THE RELATIONSHIP BETWEEN RESOURCE CONSTRAINTS AND PHYSICIAN PROBLEM-SOLVING - IMPLICATIONS FOR IMPROVING THE PROCESS OF CARE

OBJECTIVES. Research suggests that physicians will engage in more vigi lant problem-solving under conditions of resource constraints than und er conditions of resource slack, Increased vigilance related to physic ians' clinical strategies enhances care by disposing physicians toward more optimal care choices. The authors examine whether pressures for clinical resource constraints encourage increased and sustained vigila nce in problem-solving among cardiologists treating acute myocardial i nfarction. METHODS. The physician problem-solving process is reconstru cted from the medical records of all eligible cases of acute myocardia l infarction treated by the physician sample set over a 6-year period. The sample period encompasses phases of both resource slack and resou rce constraints, The Herfindahl index is used to measure the relative amount of vigilant problem-solving activity exhibited in each of five major tactical areas of the physician care strategies in each year of the study. RESULTS. The results support the hypothesis that resource c onstraints initially promote a shift to increased vigilance in physici an problem-solving. Only one of the five major tactical areas, however , is characterized by sustained vigilance over time. The other areas a re, instead, associated with a substantial reduction in vigilant activ ity after the initial peak period. CONCLUSIONS. The results suggest th at resource constraints do set the stage for improved clinical decisio n-making. Sustained vigilance, however, appears to apply only to those portions of the care strategy for which the physician can draw a clea r link between optimizing clinical activity and reducing resource cons umption. For those portions of the care strategy for which the physici an cannot establish a clear link, ongoing pressures to conserve resour ces results in reduced vigilance and a potential reduction in quality of clinical decision-making.