THE SIGNIFICANCE OF LONG-TERM DOCTOR-PATIENT RELATIONSHIPS AMONG OLDER PATIENTS. C. Crenner 1 , K.A. Greiner 2 ; 1 University of Kansas Medical Center, Kansas City, KS; 2 Kansas University Medical Center, Kansas City, KS PURPOSE: Many older Americans have a personal stake in a relationship to a single physician that extends back decades. Changes in our healthcare system and in chronic care facilities may increasingly disrupt these connections. People who have preserved such long-term relationships have much to tell us about the significance of these relationships and their relevance to care. METHODS: We invited participation at four sites: a rural nursing home; an ambulatory clinic in an urban medical center; a suburban, assisted-living facility; and a private clinic in a lowincome, urban neighborhood. We enrolled subjects who could give an account of past medical care and who had kept the same primary physician for seven years or longer. We sampled to increase variability. We recorded and transcribed 17 semi-structured interviews and conducted a focus group with seven participants including 2 subjects not interviewed individually. We elicited open-ended discussion of each subject's relationship to a long-term doctor, asking about the features that interfered with or helped to sustain the relationship, and the significance that the relationship held. Immersion in the transcribed material and simultaneous reading in social history and anthropology produced a theoretical model based on the distinction between giftexchange qualities and commodity-exchange qualities in these relationships. RESULTS: Subjects were 6 men and 13 women, with a mean age of 75 years, and a mean duration of medical relationship of 19 years. Eighteen subjects were white and one was African American. Subjects attributed much of the durability of these relationships to the positive personal and professional characteristics of their doctors. There was variability in characteristics described as important. Few informants recalled their own active role in selecting their current physicians, and some had been in practices that were``handed-down'' from doctor to doctor. Distance and transportation were very important considerations for continuing care. Subjects were generally able to describe a rational process for selecting their next physician. CONCLUSION: Our theoretical model suggested that gift-exchange qualities in these relationships implied mutual obligations between recipients and donors that extended beyond the simple transaction of services. In contrast, commodity-exchange relationships existed solely for the exchange of specific services. Services in gift-exchange relationships had a value partly determined by the value attached to the relationship, while in commodity-exchange the value was independent. Our subjects favored characterizations of their long-term relationships as forms of gift-exchange, but they demonstrated an ability to shift to a commodity-exchange model. Statements consistent with a commodity-exchange model appeared especially in references to relationships of shorter duration, or to the conclusion of relationships to long-term providers. The day-to-day practice of medicine entails many ethical quandaries and yet little is known about practicing physicians' encounters with ethical dilemmas or how they resolve them. METHODS: A randomized, national telephone survey of internists including generalists was conducted to determine the ethical dilemmas encountered, the strategies used to address them, and the use and value of ethics consultation. Coding schemes were used to categorize verbatim descriptions of ethical dilemmas. RESULTS: Responding generalists (N=95) reflected the demographic characteristics of U.S. general internists (20% female, 23% non-white, 33% foreign born). One quarter of the ethical dilemmas encountered by general internists were related to justice issues concerning uninsured patients, practice in managed care, or allocation of limited resources. During the previous 2 years respondents had requested an average of 2 consultations. Physicians were most hesitant to request consultations because they are time-consuming. While many of the ethical dilemmas encountered were related to justice issues, no justice-related dilemmas were referred for ethics consultation. Physicians handled justice related dilemmas by strategies that included explicitly discussing limits with patients, acquiescing to limits, overstepping limits, searching for alternative sources, or providing free care. Physicians were often dissatisfied with resolution of justice questions and believed institutional or policy changes were required to achieve better resolution. CONCLUSION: General internists encounter a wide array of ethical dilemmas and address the vast majority of them on their own. Medical ethicists need to be aware that justice related dilemmas are often unsatisfactorily resolved and should explore ways to help in addressing them. Recent data suggest that this funding is becoming more concentrated at the medical schools most active in research, which tend to be in urban centers. I hypothesized that over the past 20 years, NIH research funding has increased in the states and regions with the highest per-capita NIH funding