or reducing cost and maintaining quality increases health care value. Enhancing the quality of care for members leads to improved outcomes, reduced costs, and increased value. Implantable device registries and electronic health record systems support value-based medicine through identification of variations in care and clinical best practices, providing feedback on these clinical practices, and measuring the change in patient outcomes and cost savings. This article reviews a US integrated health system's experience with implant registries methods, outcomes, and cost savings. Evidence-based changes in surgical practice across multiple specialties resulted in substantial cost savings and maintained clinical outcomes. Key interventions included lowering allograft rates in anterior cruciate ligament reconstruction, reducing unnecessary use of bone morphogenetic protein in spine surgery, increasing rechargeable battery use in neurosurgery, increasing cemented fixation in hip fracture, expanding same-day discharge for joint arthroplasty, reducing antibiotic-laden cement in total knee arthroplasty, and improving endovascular aneurysm repair care management. These changes collectively saved hundreds of millions of dollars and enhanced and/or maintained quality of care.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-12"},"PeriodicalIF":0.0,"publicationDate":"2026-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147691936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exploring the Association Between Adverse Childhood Experiences and Missed Primary Care Appointments in Adult Patients.","authors":"Phillip Anjum, Bernard S Evenhuis, Rebecca Zhang, Clarke Britton, Marshall Fleurant","doi":"10.7812/TPP/25.170","DOIUrl":"https://doi.org/10.7812/TPP/25.170","url":null,"abstract":"<p><strong>Introduction: </strong>Missed medical appointments lead to adverse health outcomes and financial costs. Adverse childhood experiences (ACEs) are associated with poor health outcomes and may influence health care-seeking behavior in adulthood. This study explored the relationship between ACE scores and missed primary care appointments in a predominantly Black safety-net population.</p><p><strong>Methods: </strong>The authors conducted a retrospective cohort study of 307 adult patients in a primary care clinic between January and August of 2022. Patients were recruited using a systematic sampling protocol and completed the 10-item Adverse Childhood Experiences Questionnaire. The primary outcome was no-show behavior, defined as having at least 1 scheduled appointment not attended and not canceled in advance. Logistic regression analyses assessed associations between ACE scores and missed appointments.</p><p><strong>Results: </strong>The sample was 91.9% Black, 44.0% male, with mean age 59.6 years. Average ACE score was 2.3, with 22.5% having ACE scores ≥ 4. Overall, 43.7% of patients had at least 1 no-show visit. ACE scores were not significantly associated with missed appointments (odds ratio, 1.01; 95% confidence interval, 0.89-1.14; <i>P</i> = .94). Medicaid insurance status was the only significant predictor in multivariable analysis (odds ratio, 2.15; 95% confidence interval, 1.07-4.30; <i>P</i> = .03).</p><p><strong>Discussion: </strong>Contrary to the authors' hypothesis, ACE scores were not associated with appointment adherence. Medicaid insurance status was the strongest predictor of no-show behavior, highlighting the impact of socioeconomic disadvantage on health care engagement.</p><p><strong>Conclusion: </strong>Social determinants such as insurance status may have a stronger influence on appointment adherence than childhood trauma history. Findings underscore the need to address structural barriers in vulnerable populations.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-7"},"PeriodicalIF":0.0,"publicationDate":"2026-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147676707","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"E-Visit Usage Among a Population of Young Adults.","authors":"Abigail Eaton, Stephanie R Prausnitz, H Nicole Tran","doi":"10.7812/TPP/25.187","DOIUrl":"https://doi.org/10.7812/TPP/25.187","url":null,"abstract":"<p><strong>Introduction: </strong>Asynchronous electronic visits (e-visits) and telehealth may provide comparable health outcomes to in-person care in line with the implementation of value-based care.</p><p><strong>Methods: </strong>Study population was newly enrolled individuals (ages 18-26) in an integrated health plan in 2023 (N = 30,099). In this cross-sectional study, multivariate analyses focused on covariates associated with e-visit utilization. The association of emergent and discharge status with urinary tract infection (UTI) e-visit usage was examined in the subset of emergency department (ED) visits for female patients with UTI (n = 258).</p><p><strong>Results: </strong>During the first 18 months of membership, the newly enrolled 18- to 26-year-olds completed 22,483 e-visits. Needing a translator, using Medicare/Medicaid, and residing in areas with higher neighborhood deprivation indices were associated with a reduced likelihood of using e-visits. Having a chronic problem or identification of a primary care practitioner within 3 months were associated with increased likelihood of using an e-visit. In the ED subset, an association was seen between Hispanic identity and decreased likelihood of e-visit usage. A total of 2537 (11 %) of all e-visits were for UTI, and 258 (3%) of all ED visits were for UTI. Of the 258 ED visits for UTI, 95% were discharged home.</p><p><strong>Discussion: </strong>Most UTI-related ED visits were deemed not emergent and resulted in discharge home, which suggests room for improvement in delivery of value-based care. This could be achieved by increasing access to e-visits for individuals living in deprived neighborhoods, needing a translator, having Medicare/Medicaid, and identifying as Hispanic.</p><p><strong>Conclusion: </strong>Promotion of e-visit utilization among new young adult members could improve value-based health care utilization and maintain clinical outcomes.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-8"},"PeriodicalIF":0.0,"publicationDate":"2026-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147676668","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How Ethical Principlism Informs Health Care Access Advocacy.","authors":"G Richard Holt","doi":"10.7812/TPP/25.209","DOIUrl":"https://doi.org/10.7812/TPP/25.209","url":null,"abstract":"","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-4"},"PeriodicalIF":0.0,"publicationDate":"2026-04-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147646427","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Strengthening the Physician Workforce: An Expert Panel Discussion.","authors":"Ted O'Connell, Lupe Alonzo-Diaz, Theresa Azevedo-Rousso, Julie Byerley, Alexa McKinley Abel, Michael B Rothberg, Kevin Smith","doi":"10.7812/TPP/26.051","DOIUrl":"https://doi.org/10.7812/TPP/26.051","url":null,"abstract":"","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-12"},"PeriodicalIF":0.0,"publicationDate":"2026-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147623700","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}