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UBC Theses and Dissertations

Physician office site characteristics a cognitive behavioral approach Bottomley, John 1971

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PHYSICIAN OFFICE SITE CHARACTERISTICS A COGNITIVE-BEHAVIORAL APPROACH by JOHN BOTTOMLEY B.A. University of Keele 1 9 6 8 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in the Department of Geography We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1 9 7 1 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Depa rtment The U n i v e r s i t y o f B r i t i s h C olumbia V a n c o u v e r 8, Canada T h i s t h e s i s i s concerned w i t h a c o g n i t i v e - b e h a v i o u r a l approach toward l o c a t i o n t h e o r y . S p e c i f i c a l l y i t d e a l s w i t h the ' s i t e c h a r a c t e r i s t i c s ' of m e d i c a l p r a c t i c e s i t e s and t h e i r r e l a t i o n s h i p s to the 'Degree of S p e c i a l i s m ' and 'Need C o n s t r u c t s ' o f the p h y s i c i a n s o p e r a n t f r o m the s i t e s . The 'Need C o n s t r u c t ' o f p h y s i c i a n s i s seen t o v a r y between a c t o r s as a r e s u l t o f the d i f f e r e n t t e m p o r a l and f u n c t i o n a l p r a c t i c e c h a r a c t e r i s t i c s found w i t h i n the M e d i c a l Community. The p r a c t i c e s i t e l o c a t i o n d e c i s i o n s of s p e c i a l i s t p h y s i c i a n s are seen t o be dependent on the a c t o r ' s ' i n t e r n a l needs' f o r complex f u n c t i o n a l l i n k a g e s w i t h o t h e r s p e c i a l i s t p h y s i c i a n s and w i t h m e d i c a l f a c i l i t i e s such as h o s p i t a l s and d i a g n o s t i c r a d i o l o g y and l a b o r a t o r y s i t e s . P r i m a r y c a r e p h y s i c i a n s i n c o n t r a s t are seen as making p r a c t i c e s i t e l o c a t i o n d e c i s i o n s i n r e s ponse to the ' e x t e r n a l needs' of t h e i r p a t i e n t s and hence, adopt s i t e s m i n i m i z i n g i n c o n v e n i e n c e t o t h i s group. P h y s i c i a n s are thus seen, t h r o u g h f u n c t i o n and f u n c t i o n i n g as a d o p t i n g s i t e s p o s s e s s i n g those c h a r a c t e r i s t i c s t h a t w i l l s a t i s f y t h e i r dominant s e t of needs. Hence, p h y s i c -i a n s w i t h a h i g h 'Degree of S p e c i a l i s m ' adopt s i t e s w i t h a h i g h degree of l i n k a g e w i t h o t h e r p h y s i c i a n s and a n c i l l i a r y m e d i c a l f a c i l i t i e s , whereas p h y s i c i a n s w i t h a low 'Degree of S p e c i a l i s m ' adopt s i t e s t o m i n i m i z e i n c o n v e n i e n c e t o t h e i r p a t i e n t s . I n o r d e r t o t e s t the hypotheses d e r i v e d f r om the above c o n c e p t u a l s t r u c t u r e , an i n t e r v i e w s u r v e y was conducted i n V a n c o u v e r j B r i t i s h C o lumbia, Canada. I n s t r u m e n t s were d e v e l o p e d and p r e - t e s t e d u s i n g s t a n d a r d p s y c h o m e t r i c t e c h n i q u e s t o measure the 'Degree o f S p e c i a l i s m ' and the 'Need C o n s t r u c t ' o f a p h y s i c i a n a c t o r . The ' s i t e c h a r a c t e r i s t i c s ' of a m e d i c a l p r a c t i c e s i t e were measured on n i n e v a r i a b l e s f a l l i n g i n t o two groups. Group one c o m p r i s e d those v a r i a b l e s measuring the r e l a t i v e - l o c a t i o n a l a s p e c t s of a p r a c t i c e s i t e t o o t h e r p h y s i c i a n p r a c t i c e - s i t e s , d i a g n o s t i c f a c i l i t i e s , h o s p i t a l s , e t c . , whereas group two comprised v a r i a b l e s measuring i n t r i n s i c q u a l i t i e s o f the s i t e such as the number of p h y s i c i a n s p r a c t i c -i n g f r o m the s i t e . A random sample o f twenty p r i m a r y c a r e p h y s i c i a n s and twenty s p e c i a l i s t p h y s i c i a n s were i n t e r v i e w e d t o p r o v i d e the d a t a f o r the s t u d y . A h y p o t h e s i s t e s t i n g and c o r r e l a t i o n a n a l y s i s was performed on the d a t a t o t e s t the s t u d y h y p o t h e s e s . These a n a l y s e s c o n f i r m e d t h a t s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p s e x i s t e d between the 'Degree of S p e c i a l i s m ' and the 'Need Con-s t r u c t ' o f an a c t o r , between the 'Need C o n s t r u c t ' and the ' P r a c t i c e S i t e C h a r a c t e r i s t i c s ' o f an a c t o r and between the 'Degree o f S p e c i a l i s m ' and the ' p r a c t i c e S i t e C h a r a c t e r i s t i c s ' o f an a c t o r . I t was a l s o shown t h a t t h e r e e x i s t e d s t a t i s t i -c a l l y s i g n i f i c a n t d i f f e r e n c e s between the ' s i t e c h a r a c t e r i s t i c s ' o f S p e c i a l i s t and P r i m a r y Care p h y s i c i a n s . T h i s was a l s o the case f o r the "Need C o n s t r u c t s ' o f the two groups. On the b a s i s o f the a n a l y s e s conducted i t was c o n c l u d e d t h a t the c o n c e p t u a l s t r u c t u r e o f the s t u d y p r o v i d e d u s e f u l i n s i g h t s i n t o the p r o -c e s s e s of p h y s i c i a n s i t e a d o p t i o n . Recommendations f o r f u r t h e r r e s e a r c h suggest t h a t two f r u i t f u l a r e a s o f s t u d y would be t o i n v e s t i g a t e , over t i m e , changes i n the s p a t i a l p a t t e r n of the m e d i c a l community r e l a t i n g t h i s t o changes i n the f u n c t i o n a l s t r u c t u r e of the p r o f e s s i o n and t o i n v e s t i g a t e e x p l i c i t l y the r e l a t i o n s h i p s between the 'Degree of S p e c i a l i s m ' , 'Need C o n s t r u c t s ' , and ,<J 'Time Budgets' of p h y s i c i a n a c t o r s . CHAPTER Page I . THE PROBLEM DEFINED 1 The C o n c e p t u a l Paradigm 1 I n t r o d u c t i o n • 1 Purpose, f u n c t i o n and f u n c t i o n i n g . . . . 