RESULTS: Compared to the gold standard of standardized patients, false positives were identified in the medical record for 6.4% of measured items overall. False positives were higher for physical examination (13.5%) and diagnosis (14.6%) than for history (3.8%) and treatment (3.4%) . The difference in false positive rates between site 1 (7.1%) and site 2 (5.7%) was not statistically different (p = 0.34). The proportion of false positives for individual physician subjects ranged from 2.2% to 13.0% and for actor patients from 1.4% to 11.6%. CONCLUSION: These results suggest that chart abstraction may overestimate the quality of care due to false positives. The clustering of false positives in the domains of physical examination and diagnosis suggests that these are not incidental occurrences or underreporting by actor patients. Though false positives in the physical examination could result from careless documentation by physician subjects, they may indicate intentional misrepresentation of the process of care, perhaps to up-code a visit or save time by adding an exam element not performed. Such fabrication would violate ethical standards essential to the integrity of clinical practice, potentially putting patients at risk by including misinformation in the medical record. By contrast, documentation of diagnosis in the medical record but not by the actor patient would represent an important lapse in communication of essential information. Improved evaluation methods are needed to detect such irregularities as well as guidelines to determine appropriate actions when potentially unethical conduct is identified in studies of quality. University of Washington, Seattle, WA PURPOSE: For many physicians, the environment in which they trained differs from the current practice environment of managed care, declining revenues, patients on the Internet, and insurance paperwork. Studies of physician career satisfaction have suggested that unmet expectations may play a role in declining satisfaction, but this area remains largely unexplored. We designed a survey to examine career expectations and satisfaction, as well as evaluating trends in satisfaction over time. METHODS: We mailed surveys to half the ACP-ASIM membership in Oregon (n=550) in Fall 2000. Survey categories were developed from previous literature on career satisfaction and physician self-care. We asked respondents to rate 16 features as``not important, important, or very important'' to their current view of their career. The features included: having an adequate income, being valued by others, intellectual challenge, control of professional life, helping others, collegial relationships, being part of a team, doctor-patient relationships, working on the cutting edge of science, providing quality health care, managing own business, and others. We then asked whether expectations about these features were``not met, matched, or exceeded'' in their career currently. RESULTS: We had a 75% response rate (n = 412). We removed surveys returned from retired physicians and residents, analyzing 345 (67% male, 33% female). The highest number of physicians ranked``providing a high standard of care'' as a``very important'' feature of their career (81%), with 93% stating that this expectation was either matched or exceeded in their current work.``Physician-patient relationships'' and``helping others'' were also ranked as very important (68% and 63% respectively) and were matched or exceeded (84% and 94% respectively). 98% of respondents reported``autonomy/control over professional life'' as an important or very important to their career, yet a high proportion of unmet expectations appeared in the following areas:``having control over my professional life'' (52% unmet), and`h aving autonomy in current position'' (38% unmet). There was also high rates of unmet expectations in``making as much money as anticipated'' (42% unmet) and``work is fun'' (33% unmet). 71% report being``somewhat-very satisfied'' with their current practice situation, while 83% selected these satisfaction levels for their situations 10 years ago. 61% would go to medical school again. CONCLUSION: Overall career satisfaction appears to be declining with high unmet expectations regarding professional autonomy and control while, in this sample, internists reported that expectations regarding quality of care were generally met. Improved understanding of expectations and practice changes should help educators and professional groups in their efforts to educate and promote professional development. Part B in 1998 and 1999 . We utilized Medicare claims to measure quality of care based on whether or not beneficiaries had received an influenza immunization in 1999, a pneumococcal immunization between 1991 and 1999, whether females had a mammogram in 1998 or 1999, and whether persons with diabetes had an eye examination or a lipid profile in 1998 or 1999 or a hemoglobin A1C in 1999. We linked patients to primary care providers based on office visit