Abstract In Hirschman’s classic formulation, physicians can signal discontent with their conditions of work by “exiting” (leaving the profession or not entering it in the first place) or by giving “voice” to their concerns (e.g. complaining, protesting, bargaining collectively, or conducting work actions and strikes). This Commentary reviews the findings of a survey of Israeli neonatologists by Moshe et al. Survey respondents were satisfied with their careers but not with salary, patient care demands, and leisure time, a pattern that has been seen in other countries, particularly within “small, acute care specialties” (SACS). One question for policymakers is how to help physicians in SACS maintain work-life balance and avoid burnout while providing superb patient care. The Commentary considers several possible solutions while advocating for rigorous and comprehensive monitoring of physician satisfaction over time.

The mainstay of evidence development in medicine is the parallel-group randomized controlled trial (RCT), which generates estimates of treatment efficacy or effectiveness for the average person in the trial. In contrast, personalized trials (sometimes referred to as 'single-person trials' or 'N-of-1 trials') assess the comparative effectiveness of two or more treatments in a single individual. These single-subject, randomized crossover trials have been used in a scattershot fashion in medicine for over 40 years but have not been widely adopted. An important barrier is the paucity of strong evidence that personalized trials improve outcomes. However, the principal impediment may have less to do with proof of efficacy than with practical aspects of design and implementation. These include decisions about treatment regimen flexibility, blinding, and washout periods as well as organizational, clinician, and patient-level challenges. After reviewing the essential elements of personalized trials, this article addresses these speed bumps and fundamentally asks, 'Why have personalized trials not been more widely adopted, and how can they be made more readily deployable and useful?' The article concludes by suggesting ways in which emerging technologies and approaches promise to overcome existing barriers and open promising vistas for the next generation of personalized-trial researchers and practitioners.

Abstract Background Over the past 30 years, patients’ options for accessing information about prescription drugs have expanded dramatically. In this narrative review, we address four questions: (1) What information sources are patients exposed to, and are they paying attention? (2) Is the information they hear credible and accurate? (3) When patients ask for a prescription, what do they really want and need? Finally, (4) How can physicians reconcile what patients hear, want, and need? Analysis A critical synthesis of the literature is reported. Observations indicate that the public is generally aware of and attends to a growing body of health information resources, including traditional news media, advertising, and social networking. However, lay audiences often have no reliable way to assess the accuracy of health information found in the media, on the Internet, or in direct-to-consumer advertising. This inability to assess the information can lead to decision paralysis, with patients questioning what is known, what is knowable, and what their physicians know. Many patients have specific expectations for the care they wish to receive and have little difficulty making those expectations known. However, there are hazards in assuming that patients’ expressed desires are direct reflections of their underlying wants or needs. In trying to reconcile patients’ wants and needs for information about prescription medicines, a combination of policy and clinical initiatives may offer greater promise than either approach alone. Conclusions Patients are bombarded by information about medicines. The problem is not a lack of information; rather, it is knowing what information to trust. Making sure patients get the medications they need and are prepared to take them safely requires a combination of policy and clinical interventions.

Abstract Background Specialty-specific data on career satisfaction may be useful for understanding physician workforce trends and for counseling medical students about career options. Methods We analyzed cross-sectional data from 6,590 physicians (response rate, 53%) in Round 4 (2004-2005) of the Community Tracking Study Physician Survey. The dependent variable ranged from +1 to -1 and measured satisfaction and dissatisfaction with career. Forty-two specialties were analyzed with survey-adjusted linear regressions Results After adjusting for physician, practice, and community characteristics, the following specialties had significantly higher satisfaction levels than family medicine: pediatric emergency medicine (regression coefficient = 0.349); geriatric medicine (0.323); other pediatric subspecialties (0.270); neonatal/prenatal medicine (0.266); internal medicine and pediatrics (combined practice) (0.250); pediatrics (0.250); dermatology (0.249);and child and adolescent psychiatry (0.203). The following specialties had significantly lower satisfaction levels than family medicine: neurological surgery (-0.707); pulmonary critical care medicine (-0.273); nephrology (-0.206); and obstetrics and gynecology (-0.188). We also found satisfaction was significantly and positively related to income and employment in a medical school but negatively associated with more than 50 work-hours per-week, being a full-owner of the practice, greater reliance on managed care revenue, and uncontrollable lifestyle. We observed no statistically significant gender differences and no differences between African-Americans and whites. Conclusion Career satisfaction varied across specialties. A number of stakeholders will likely be interested in these findings including physicians in specialties that rank high and low and students contemplating specialty. Our findings regarding "less satisfied" specialties should elicit concern from residency directors and policy makers since they appear to be in critical areas of medicine.

Objective

We examined rheumatologists' approaches to and perceptions of depression in everyday practice.

Methods

A questionnaire was mailed to 470 practicing rheumatologists in California; 226 were included in the final analyses. Respondents provided information on demographics, practice characteristics, and attitudes, perceptions, and practices related to depression. Logistic regression models were constructed to assess the relationship of rheumatologists' personal and practice characteristics with their depression-related practices.

Results

Fifty-one percent of respondents reported that at least half of their patients had depression. Nearly all providers (99%) reported addressing mental health issues during some visits. Rheumatologists were about equally likely to prescribe antidepressants, refer to a psychiatrist, or return the patient to the primary care physician, with roughly 60% often applying each of the 3 strategies. Respondents identified access to services and patients' resistance to mental health diagnoses as major barriers to effective depression management. In logistic regression models, greater number of patient visits per week, greater percentage of patients with fibromyalgia, and private practice setting were associated with more prescription of antidepressants (P < 0.05).

Conclusions

Depression is common in rheumatologic practice, yet systems for identification, treatment, and referral of depressed patients are not universal. Rheumatologists' awareness of the need for mental health services is high, but they may lack the confidence, time, and/or referral networks to provide consistently effective care for depressed patients. Improving depression care in rheumatology may require a combination of clinician-level interventions (e.g., enhanced behavioral health training) and practice-level reforms (e.g., collaborative care).