4 I m p l i c a t i o n s f o r the s t u d y o f s e r v i c e a c t i v i t y 6 The c a s e - o f m e d i c a l p r a c t i c e 1 3 The R e s e a r c h Model 24 Nature o f the model 24 The h y p o t h e s i z e d r e l a t i o n s h i p s 2 5 I I . THE METHODOLOGICAL APPROACH OF THE STUDY. . . 2 8 The Sample o f A c t o r s 2 8 The p o p u l a t i o n 2 8 The sample 2 9 The I n t e r v i e w Schedule 2 9 C o n s t r u c t i o n o f the p r e l i m i n a r y i n s t r u m e n t s and the p r e - t e s t 2 9 I t e m a n a l y s i s o f the p r e l i m i n a r y i n s t r u m e n t 3 0 The method o f d a t a c o l l e c t i o n 3 1 The S i t e D a t a 3 2 The s i t e v a r i a b l e s 3 2 The method o f d a t a c o l l e c t i o n 3 3 I I I . DATA ANALYSIS AND RESULTS 3 4 The G e n e r a l Approach t o the A n a l y s i s . . . . 3 4 The S i t e D a t a 3 4 The l e v e l o f measurement o f the s i t e v a r i a b l e s 3 4 The d i s t r i b u t i o n s o f the s i t e v a r i a b l e s 3 5 The I n t e r v i e w Schedule Data 4 2 The i n s t r u m e n t 4 2 Need 4 2 The degree of s p e c i a l i s m s c a l e 5 2 The Hypotheses 5 8 H y p o t h e s i s one 5 8 H y p o t h e s i s two 5 9 H y p o t h e s i s t h r e e 6 2 H y p o t h e s i s f o u r 6 3 IV. SUMMARY OF MAJOR FINDINGS AND RECOMMENDATIONS FOR FUTURE RESEARCH . . . . 6 9 Summary o f the Major F i n d i n g s 6 9 Degree of s p e c i a l i s m can be measured. . . 6 9 The need c o n s t r u c t o f an a c t o r can be measured 7 0 Need r e l a t e s t o degree o f s p e c i a l i s m . . . 7 1 Need r e l a t e s t o s i t e c h a r a c t e r i s t i c s . . . 7 2 Degree o f s p e c i a l i s m r e l a t e s t o s i t e c h a r a c t e r i s t i c s 7 2 S u g g e s t i o n s f o r F u t u r e R e s e a r c h 7 3 The need f o r a s t r u c t u r a l a n a l y s i s . . . . 7 3 The need f o r an e x p l i c i t l i n k a g e a n a l y s i s 7 5 LITERATURE CITED 7 7 APPENDIX A. The S i t e V a r i a b l e s , 8 l B. The I n t e r v i e w Schedule 8 2 C. The Degree o f S p e c i a l i s m S c a l e 9 1 D. P o i n t B i s e r i a l C o r r e l a t i o n s Between Degree of S p e c i a l i s m S c a l e I t e m Responses and S c a l e Score 9 2 E. The P r e l i m i n a r y I n s t r u m e n t Used i n the P r e - T e s t 9 3 F. P o i n t B i s e r i a l C o r r e l a t i o n s Between Item Responses and S c a l e Score on the P r e l i m i n a r y I n s t r u m e n t 1 0 3 G. Tree Graph of Need Grouping A n a l y s i s . . . . 104 LIST OF TABLES 3 . 1 C o n t i n g e n c y t a b l e o f s i t e v a r i a b l e s t h r e e . . . 41 3 . 2 C o n t i n g e n c y t a b l e o f s i t e v a r i a b l e s i x • 41 3.3 C o n t i n g e n c y t a b l e o f s i t e v a r i a b l e seven. . . . 41 3.4 C o n t i n g e n c y t a b l e of s i t e v a r i a b l e e i g h t . . . . 4 2 3-5 S t i m u l i p r e s e n t e d i n the need s c a l e 43 3.6 Rank o r d e r f r e q u e n c y m a t r i x o f p r i m a r y ca r e p h y s i c i a n s . .' 44 3.7 Rank o r d e r f r e q u e n c y m a t r i x o f s p e c i a l i s t p h y s i c i a n s 45 3 . 8 Composite r a n k i n g s o f s p e c i a l i s t p h y s i c i a n s . . 47 3.9 Composite r a n k i n g s o f p r i m a r y ca r e p h y s i c i a n s . 47 3 . 1 0 S p e c i a l t i e s o f p h y s i c i a n s i n the f o u r need groups 5 1 3 . 1 1 Rank on degree o f s p e c i a l i s m s c a l e and s p e c i a l t y of sample p h y s i c i a n s 57 3 . 1 2 R e l a t i o n s h i p between a c t o r need c o n s t r u c t and degree o f s p e c i a l i s m . 59 3 . 1 3 R e l a t i o n s h i p between a c t o r need c o n s t r u c t and a c t o r p r a c t i c e s i t e c h a r a c t e r i s t i c s . . . 6l 3 . 1 4 R e l a t i o n s h i p between a c t o r degree of s p e c i a l i s m s c o r e and a c t o r p r a c t i c e s i t e c h a r a c t e r i s t i c s 64 3.15 Mann-Whitney TJ t e s t r e s u l t s : p r i m a r y c a r e vs.. s p e c i a l i s t p h y s i c i a n s 66 3.16 x t e s t r e s u l t s : p r i m a r y c a r e v s . s p e c i a l i s t p h y s i c i a n s 67 LIST OF FIGURES FIGURE Page 1.1 The r e s e a r c h model o f the s t u d y 25 • 3.1 Histograms o f s i t e v a r i a b l e one 36 3.2 Histograms o f s i t e v a r i a b l e two. . . . . . . 37 3.3 Histograms o f s i t e v a r i a b l e f o u r 38 3.4 Histograms of s i t e v a r i a b l e f i v e 39 3.5 Histograms o f s i t e v a r i a b l e n i n e 40 ACKNOWLEDGEMENTS I w o u l d . f i r s t l i k e t o thank P r o f e s s o r s W. G. Hardwick and R. J . C l a u s o f the Department o f Geography, U.B.C. As my a d v i s o r s they h e l p e d and encouraged a t a l l s t a g e s o f t h i s p r o j e c t . S p e c i a l thanks are a l s o due t o P r o f e s s o r D. P. Hardwick o f the Department o f P a t h o l o g y , U.B.C, f o r h i s k i n d h e l p i n s e t t i n g up the i n t e r v i e w s and to Dr. Ka r e n E. C l a u s of the U n i v e r s i t y o f C a l i f o r n i a , San F r a n c i s c o M e d i c a l C e n t r e f o r h e r i n v a l u a b l e h e l p i n the d e s i g n o f the stu d y s c a l e s . I must a l s o thank a l l those p h y s i c i a n s , too numerous to mention p e r s o n a l l y , who gave of t h e i r time t o make t h i s s t u d y p o s s i b l e . I would a l s o l i k e t o thank the U n i v e r s i t y of B r i t i s h Columbia f o r the f i n a n c i a l s u p p o r t they showed f o r the p r o j e c t and a l s o the C e n t r a l Mortgage and Housing C o r p o r a -t i o n whose r e s e a r c h g r a n t t o s t u d y the Urban L o c a t i o n a l D e c i s i o n s o f S p e c i f i c Urban i n t e r e s t groups h e l p e d f i n a n c e p a r t of the p r o j e c t . Any c r e d i t f o r the diagrams i s due t o Dave R o t h w e l l whose w i f e Judy a l s o t y p e d a d r a f t . F i n a l l y I would l i k e t o thank Mrs. R. Ley who ty p e d the f i n a l t h e s i s and a l l . t h o s e p e o p l e who i n some way or another h e l p e d see t h i s t h e s i s completed. THE PROBLEM DEFINED T h i s t h e s i s concerns i t s e l f w i t h a ' c