and highest population density, relative to the other states and regions. If present, the hypothesized shift in research funding may hinder efforts to reduce regional disparities in medical care. METHODS: Data from the NIH and US census bureau were used to calculate the per-capita NIH funding received by each state during 1980 ± 2000. The per-capita NIH funding amount for each state was obtained by dividing the annual funding amount by the population that year. To enable comparisons between years, per-capita funding for each state was standardized by dividing by the mean for all states in the same year. Regional disparities in per-capita NIH funding were evaluated in 2 ways: standardized funding amounts and their changes over 20 years were calculated for each formal US census region (Northeast, Midwest, South, and West), and standardized values and 20-year changes for each state were plotted on US maps. To determine whether per-capita funding shifted from rural to populous states over the past 20 years, the temporal trends in correlation between per-capita funding and population density were examined. RESULTS: Year 2000 per-capita NIH funding ranged from $3 in Idaho, to $247 in Massachusetts. Over the past 20 years, 7 of the 10 states with the highest per-capita NIH funding in 1980 had relative decreases, and 7 of the 10 states with the lowest per-capita NIH funding had relative increases in per-capita NIH funding. During this time, the Northeastern region of the US received the highest relative per-capita funding (1.6 times the national average), but the proportion (34%) of total research dollars did not significantly change during that time. Analysis according to formal US census region, and by US map inspection, suggested that per-capita funding was relatively stable for large regions, but considerable shifting of percapita funding occurred within states of every region. States with relatively higher population density tended to receive higher funding per capita (r=0.59, p < 0.01), but this relationship did not substantially change during the past 20 years, suggesting that per-capita NIH funding is not moving toward populous states at the expense of more rural states. CONCLUSION: During the past 20 years, disparities in relative per-capita NIH funding have shifted substantially among states, but changed little among major regions of the US. There is no evidence to suggest that NIH funding became more concentrated in the states with the highest per-capita funding or population density during that time. PURPOSE: Repeatedly, race has been shown to be a powerful predictor of health and access to care, but the reasons for racial disparities in health often remain obscure and speculative. Recognizing many concerns about vague and essentialist notions of race in epidemiological and clinical research, the Institute of Medicine, the American Academy of Pediatrics and the National Cancer Institute have recently called for more cautious use of the race variable. The goal of this paper is to provide a much-needed synthesis of key critiques of race, some of which go beyond the concerns expressed by the aforementioned medical bodies. Armed with more complete knowledge about race, investigators should be better able to evaluate, plan, and conduct studies on health differences among human populations. METHODS: In an iterative fashion, and on the basis of clarity and logic, important critiques of race were identified through online and bibliographic searches and reviews of biomedical and social science publications and through discussions with colleagues. Subsequently, recently published studies in highly-regarded medical journals were selected to illustrate major themes. RESULTS: Delineating the causes of health disparities is often limited by misunderstandings of race and inadequate attention to its fundamental confounders, including: BIOLOGY (e.g. race is a social construct, not a biological one); SOCIAL CLASS (e.g. emphasizing biology diverts attention from considerations of SES, and SES is frequently gauged using an inadequate number of measures); CULTURE (e.g. biomedical studies of patients' culturally-based preferences and practices may rely on notions of culture that are overly deterministic, ethnocentric, and unduly constrained by the use of questionnaire data); ETHNICITY (e.g. self-reported ethnicity has become a common substitute for race, but although it offers some advantages, researchers should bear the ultimate responsibility for specifying membership in groups, ethnic or otherwise); RACISM (e.g. the most disturbing explanation for health disparities, racism is also one of the most difficult to study because it is politically charged and open to competing interpretations). CONCLUSION: A great deal of important work has been accomplished in terms of documenting the variety and widespread nature of health disparities, generally, and racial disparities in health, more specifically. The next step is extremely challenging: we must discover more precise information regarding causes and mechanisms. This can be accomplished by remaining aware of the shortcomings of overarching categories of race/ethnicity, focusing on more narrowly defined subgroups, and giving more explicit attention to the confounders of race.