claims and merged providers into practices based on common provider numbers. We restricted our analyses to 141 practices with at least 50 patients in the denominator for each quality indicator. We identified benchmarks as the 90th percentile in performance on each indicator and compared benchmark performance with median performance and performance at the 10th percentile. RESULTS: We observed large discrepancies in performance among practices on all quality indicators (see table) . Performance on certain quality measures was highly correlated (i.e. practices performing well on one measure were more likely to perform well on other measures). CONCLUSION: There is substantial variation among physician's practices in their performance on commonly utilized quality markers. Further efforts are needed to describe the characteristics of practices that are performing at the highest levels. PURPOSE: Previous attempts to improve the triage of patients with suspected acute cardiac ischemia in the Emergency Department (ED) have been disappointing. We developed and prospectively evaluated a decision aid based on a validated clinical prediction rule to determine if physicians' triage behavior would change and whether any changes would be beneficial. METHODS: We constructed a decision aid from Goldman and colleagues' published clinical prediction rule, which predicted major cardiac complications (N Engl J Med 1996) . After achieving over 80% compliance with use of the decision aid in our ED, we prospectively collected data on 1011 consecutive patients admitted from the ED with suspected cardiac ischemia during late 1999. Clinical data collected in the ED allowed us to adjust for possible differences in case mix when comparing decisions and outcomes before and after the intervention. We compared triage decisions (CCU vs. inpatient telemetry vs. observation unit or ward) and their safety and efficiency with similar patient cohorts studied prospectively in our institution during 1997 (n = 207) and 1998 ± 99 (n = 1033). Triage safety was defined as the proportion of all patients who had major cardiac complications within 3 days who were admitted to either the CCU or inpatient telemetry unit. Triage efficiency was defined as the proportion of all patients who did not have major cardiac complications who were not admitted to either the CCU or the telemetry unit. RESULTS: Among the 1011 patients, 1008 were eligible, with clinical follow-up on over 98%. Major complications occurred within 3 days for 3.5% (35/1008). A greater proportion of patients were admitted to an observation unit in 1999 compared to 1997: 35% vs. 21%; P < 0.001. In 1999, a smaller proportion of admissions to the inpatient telemetry unit were very low risk patients compared to 1998 ± 99: 41% vs. 52%; P < 0.001. Triage safety was slightly higher in 1999 compared to 1997: 94% (33/35) vs. 89% (8/9); P = 0.3. Triage efficiency was much greater in 1999: 36% vs. 21%; difference: 15 percentage points (95% CI: 8% to 21%); P < 0.001. CONCLUSION: A new decision aid changed physicians' triage decisions and improved triage efficiency without compromising triage safety. We therefore surveyed internists about how they inform patients about bad news. METHODS: A survey instrument asked how frequently physicians perform different activities in giving bad news to patients, based on a four point Likert scale. Categories included previously recommended activities involving emotional support of the patient (11 items) and those involving the proper setting (9 items). The average amount of time spent with patients while giving bad news was assessed. The impact of demographic variables on the number of emotional support items, setting and time items, and number of minutes spent informing patients were analyzed via ANOVA. All significant variables for each category were entered into a multiple linear regression model. RESULTS: Of the 961 surveys which were received by subjects, 461 (48%) were completed and returned. A majority of physicians (52 ± 93%) always or frequently performed 10 of the 11 recommended emotional support items and 6 (60 ± 92%) of the 9 proper setting items while giving bad news to patients. The average time spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the emotional support items provided to patients (p < 0.05), only 25% of respondents had any previous training in this area. A number of demographic factors were also associated with an increased number of emotional support items provided to patients, including being single (p < 0.05), being female (p < 0.005), and having personally had a life-threatening illness ( p < 0.05). CONCLUSION: By their own report, internists generally inform patients of bad news in an appropriate fashion. Some deficiencies do exist, but training in giving bad news can improve this important type of communication. Educational opportunities about how to give bad news should be provided to practicing physicians; and curricula designed for medical students and residents.