o g n i t i v e -b e h a v i o r a l ' approach t o l o c a t i o n t h e o r y i n w h i c h the concept of 'user-need c o n s t r u c t ' i s c e n t r a l . The s t u d y f o c u s e s on the l o c a t d i o n a l d e c i s i o n o f p r a c t i c e s i t e l o c a t i o n o f a sample of p h y s i c i a n s as these r e l a t e t o the 'need c o n s t r u c t ' o f the u s e r s o f the s i t e and to the 'degree of s p e c i a l i s m ' o f the p h y s i c i a n . I . THE CONCEPTUAL PARADIGM I n t r o d u c t i o n The s t r u c t u r a l approach t o s e r v i c e a c t i v i t y . One f i e l d i n w h i c h urban geographers have been p a r t i c u l a r l y a c t i v e i s i n the s t u d y o f the i n t r a urban l o c a t i o n o f t e r t i a r y a c t i v i t y . The f o c u s of much o f t h i s work has been the s t u d y of i n t r a urban r e t a i l i n g p a t t e r n s ; w h i c h had i t s f o u n d a t i o n s i n the t y p o l o g y o f urban r e t a i l c l u s t e r s produced by P r o u d f o o t i n the l a t e 1 9 3 0 ' s ( P r o u d f o o t , 1 9 3 7 and 1 9 3 8 ) , growing out o f the e x i s t i n g s o c i a l e c o l o g y (see B a r g e s s , 1 9 2 5 and P a r k , 1 9 2 5 ) and urban hand r e n t (see H a i g , 1 9 2 6 ) l i t e r a t u r e . B u i l d i n g upon t h i s work, and i n c o r p o r a t i n g t h e i r f i n d i n g s I n t o the frame-work o f C e n t r a l P l a c e Theory, B e r r y and numerous o t h e r workers have produced a h o s t o f t h e o r e t i c a l s t a t ements and e m p i r i c a l s t u d i e s w i t h i n the p a s t t e n y e a r s (see f o r example B e r r y , 1 9 5 9 , 1 9 6 3 and 1 9 6 7 ; Garner, 1 9 6 6 ; Simmons, 1 9 6 4 and 1 9 6 6 ) . These w o r k e r s , s t a r t i n g f r o m the p o s t u l a t e s of c e n t r a l p l a c e t h e o r y , assume b o t h p r o d u c e r s and consumers t o be b o u n d l e s s l y r a t i o n a l economic men and attempt t o account f o r r e a l w o r l d d e v i a t i o n s f r o m p r e d i c t e d p a t t e r n s by r e f e r e n c e t o the v i o l e n c e wrought on the t h e o r y ' s assumptions by the ' r e a l w o r l d ' . A t h e o r e t i c a l 'economic l a n d s c a p e ' thus d e v e l o p s i n w h i c h ' c o n s u m e r - v a r i a b l e s ' determine the p a t t e r n o f a c t i -v i t y , i n t e r a c t i o n e t c . i . e . e n t r e p r e n e u r s l o c a t e i n response t o the s p a t i a l v a r i a b i l i t y of demand so as t o maximize p r o f i t s . I n such an 'economic l a n d s c a p e ' s i t e c h a r a c t e r i s t i c s and l o c a t i o n s r e s u l t f r o m the response o f b o u n d l e s s l y r a t i o n a l economic men t o a p a t t e r n of demand c h a r a c t e r i s t i c s . The b e h a v i o r a l , approach t o s e r v i c e a c t i v i t y . R e c e n t l y , geographers have e x p l i c i t l y r e c o g n i z e d the l i m i t a t i o n s o f such an approach and have t e n t a t i v e l y f o r m u l a t e d ' c o g n i t i v e -b e h a v i o r a l ' approaches toward an e x p l a n a t i o n o f u r b a n - r e t a i l p a t t e r n s . These have e x p l i c i t l y r e c o g n i z e d t h a t consumer b e h a v i o r (see G o l l e g e and Brown, 1 9 ^ 7 ; G o l l e g e , 1 9 6 7 ; and E n g e l e t a l . , 1 9 6 8 ) and the b e h a v i o r o f the e n t r e p r e n e u r (see P r e d , 1 9 6 7 and 1 9 6 9 ) are more complex than the p o s t u -l a t e s of C e n t r a l P l a c e Theory a l l o w and attempt t o ge n e r a t e s t a t e m e n t s r e g a r d i n g s p a t i a l f o r m f r o m b e h a v i o r a l p o s t u l a t e s r a t h e r t h a n i n f e r i n g human b e h a v i o r f r o m an ob s e r v e d s p a t i a l p a t t e r n . These s t u d i e s e x p l i c i t l y i n v e s t i g a t e the ' p r o c e s s e s ' o f s p a t i a l o r g a n i z a t i o n r a t h e r t h a n the s p a t i a l s t r u c t u r e i t s e l f . As Harvey n o t e d "the laws of s p a t i a l p a t t e r n do not n e c e s s a r i l y t e l l us a n y t h i n g as r e g a r d s p r o c e s s " (Harvey, 1967, p. 8) and K i n g s a i d " . . . e x i s t i n g t h e o r e t i c a l s t a tements i n Geography appear weak..., i t i s u s u a l l y the case t h a t the b a s i c s p a t i a l s t r u c t u r e appears as g i v e n , r a t h e r than as a l o g i c a l consequence of the t h e o r y " ( K i n g , 19^ 9? p. 593)• The major works i n ' c o g n i t i v e b e h a v i o r a l ' l o c a t i o n t h e o r y p u b l i s h e d t o date have been the monographs of P r e d (1967, and 1969). Pred's b a s i c t h e s i s i s t h a t " e v e r y l o c a t i o n a l d e c i s i o n i s viewed as o c c u r r i n g under c o n d i t i o n s o f v a r y i n g i n f o r m a t i o n a b i l i t y , r a n g i n g , a t l e a s t t h e o r e t i -c a l l y , f r o m n u l l t o p e r f e c t knowledge of a l l . a l t e r n a t i v e s and as b e i n g governed by the v a r y i n g a b i l i t i e s (as w e l l as o b j e c t i v e s ) of the d e c i s i o n m a k e r ( s ) . I n the b e h a v i o r a l m a t r i x the i n f o r m a t i o n v a r i a b l e i s d e p i c t e d on the v e r t i c a l a x i s , and the a b i l i t y t o use v a r i a b l e , w h i c h t h e o r e t i c a l l y ranges f r o m t o t a l i n e p t i t u d e t o an a p t i t u d e f o r o p t i m a l s o l u t i o n , i s r e p r e s e n t e d on the h o r i z o n t a l a x i s . Hence, i n any g i v e n s i t u a t i o n , each l o c a t i o n a l d e c i s i o n making u n i t or a c t o r , be i t a s i n g l e p e r s o n o r a f i r m can be thought of as h a v i n g a r e a l s p a t i a l a t t r i b u t e , ( s i t e and s i t u a t i o n , l a n d use or p a t h o f movement) t h a t i s r e p r o d u c a b l e (convey-a b l e ) on a map, and b e h a v i o r a l q u a l i t i e s t h a t can be hypo-t h e t i c a l l y l o c a t e d i n the b e h a v i o r a l m a t r i x " ( P r e d , 1967> p. 24). I n t h i s f o r m u l a