and balance are likely to rethe incidence of falls and bone fractures. A number of controlled trials have demonstrated skeletal benefits from exercise. Using fairly high impact activity, the authors of this study found that bone mineral density increased 1.4-3.7% in the exercising group. Given the relatively sedentary nature of our population and their poor record of compliance with longterm exercise programs, it remains to be seen how practical the findings of this study may be. New strategies to motivate sedentary people to incorporate physical activity into their daily lives will be important if we are to reduce the incidence of falls and fractures. duce
Resolutionof legal Claims B-Lynch C, Coker A, Dua JA. A clinical analysis of 500 medico-legal claims evaluating the causes and assessing the potential benefit of alternative dispute resolution. Br J Obstet Gynaecol 1996; 103:123642.
Synopsis: The authors reviewed 500 cases requesting medical expert opinion to evaluate the common causes of medicolegal disputes in obstetrics and gynecology and to assess the potential benefit of early alternative dispute resolution. Most cases (46%) were the result of misguided allegations, but incompetent management (19%) and errors of judgment (12O/,) were not uncommon. Improper counseling or consent (7%), lack of expertise (9%), and inappropriate supervision (6%) made up the remainder of the cases. Of the 225 obstetric cases, dispute most commonly involved cases of cerebral palsy (22%) and neonatal death (lo%), whereas in the 275 gynecology cases, dispute most often involved failed sterilization (19%) and perforated uterus (8%). Because of the unacceptably long delay in preparing medical litigation cases and the slow process of resolution through the court system, the authors state that mediation may be an acceptable alternative to reduce costs and expedite case resolution.
. . .
Commentary: No event in the practice of medicine provokes as much anxiety, fear, and anger as involvement as a defendant in a malpractice suit. Although many legal actions result from misguided allegations with little basis for successful litigation, the time and financial investment to seek resolution is often significant. Dispute mediation leading to negotiated settlement may be effective when the process of initial complaint management has failed. Arbitration may be useful if the mediation process fails or does not lead to a solution with which both parties agree. Both mediation and arbitration, however, may be less expensive and time consuming, and provide both parties with more control in negotiations, than litigation.
Patient Satisfaction With Collaborative Practice Hankins GDV, Shaw SB, Cruess DF, Lawrence HC III, Harris CD. Patient satisfaction with collaborative practice. Obstet Gynecol 1996;88:1011-5.
Synopsis: To gather information on women’s perceptions of the services delivered in collaborative oblgyn practices, and to determine whether patients perceive a difference in the delivery ofservices in a variety of practice settings, the authors used a crosssectional patient satisfaction survey developed by the Collaborative Practice Advisory Group ofACOG to collect data from 3257 women attending ten practice settings throughout the United States. The practices used were primarily those represented by members of the Advisory Group and included five private office practices, two clinics, two health maintenance organizations, and one large military facility. Between 75% and 92% of respondents expected services provided in a collaborative practice to differ from those provided in a noncollaborative practice. Regardless of whether the collaborative practice was private, 71-92% of women agreed with statements regarding possible benefits of being cared for in a collaborative practice. Among reasons for selecting a particular collaborative practice, referral by a friend (34.6%) and physician reputation (30.5%) were selected
most often. In the under age 45 group, approximately 64% expressed no preference for a male or female provider. Of women who indicated a preference, however, 92.9% preferred a female care provider.
Commentary: As the trend toward managed health care increases, cost differences between groups are likely to decrease. Ultimately, for patients and other health care payers, provider selection will be based on quality of care, patient service, and accessibility. Collaborative practice in some settings, using nurse practitioners, nurse midwives, physician assistants, or other providers, offers a unique opportunity to maximize provider resources, provide high-quality care, and improve patient service and accessibility. In this survey, nonphysicians were perceived to spend more time with patients and to be less rushed in providing care. Physicians, however, were perceived to provide more complete information. New patients had higher expectations of the practices they selected than did return patients. For physicians in collaborative practices, strategies may be developed to meet and maintain the expectations of both new and return patients.
Managed Care & Nurses Buerhaus PI, Staiger DO. Managed care and the nurse workforce. JAMA 1996;276: 1487-93.
Synopsis: The authors did a retrospective analysis of trends in nursing employment and earnings based on 1983-1994 U.S. Census surveys. To determine the impact of managed care, these trends were compared between states with a high proportion of managed health care and states in which managed care is not as prevalent. From 1983 through 1994, the authors found strong growth in employment (37%) and inflationadjusted wages (22%). Beginning in the early 199Os, however, registered nurses experienced essentially no growth in wages, a small but steady decline in hospital employment, and a shift toward employment in lower-