Smoking status was documented at 84% of the visits on the minimal intervention team, 91% on the enhanced intervention team, and 49% on the control teams (p-value < 0.0005). Cessation counseling was documented at 36% of the visits on the minimal intervention team, 47% on the enhanced intervention team and 30% on the control teams (p-value = 0.015). The improvement in smoking status documentation was mainly noted 1) for routine and non-cardiac/pulmonary urgent care visits compared with new patient or cardiac/pulmonary urgent care visits, and 2) among nurse practitioners and a patient's primary care physician compared with residents or urgent care physicians. The trends were similar for cessation counseling documentation. Two hundred forty-five patients completed the smoking status assessment at the end of the study period: 58% were female, the mean age was 46 years, and 40% were evenly divided between the minimal and enhanced intervention teams. There were no significant differences between groups in mean length of follow-up, or median number of visits or cigarettes smoked. A total of 33 (13.5%) patients had stopped smoking by the end of the follow-up period: 4% in the minimal intervention team, 30% in the enhanced intervention team, and 11% in the control teams (p-value < 0.0005). The proportion of patients reporting increased awareness of the health risks associated with smoking or improved motivation to stop smoking was higher among the intervention (56 and 67%) than control teams (40 and 59%). CONCLUSION: An enhanced intervention that uses a short questionnaire to identify patients who smoke and assess their level of cessation readiness may significantly improve smoking cessation rates compared with minimal or no intervention. Both enhanced and minimal interventions can improve physician documentation of patient smoking status and cessation counseling. The rate of new applications to medical school in the United States has been declining over the past three years, possibly because of less interest in medicine as a career among young persons. It has been suggested, however, that even established physicians are leaving medicine for a host of reasons (e.g., financial issues, time factors). Our study attempts to qualify and describe this issue in relation to financial pressures of physicians. METHODS: We conducted a state-wide, randomized survey of 1000 Maryland chapter members of the American College of Physicians. Surveys were mailed, with a follow-up reminder letter and survey sent at one month to non-responders. The 24-item survey collected data on physician demographics, satisfaction with income, activities to generate income outside of medical practice, and plans to remain in medicine in 5 years. RESULTS: After initial mailings, the response rate was 40%. Mean age was 47.7 years, and 76.2% were male. Excluding the 11.9% of physicians who planned to retire, only 193 (62.1%) intended to remain in their current practice or position in 5 years. 11.6% felt they would still be in medicine, but in a different practice or setting, and another 6.5% expected to be in medical industry or management. A surprising 16.4% planned to be in a profession outside of medicine or were unsure about remaining in the medical field. In univariate analysis, factors associated with a desire to change positions were female gender, unmarried status, no dependents, generalist (vs. specialist), decrease in primary medical income over 5 years, and low level of satisfaction with primary medical income. If starting over, 25% of all responders would not have chosen medicine again as a career. CONCLUSION: In our survey of Maryland physicians, over 35% planned to be in a different practice or position, many not related to medicine. This documents further the growing dissatisfaction with medicine among physicians, much of which is related to financial pressures. The impact of these findings on continuity and quality of patient care deserves further study. The effects of maternal smoking on infant mortality and morbidity are well recognized. Brief physician advice has been shown to increase quit rates among pregnant smokers and to improve pregnancy outcomes. Frequent prenatal visits offer repeated opportunities for smoking cessation counseling. We evaluated how frequently physicians identify the smoking status of pregnant patients and how frequently physicians counsel pregnant smokers. METHODS: The National Ambulatory Medical Care Survey is an ongoing national survey of U.S. office based physicians. During the years 1991 through 1996, physicians answered questions both about patient smoking status and whether or not tobacco counseling was performed. We analyzed data from these six years to determine the frequency with which physicians identified the smoking status of pregnant patients and the frequency with which physicians counseled pregnant smokers. We compared smoking status identification and counseling rates for different specialties. RESULTS: 9807 physicians recorded data on 5622 visits by pregnant women. The Figure  presents is not yet widely used. A wide variety of physician order entry systems currently exists making it important to determine which systems physicians are likely to accept. While studies have evaluated physician satisfaction with institution-specific order entry systems, few published studies have assessed