t i o n the s i t e c h a r a c t e r i s t i c s o f an a c t i v i t y a re seen as a f u n c t i o n of the g o a l s ( o b j e c t i v e s ) , a b i l i t i e s and. i n f o r m a t i o n of the e n t r e p r e n e u r i a l a c t o r . The ' b e t t e r ' the ' i n f o r m a t i o n ' and ' a b i l i t y t o use' o f an a c t o r the h i g h e r w i l l be the ' q u a l i t y ' o f the s i t e chosen i n terms of the c r i t e r i a e s t a b l i s h e d by the a c t o r ' s g o a l . The f o l l o w i n g d i s c u s s i o n a t t e m p t s t o c l a r i f y the p r o b l e m o f c o n s i d e r i n g the ' s i t e c h a r a c t e r i s t i c s ' o f a g i v e n i n t r a c i t y a c t i v i t y w i t h i n the framework e s t a b l i s h e d above. C e n t r a l c o n c e p t s of the d i s c u s s i o n are those o f Need Con-s t r u c t , F u n c t i o n , F u n c t i o n i n g and Purpose. These c o n c e p t s w i l l be d i s c u s s e d i n the n e x t s e c t i o n . P u r p o s e , F u n c t i o n and F u n c t i o n i n g D e f i n i t i o n s . I n p s y c h o l o g i c a l usage "A f u n c t i o n i s an a c t i o n o f a s t r u c t u r e ; a p u r p o s e , an i n t e n t i o n t o a c t ; a f u n c t i o n i n g , the f u n c t i o n i n o p e r a t i o n . To summarize how the t h r e e d i f f e r ; the a c t i o n c a l l e d a w a l k i s a f u n c t i o n ; the a c t i v i t y o f w a l k i n g i s a f u n c t i o n i n g ; and the i n t e n t i o n t o w a l k i s a p u r p o s e " (Cowley, 1966, p. 59). Most psycho-l o g i c a l work concerned w i t h f u n c t i o n and f u n c t i o n i n g concerns i t s e l f w i t h need, a complex phenomena d i s c u s s e d below. Need. Need i s a c o n s t r u c t , i . e . a concept o f f e r e d as a way o f e x p l a i n i n g o b s e r v a t i o n s and has been viewed f r o m d i f f e r e n t vantage p o i n t s . Most t h e o r e t i c a l d i s c u s s i o n s o f need make r e f e r e n c e t o b o t h p h y s i o l o g i c a l and p s y c h o l o g i c a l needs. Maslow ( 1 9 5 4 ) l i s t e d the ' b a s i c needs' as p h y s i o l o g i -c a l needs, s a f e t y needs, b e l o n g i n g n e s s and l o v e needs, esteem needs, and the need f o r s e l f a c t u a l i z a t i o n . H u l l ( 1 9 4 3 ) and Tolman ( 1 9 3 8 ) have s i m i l a r need systems b u t o t h e r p s y c h o l o -g i s t s have c o n s t r u c t e d much l o n g e r l i s t s . Murray ( 1 9 3 8 ) f o r example l i s t e d t w e l v e v i s c e r o g e n i c ( p h y s i o l o g i c a l ) and t w e n t y - e i g h t p s y c h o g e n i c needs. M c C l e l l a n d i n a s e r i e s o f a r t i c l e s has a l s o d e v e l o p e d a complex need system. The i m p o r t a n t concept i s t h a t need i s a ' c o n s t r u c t ' or con c e p t -u a l i z a t i o n and i s i n f e r e d f rom o v e r t b e h a v i o r . A need e x i s t s o n l y when an a c t o r behaves c o n s i s t e n t l y i n a way p r e d i c t e d by the need c o n s t r u c t . A work o f w a r n i n g i s g i v e n by H i l g a r d and A t k i n s o n . "An i n v e n t o r y of b e h a v i o r w i l l n o t be an i n v e n t o r y o f m o t i v e s ( g o a l s ) because the motive has t o be i n f e r r e d by a somewhat complex p r o c e s s . There i s a s t r o n g t e m p t a t i o n , however, t o p r e p a r e c l a s s i f i c a t i o n s o f m o t i -v a t i o n a l d i s p o s i t i o n s (needs) c l o s e l y r e l a t e d t o human b e h a v i o r i n a l l i t s v a r i e t y " ( H i l g a r d and A t k i n s o n , 1 9 6 7 . , p. 1 3 9 ) - "The same h o l d s t r u e f o r f u n c t i o n s . F u n c t i o n can o n l y be d e f i n e d i n terms o f b e h a v i o r " ( C l a u s , 1 9 6 9 ( b ) , p. 1 6 ) . A s i m i l a r work o f w a r n i n g has been g i v e n by G o l l a n t ( 1 9 7 0 ) who i n d i s c u s s i n g i n t r a - u r b a n m i g r a t i o n s t r e s s e s t h a t the o v e r t b e h a v i o r of an a c t o r i s a r e f l e c t i o n of b o t h the M o t i v a t i o n (needs, d r i v e s e t c . d i r e c t e d toward g o a l s ) and of the M o t i l i t y ( i . e . the c a p a b i l i t y of b e i n g M o b i l e ) o f the a c t o r , i . e . the f a c t t h a t an i n d i v i d u a l ' s o v e r t b e h a v i o r i s to r e m a i n i n h i s nei g h b o r h o o d does not i m p l y t h a t he i s not 'mo t i v a t e d ' t o m i g r a t e . T h i s can o n l y o ccur i f the i n d i v i -d u a l ' s ' m o t i l i t y ' makes him ca p a b l e of m i g r a t i n g . I m p l i c a t i o n s f o r the Study o f S e r v i c e A c t i v i t y S u p p l i e r - c o n s u m e r need c o n s t r u c t s . The c o n c e p t s o f need c o n s t r u c t s , p u r p o s e , f u n c t i o n and f u n c t i o n i n g are cen-t r a l t o any d i s c u s s i o n of the s i t e c h a r a c t e r i s t i c s o f a s e r v i c e a c t i v i t y . B o t h s u p p l i e r s and consumers have need c o n s t r u c t s ( t h e term s u p p l i e r i s used here t o cover s u p p l i e r s o f b o t h goods and s e r v i c e s ) . These need s t r u c t u r e s d i f f e r and as such so do the f u n c t i o n and f u n c t i o n i n g o f the a c t o r s as t h e y a t tempt t o s a t i s f y the g o a l s (purposes) produced by t h e i r c o r r e s p o n d i n g need c o n s t r u c t . The e f f e c t o f these d i f f e r e n c e s on the s i t e c h a r a c t e r i s t i c s o f a s e r v i c e a c t i v i t y w i l l now be d i s c u s s e d . The dominance o f the s u p p l i e r o r consumer need  c o n s t r u c t . I t i s a s s e r t e d t h a t one o f the s u p p l i e r or con-sumer need c o n s t r u c t s w i l l dominate the o t h e r i n i t s i n f l u e n c e on the s i t e c h a r a c t e r i s t i c s of an a c t i v i t y and t h a t t h e s e w i l l o n l y be seen t o produce ' r a t i o n a l p a t t e r n s ' when the s i t e s are seen to f i t i n t o the need c o n s t r u c t o f the dominant s e t o f a c t o r s , i . e . i n t o the s u p p l i e r s need c o n s t r u c t or the consumers need c o n s t r u c t . The concept o f a 'dominant need c o n s t r u c t ' i s s i m i l a r t o the ' p r i n c i p l e of a c t i o n ' w h i c h i s c e n t r a l t o d i s c u s s i o n s o f g o a l o r i e n t e d b e h a v i o r r e s u l t i n g f r o m the 'need c o n s t r u c t ' o f an i n d i v i d u a l . "Whether we are t a l k i n g about consummatory o r i n s t r u m e n t a l a c t i v i t y we d e s i r e e v e n t u a l l y t o p r e d i c t when an o r g a n i s m w i l l s h i f t f r o m one u n i t o f a c t i v i t y t o a n o t h e r , what a c t i v i t y the or g a n i s m w i l l s h i f t t o , and a l s o the i n t e n s i t y w i t h w h i c h the or g a n i s m w i l l engage i n the a c t i v i t y . To do t h i s , we have s t a t e d t h a t we need t o know the s t r e n g t h o f t e n d e n c i e s a t a moment i n t i m e . . We have assumed a p r i n c i p l e o f a c t i o n t h a t s t a t e s t h a t  the s t r o n g e s t o f a s e t o f t e n d e n c i e s competing a t a g i v e n  moment w i l l be evoked as an a c t i v i t y " ( B i r c h and V e r o f f , 1 9 6 6 , p. 2 ) . I m p l i c i t w i t h i n much o f the work on i n t r a u r b a n s e r v i c e a c t i v i t y i s the assu m p t i o n t h a t i t i s the consumer •need c o n s t r u c t ' t h a t i s the dominant i n f l u e n c e on the s i t e c h a r a c t e r i s t i c s o f the a c t i v i t y . A r e v i e w o f some o f the l i t e r a t u r e i s here a p p r o p r i a t e . Consumer need c o n s t r u c t s i n the g e o g r a p h i c l i t e r a t u r e . The b i g g e s t body o f l i t e r a t u r e i n w h i c h i t i s i m p l i e d t h a t the consumer's 'need c o n s t r u c t ' i s the dominant one i s i n the C e n t r a l P l a c e l i t e r a t u r e , o r more s p e c i f i c a l l y the l i t e r a t u r e on i n t r a u r b a n . t e r t i a r y a c t i v i t y . B e r r y and P r e d say "The f e a t u r e s o f C h r i s t a l l e r ' s t h e o r y are now w e l l known. I n b r i e f t h e s e f e a t u r e s are t h a t the b a s i c f u n c t i o n o f a c i t y i s t o be a c e n t r a l p l a c e p r o v i d i n g goods and s e r v i c e s f o r a s u r r o u n d i n g t r i b u t a r y a r e a . The term ' c e n t r a l p l a c e 1 i s used because to p e r f o r m such.a f u n c t i o n e f f i c i e n t l y a c i t y l o c a t e s a t the c e n t r e of minimum aggregate t r a v e l f o r i t s t r i b u t a r y a r e a " ( B e r r y and P r e d , 1965, p. 3). They go on t o s t a t e t h a t they c o n s i d e r t h i s p r i n c i p l e h o l d s i n r e g a r d t o the t r i b u t a r y a r e a s of t e r t i a r y a c t i v i t i e s w i t h i n the c i t y " . . . c e n t r a l p l a c e t h e o r y i s a t h e o r y o f the l o c a t i o n o f t e r t i a r y a c t i v i t i e s . Yet ( i t i s ) more g e n e r a l because i t a l s o a p p l i e s w i t h i n c i t i e s " ( B e r r y .and P r e d , 1965, p. 6). There i s a c l e a r i m p l i c a t i o n i n t h i s approach t h a t the l o c a t i o n and s i t e c h a r a c t e r i s t i c s o f an a c t i v i t y are depen-dent upon consumer g o a l s and s t r a t e g i e s t h a t are implemented t o s a t i s f y the consumers' need s t r u c t u r e . B e r r y and Pred's i n t e r p r e t a t i o n o f C h r i s t a l l e r appears t o a c c u r a t e l y r e p r e s e n t h i s p o s i t i o n " . . . C o n s e q u e n t l y the most f a v o r a b l e s i t u a t i o n must l i e somewhere between where a l l demands are s a t i s f i e d and where no demands are s a t i s f i e d . I t must l i e where as many demands as p o s s i b l e are s a t i s f i e d , and where, s i m u l -t a n e o u s l y the s e r v i c e r e s u l t s i n an income as h i g h as p o s s i b l e f o r the one who o f f e r s the c e n t r a l g o o d . . . . I f the c e n t r a l p l a c e where the d o c t o r p r a c t i c e s does n o t l i e a t the c e n t r e o f the r e g i o n and i t s d i s p e r s e d p o p u l a t i o n , b u t r a t h e r l i e s e c c e n t r i c a l l y , t h e n the consumption of c e n t r a l goods, and a c c o r d i n g l y , the income o f the d o c t o r , a r e not maximized. I n t h i s i n s t a n c e , r e l a t i v e l y more p e o p l e l i v e a g r e a t e r d i s t a n c e f r o m h i s o f f i c e , and t h e r e f o r e r e l a t i v e l y more people are t o a l e s s e r degree i n the market f o r c e n t r a l goods" ( C h r i s t a l l e r , 1966, p. 31). More e x p l i c i t s t a t e m e n t s come f r o m B e r r y " T h i s s u c c e s s i v e e l a b o r a t i o n c u l m i n a t e s w i t h i n a major m e t r o p o l i s l i k e C h i c a g o , i n w h i c h seven m i l l i o n p e o p l e s p r e a d a c r o s s n i n e c o u n t i e s i n two s t a t e s . The o v e r a l l p a t t e r n o f consumer o r i e n t a t i o n o f b u s i n e s s l a n d  use r e m a i n s " ( B e r r y , 1967^  p. 44) and Simmons "From the knowledge of i t s customers each f i r m , c o n s c i o u s l y or n o t , d e f i n e s a s u r f a c e o f r e n t p a y i n g a b i l i t y over the c i t y on the b a s i s of the s a l e s i t can e x p e c t a t v a r i o u s p l a c e s . T h i s  i n d i f f e r e n c e s u r f a c e i s a f u n c t i o n of p o p u l a t i o n , income d i s t r i b u t i o n , t r a f f i c f l o w s , l o c a t i o n s of o t h e r b u s i n e s s t y p e s and c o m p e t i t o r s . There i s another s u r f a c e of a c t u a l l a n d r e n t s a c r o s s the c i t y . A c c o r d i n g t o l a n d v a l u e t h e o r y t h i s i s the r e n t w h i c h the h i g h e s t and b e s t use a t t h a t p o i n t can a f f o r d . I t i s the l i m i t i n g o u t e r s u r f a c e , an 'envelope' e n c l o s i n g the whole s e t of b i d r e n t s u r f a c e s d e f i n e d by i n d i v i d u a l f i r m s . The f i r m under