commercial products, even though nationally these products will represent the majority of systems that will be implemented. METHODS: We distributed the Questionnaire for User-Interface Satisfaction (QUIS) to Internal Medicine physician housestaff who use both a commercially available order entry system and the Veterans Affairs Computerized Patient Record System (CPRS). The QUIS is a validated questionnaire that has been used to measure user satisfaction with the humancomputer interface with electronic medical records. It is a twenty-seven-item survey and questions are scored on a 0 (lowest) to 9 (highest) scale. RESULTS: 90 and 84 surveys were returned giving a response rate of 63% and 64% for the commercially available product and the CPRS surveys respectively. Overall, residents were dissatisfied with the commercial system giving it an overall mean score of 3.67 (95% confidence intervals 3.37,3.97). In contrast, the Veterans Affairs CPRS had a mean score of 7.21 (95% confidence interval 7.00, 7.43) indicating the residents were more satisfied with the CPRS (pvalue < 0.0001). Overall satisfaction was strongly correlated (& = 0.71) in both surveys with the ability to perform tasks in a``straight-forward'' manner. Overall satisfaction was also correlated with terminology consistency (&=0.60, &=0.71) and screen sequence (&=0.61, &=0.67) for the commercial product and the CPRS respectively. CONCLUSION: Satisfaction with the user interface for the two order entry systems differed dramatically between the two systems, suggesting that all physician order entry systems are not equally accepted. Satisfaction was highly correlated with the ability to perform given tasks in a direct and consistent manner. These data support prior studies that have found correlations between user satisfaction and efficiency with order entry systems. If maximal benefit is to be gained from the implementation of such systems further studies are needed to investigate what specific order entry features physicians find most useful and least disruptive to daily workflow. PURPOSE: Nearly half of all California physicians still practice in solo or self-employed group practices. The recent and well-publicized demise of independent practice associations (IPA) and practice management organizations in the state has underscored the tenuous financial status of these practices. As part of a larger study about the state of physician practice in California, we interviewed community-based physicians and asked them to describe various aspects of their practice lives. We describe here the variety of approaches that physicians are taking to enhance or maintain the viability of their practices. METHODS: We interviewed fifteen physicians throughout California who spend > 50% time providing care in office-based practices. Participants were identified using the snowball sampling method. Each individual was interviewed by telephone by a study physician. The average age of participants was 41 years (31 ± 55), 43% were specialists, 36% were female and 30% practiced in community health center or public clinics. Only 13% expressed any dissatisfaction with their practices. Transcribed interviews were thematically analyzed using ATLAS 4.1 software.4.1 software. RESULTS: Physicians in solo or small group practices were more apt to discuss financial issues related to their practices than those affiliated with larger groups or with health maintenance organizations. Specific methods for improving the financial viability of their practices included improving``customer service'' for patients and referring physicians, limiting contracts with low paying insurers and or patients when feasible, lengthening work hours, shortening duration of office visits, offering supplemental patient services for out-of-pocket pay, streamlining office processes and staffing, optimizing billing and using physician extenders. A few physicians described colleagues whose response was to leave practice for administrative positions or early retirement. CONCLUSION: Physicians are experiencing financial pressures that in California have been amplified by the financial insolvency of IPAs and other practice organizations. The predominant response to improve the financial viability of their practices has been more efficient and effective utilization of existing resources (including personnel). Less common approaches include providing supplemental services that patients are willing to pay for out-ofpocket and leaving clinical practice. These experiences, to some degree, mimic those experienced by other professions such as dentistry. The frequency with which the approaches are used and their implications for access, patient outcomes and physician workforce requires further study. Virginia has the greatest number of free clinics of any state. We evaluated the type and dollar value of medical services provided in 1999. METHODS: Survey completed by the directors of all 32 clinics registered in 1999 with the Virginia Association of Free Clinics. Dollar value of services provided was estimated to be thè`u sual and customary'' charges for the region of each clinic; prescription value was estimated to be $45, the average retail price of a prescription for Virginia in 1999. Operating expenses were expenditures for clinic administration, fund raising, and direct services, excluding capital expenses.