c o n s i d e r a t i o n w i l l s e l e c t l o c a t i o n s a l o n g l i n e s o r w i t h i n a r e a s of tangency of these two s u r f a c e s , i . e . where i t s r e n t p a y i n g a b i l i t y i s as h i g h or h i g h e r t h a n any o t h e r l a n d use. The b i d r e n t s u r f a c e o f each f i r m i s unique: each f i r m a p p e a l s t o a s p e c i a l s e t of customers" (Simmons, 1964, p. 34). T h i s i s the approach d i s c u s s e d a t the b e g i n n i n g of the c h a p t e r , i m p l i c i t w i t h i n the assumptions o f w h i c h i s the assu m p t i o n o f the dominance of the consumer need c o n s t r u c t . S u p p l i e r need c o n s t r u c t s i n the g e o g r a p h i c l i t e r a t u r e . T h i s i s n o t the p l a c e f o r a l o n g c r i t i q u e of the u n d e r l y i n g assumptions o f such w o r k e r s ; made as they a re t o a i d i n the d e d u c t i o n o f m a t h e m a t i c a l l y f o r m u l a t e d t h e o r y . S u f f i c e t o say t h a t a l t h o u g h the assu m p t i o n o f dominance of consumer need c o n s t r u c t may be v a l i d when convenience r e t a i l i n g i s b e i n g c o n s i d e r e d i t i s v e r y q u e s t i o n a b l e i f t h i s i s so f o r a l l t e r t i a r y a c t i v i t y . McCarty and L i n d b e r g o f f e r a word of w a r n i n g r e g a r d i n g the s e r v i c e a c t i v i t i e s : "The l o c a t i o n a l a f f i n i t i e s between the s e r v i c e and the s p a t i a l d i s t r i b u t i o n of demand f o r them are p a r t i c u l a r l y s t r o n g . A l l o f us know the p r i n c i p a l r e a s o n s why the s e c o n d i t i o n s p r e v a i l . The s e r v i c e s g e n e r a l l y a re c l a s s i f i e d as e x t r e m e l y ' p e r i s h a b l e ' and most of them must be performed w h i l e i n c l o s e p r o x i m i t y t o the p u r c h a s e r . S e r v i c e e s t a b l i s h m e n t s thus t e n d t o be l o c a t e d near the customer, an a f f i n i t y t h a t i s s t r e n g t h e n e d by the f a c t t h a t i n many cases the work can be performed by s m a l l a g g r e g a t i o n s ' o f w o r k e r s , even lon e i n d i v i d u a l s , i n some c a s e s . G e n e r a l i z a t i o n s o f the s e s o r t s have prompted many s t u d e n t s of Geography t o d i s m i s s the s e r v i c e s as b e i n g found 'wherever t h e r e are pe o p l e w i t h money'. We are d i s - c o v e r i n g however, t h a t the geography of the s e r v i c e s i s much too c o m p l i c a t e d t o w a r r a n t such g e n e r a l c o n c l u s i o n s and t h a t i t m e r i t s d e t a i l e d s t u d y i n i t s s e v e r a l component b r a n c h e s " (McCarty and L i n d b e r g , 1966, p. 113). Other workers have found t h a t the g e n e r a l i z a t i o n s o f t e n b r e a k down even when r e t a i l i n g i s b e i n g d i s c u s s e d . C l a u s f o u n d t h a t t h e r e e x i s t e d a high' " c o r r e l a t i o n between the ' g o a l s ' o f the s u p p l i e r and s i t e c h a r a c t e r i s t i c s i n h i s s t u d y of the g a s - r e t a i l i n g i n d u s t r y . "Evidence o f d i f f e r e n c e s i n c o r p o r a t e g o a l s among the a c t o r s was n o t e d i n s i t e r a t i n g s and i n i n t e r v i e w s . Some companies o p t e d f o r h i g h g a l l o n a g e f a c i l i t i e s . T h i s purpose was o f t e n s t a t e d i n the i n t e r v i e w s and was a l s o a p p a r e n t i n the s i t e r a t i n g s . Two companies w h i c h s t a t e d h i g h g a l l o n a g e g o a l s as of p r i m a r y importance had a l a r g e share of the h i g h e r pumping s i t e s . Other companies, one i n p a r t i c u l a r , o p t e d f o r l o n g - l i v e d f a c i l i t i e s . T h i s g o a l was s t a t e d i n the i n t e r v i e w s i n terms of p r e f e r e n c e s . G e n e r a l l y the f a c i l i t i e s o f these a c t o r s had s i t e r a t i n g s i n the middl e t o lower g a l l o n a g e r a n g e s . None of these companies had s i t e s r a t e d i n the h i g h e r r a n g e s " ( C l a u s , 1969(a), p. 17). I n t h i s b r a n c h o f r e t a i l i n g the s u p p l i e r s need c o n s t r u c t would appear t o be dominant. F u r t h e r e v i d e n c e of the impor-tance o f s u p p l i e r need c o n s t r u c t s i s g i v e n by R a n n e l l s i n h i s d i s c u s s i o n o f downtown a c t i v i t y . " E s t a b l i s h m e n t s s e r v e as bases of o p e r a t i o n s , b o t h f o r o r g a n i z a t i o n s (such as b u s i n e s s f i r m s , government a g e n c i e s ) and f o r i n d i v i d u a l s (members o f e s t a b l i s h m e n t s ) engaged i n the a c t i v i t i e s of these o r g a n i z a t i o n s . I n d e a l i n g w i t h the v a r i o u s systems of a c t i v i t y as t h e y converge on e s t a b l i s h m e n t s , i t w i l l be u s e f u l t o s i m p l i f y systems of a c t i o n and t h e i r e f f e c t by d e a l i n g w i t h the r o l e s p l a y e d by e s t a b l i s h m e n t s i n much the same way t h a t the r o l e s i n w h i c h p e o p l e a c t are used t o s i m p l i f y the t a n g l e o f a c t i v i t i e s a t the p e r s o n a l l e v e l " ( R a n n e l l s , 1956, p. 23); and "The a t t i t u d e s and e x p e c t a t i o n s . . . . o f o r g a n i z a t i o n s j u d g i n g . . . e s t a b l i s h m e n t s as they may  a f f e c t b u s i n e s s r e l a t i o n s h i p s are compounded o f b o t h o b j e c -t i v e and s u b j e c t i v e elements: the s t u b b o r n f a c t s o f each s i t u a t i o n and the e v a l u a t i o n o f the s e f a c t s , w h i c h may or may n o t be r e a l i s t i c and o b j e c t i v e . B o t h the f a c t s and t h e i r e v a l u a t i o n change; b o t h are p o w e r f u l f a c t o r s i n the a l l o c a t i o n o f a c t i v i t i e s t o d i f f e r e n t l o c a t i o n s " ( R a n n e l l s , 1956, p. 29). The consumer i n t h i s f o r m u l a t i o n i s o f minor importance i n d e t e r m i n i n g the l o c a t i o n and s i t e c h a r a c t e r -i s t i c s o f an a c t i v i t y . Type of s i t e as a f u n c t i o n o f the dominant need  c o n s t r u c t . I t has been argued t h r o u g h r e f e r e n c e t o the r e l e v a n t l i t e r a t u r e t h a t the s i t e c h a r a c t e r i s t i c s o f an a c t i v i t y o n l y f o r m r a t i o n a l p a t t e r n s when t h e y a re viewed as a f u n c t i o n of the need c o n s t r u c t o f the dominant s e t o f a c t o r s . That the ' q u a l i t y ' o f a s i t e i s a f u n c t i o n o f the b e h a v i o r a l c h a r a c t e r i s t i c s of the s u p p l i e r i s a concept i n t r o d u c e d by P r e d (1969); i . e . as the ' i n f o r m a t i o n ' and ' a b i l i t y t o use' s c o r e s o f an e n t r e p r e n e u r i n c r e a s e so does the ' s p a t i a l l o g i c ' o f the aggregate l o c a t i o n a l d e c i s i o n s made. T h i s p o i n t i s w e l l t a k e n b u t i t i s argued t h a t b e f o r e Pred's model becomes c o n c e p t u a l l y c l e a r i t must be a c c e p t e d t h a t the 'type' o f s i t e i s a l s o dependent o f the b e h a v i o r a l c h a r a c t e r i s t i c s o f e i t h e r the s u p p l i e r or the consumer. Pred's ' b e h a v i o r a l m a t r i x ' i s i n essence a ' c o n s t r a i n t m a t r i x ' and c o r r e s p o n d s t o G o l l a n t ' s (1970) M o t i l i t y f a c t o r . A t r u e ' b e h a v i o r a l m a t r i x ' would be concerned w i t h such con-c e p t s as "'goal', 'need', e t c . D i f f e r e n t s u p p l i e r s have d i f f e r e n t g o a l s , as do consumers, and i t i s argued t h a t the type o f s i t e i s a f u n c t i o n of the needs produced by these g o a l s , e s t a b l i s h e d t h r o u g h f u n c t i o n and f u n c t i o n i n g whereas the i n f o r m a t i o n and ' a b i l i t y t o use' s c a l e s a re concerned o n l y w i t h the ' q u a l i t y ' of s i t e judged by c r i t e r i a e s t a b l i s h e d by the a c t o r s g o a l . What i s proposed t h e r e f o r e i s n o t a r e j e c t i o n o f Pred's. c o n c e p t s b u t r a t h e r t o use them as a f o u n d a t i o n upon w h i c h t o b u i l d f u r t h e r . The Case of M e d i c a l P r a c t i c e B e f o r e the s i t e c h a r a c t e r i s t i c s of an a c t i v i t y can be reduced t o ' r a t i o n a l p a t t e r n s ' i t i s n e c e s s a r y , u s i n g the above f o r m u l a t i o n , t o determine whether i t i s the con-sumers o r s u p p l i e r s need c o n s t r u c t t h a t i s dominant. I n the a c t i v i t y under s t u d y , p r i v a t e m e d i c a l p r a c t i c e , w h i c h need s t r u c t u r e , the p h y s i c i a n s or the p a t i e n t s , i s dominant? B e f o r e a t t e m p t i n g t o answer t h i s q u e s t i o n by r e f e r e n c e t o the r e l e v a n t m e d i c a l s o c i o l o g y l i t e r a t u r e a b r i e f r e v i e w w i l l be g i v e n o f p r e v i o u s work w i t h i n the d i s c i p l i n e of Geography t h a t has been concerned w i t h the i n t r a urban l o c a t i o n a l p a t t e r n s o f m e d i c a l p r a c t i c e . Geographic work on the m e d i c a l community. I n an e a r l y work M o r r i l l ( G a r r i s o n et_ a l . , 1959) approached the p r o b l e m f r o m the vantage p o i n t of C e n t r a l P l a c e Theory a l t h o u g h he h i m s e l f e x p r e s s e d c o n c e r n w i t h i t h e t h e o r y ' s b a s i c a s s u m p t i o n s : " I n r e a l i t y , p a r t i c u l a r l y i n the case of p e r s o n a l s e r v i c e s , p e o p l e do n o t always make d e c i s i o n s i n s t r i c t l y economic terms. There are o v e r l a p p i n g s o f t r a d e or s e r v i c e a r e a s , l o n g u n e c o n o m i c a l movements, and s u b t l e g r a d a t i o n s i n the a t t r a c t i v e n e s s o f s u p p o s e d l y homogeneous s e r v i c e s . I n the case of m e d i c a l s e r v i c e s , f o r example, pe o p l e may go t o the f a m i l y d o c t o r l o n g a f t e r t hey have moved away. A l s o , p e o p l e may go m i l e s t o a l a r g e r c e n t r e on the e x p e c t a t i o n t h a t the q u a l i t y o f m e d i c a l c a r e must be h i g h e r " ( G a r r i s o n e_t a l . , 1959, P« 230). I n two case s t u d i e s , a t Cedar R a p i d s , Iowa and S e a t t l e , Washington, the c h a n g i n g post-war l o c a t i o n s o f p h y s i c i a n s ' p r a c t i c e s were i n v e s t i g a t e d and the c o n c l u s i o n drawn t h a t " P h y s i c i a n s seem v e r y dependent, as do o t h e r b u s i n e s s e s , on shopping c e n t r e l o c a t i o n s and l o c a t i o n s on a r t e r i a l s " ( G a r r i s o n e t a l . , 1959, P. 249). I n a more r e c e n t s t u d y S c h n e i d e r c o n c l u d e d "A p h y s i c i a n s c h o i c e o f an o f f i c e l o c a t i o n i s s t r o n g l y i n -f l u e n c e d hy a t l e a s t t h r e e f a c t o r s : i ) i t s a c c e s s i b i l i t y t o one or more h o s p i t a l s , i i ) i t s p o s i t i o n r e l a t i v e to a s u i t a b l e p a t i e n t market and i i i ) i t s a c c e s s i b i l i t y t o t r a n s p o r t a t i o n f a c i l i t i e s . I n a d d i t i o n t o these b a s i c c o n s i d e r a t i o n s , o t h e r f a c t o r s such as r e n t , f l o o r space, p r o x i m i t y t o r a d i o l o g y and c l i n i c a l l a b o r a t o r y f a c i l i t i e s , the p r e s t i g e r a t i n g of the a d d r e s s , and p r a c t i c e p r e f e r e n c e ( f o r example, s o l o or group) u n d o u b t e d l y p l a y an i m p o r t a n t r o l e i n a p h y s i c i a n s c h o i c e o f an o f f i c e l o c a t i o n " ( S c h n e i d e r , 1967:, p. 158). The most comprehensive s t u d i e s t o date have been concerned w i t h the p r o b l e m of the l o c a t i o n o f m e d i c a l f a c i l i t i e s i n g e n e r a l w i t h i n m e t r o p o l i t a n C h i c a g o . M o r r i l l and E a r i c k s o n note the c l o s e a s s o c i a t i o n between p h y s i c i a n o f f i c e l o c a t i o n and more g e n e r a l c o m m e r c i a l a r e a s . "The p a t t e r n of p h y s i c i a n l o c a t i o n i s v i r t u a l l y i n d i s t i n g u i s h a b l e f r o m the p a t t e r n o f r e t a i l b u s i n e s s i n g e n e r a l " ( M o r r i l l and E a r i c k s o n , 1966, p. 1). They t h e n go on t o d i s c u s s , the h i e r a r c h i c a l s t r u c t u r e o f the p a t t e r n "An h i e r a r c h i c a l s t r u c t u r e i s a p p a r e n t , i f h a r d t o s p e c i f y . T h i s i s p a r t l y seen i n the d i s t r i b u t i o n o f p h y s i c i a n s by type and s i z e o f c o m m e r c i a l a r e a . Almost one f o u r t h are i n the l o o p where few p e o p l e l i v e . The p a t t e r n o f s p e c i a l i z a t i o n i s f u r t h e r e v i d e n c e of the h i e r a r c h y . Almost a l l l o o p p h y s i c i a n s are s p e c i a l i s t s , as are the  m a j o r i t y of p h y s i c i a n s i n major shopping c e n t r e s . G e n e r a l p r a c t i t i o n e r s and l e s s e x o t i c s p e c i a l i s t s are most common i n s m a l l e r c e n t r e s and a l o n g b u s i n e s s a r t e r l a l s " ( M o r r i l l and E a r i c k s o n , 1 9 6 6 , p. 3 ) . Morgan and M a n s f i e l d , i n a s t u d y on Vancouver, c o n c l u d e " t h a t Vancouver p h y s i c i a n s ' o f f i c e s a r e c e n t r a l i z e d ; b u t one o n l y s p e c u l a t e s as t o cause. C e r t a i n l y , a v a i l a b i l i t y o f d i a g n o s t i c and r e f e r r a l f a c i l i t i e s and the pre s e n c e of ' m e d i c a l space' are p o t e n t i n f l u e n c e s . The more s o p h i s t i c a t e d m i d d l e and upper c l a s s e s ' g r e a t e r use o f p h y s i c i a n s may encourage the e s t a b l i s h m e n t of o f f i c e s nearby. The e v i d e n c e s u g g e s t s , however, t h a t p o p u l a t i o n needs may be  d i s r e g a r d e d i n p h y s i c i a n s c h o i c e o f o f f i c e l o c a t i o n . P h y s i -c i a n s l o c a t e among t h e i r p r o f e s s i o n a l p e e r s i n l o c a l a r e a s o f t h e i r own s o c i o - e c o n o m i c s t r a t a , or a d j a c e n t t o c e r t a i n f a c i l i t i e s such as h o s p i t a l s " ( 1 9 6 9 , p. 1 2 7 ) . Marsden a l s o f o u n d a c l u s t e r e d p a t t e r n t h a t was s t r o n g l y a s s o c i a t e d w i t h the p a t t e r n o f r e t a i l a c t i v i t y . "A s t r o n g p o s i t i v e c o r r e -l a t i o n i s found between n u c l e a t e d r e t a i l c e n t r e s and p h y s i -c i a n o f f i c e l o c a t i o n s . 8 7 . 3 $ o f a l l p h y s i c i a n s o f f i c e s are l o c a t e d i n r e t a i l c e n t r e s w i t h s a l e s over 1 9 m i l l i o n p e r ye a r " (Marsden, 1 9 6 6 , p. 4 0 ) . He found however, as d i d M o r r i l l and E a r i c k s o n , t h a t the degree o f c l u s t e r i n g v a r i e d between d i f f e r e n t elements of the m e d i c a l community. "The change i n l o c a t i o n o f p h y s i c i a n s ' o f f i c e s r e f l e c t s a d e c l i n e o f CBD frame importance f o r the G e n e r a l P r a c t i t i o n e r ( f a m i l y d o c t o r ) and an i n c r e a s e i n i t s importance f o r the s p e c i a l i s t " (Marsden, 1 9 6 6 , p. 2 4 ) . These changes he su g g e s t s may be due to the u n w i l l i n g n e s s o f p e o p l e t o t r a v e l l o n g d i s t a n c e s t o v i s i t a g e n e r a l p r a c t i t i o n e r and t o the s t r o n g l i n k a g e s p r e s e n t w i t h i n the s p e c i a l i s t community. "The decrease i n the number of g e n e r a l p r a c t i t i o n e r s i n the S e a t t l e c e n t r a l a r e a may be due t o the t r a v e l d i s t a n c e t o the c e n t r a l a r e a , and the u n w i l l i n g n e s s o f a p a t i e n t t o t r a v e l beyond s e r v i c e s o f a s i m i l a r q u a l i t y . Thus, the g e n e r a l p r a c t i t i o n e r may have e x p e r i e n c e d a r e d u c t i o n i n the number of p a t i e n t s coming downtown, r e q u i r i n g him t o d e c e n t r a l i z e t o o u t l y i n g l o c a t i o n s " (Marsden, 1966, p. 33), and " . . . a l t h o u g h g e n e r a l p r a c t i t i o n e r s  a r e p r o b a b l y o r i e n t e d toward f o l l o w i n g the p o p u l a t i o n t r e n d to o u t l y i n g a r e a s , s p e c i a l i s t s seem t o aggregate f o r purposes  o f m u t u a l a s s o c i a t i o n and l i n k a g e w i t h h o s p i t a l f a c i l i t i e s . The s t r o n g h o s p i t a l node of 15 h o s p i t a l s , ' c o n t a i n i n g 2,200 beds, and r e s e a r c h f a c i l i t i e s , p r o b a b l y produces s t r o n g a s s o c i a t i o n p a t t e r n s f o r the s p e c i a l i s t " (Marsden, 1966, P. 39). T h i s work, t o d a t e , has d e a l t w i t h the s p a t i a l s t r u c -t u r e of the p a t t e r n o f m e d i c a l p r a c t i c e , and has n o t d e a l t e x p l i c i t l y w i t h the p r o c e s s e s by w h i c h t h i s p a t t e r n i s gener-a t e d . I m p l i c i t i n Marsden's work i s the s u g g e s t i o n t h a t l i n k a g e i s o f g r e a t importance b u t he does n o t suggest a mechanism whereby a d e s i r e f o r l i n k a g e s w i t h c e r t a i n f a c i l i -t i e s produces o b s e r v e d p a t t e r n s . Two c o n s i s t e n t f e a t u r e s emerge f r o m the work r e p o r t e d : l ) t h a t p h y s i c i a n s l o c a t e so as to be i n complementary l o c a t i o n s t o h o s p i t a l and d i a g n o s t i c f a c i l i t i e s , o f t e n i n more g e n e r a l r e t a i l n u c l e i , and 2) t h a t the p a t t e r n of p r a c t i c e s becomes more agglomerated as the degree o f s p e c i a l i z a t i o n o f p h y s i c i a n s r i s e s . The s t r o n g s i m i l a r i t y between p h y s i c i a n o f f i c e l o c a t i o n s and more g e n e r a l r e t a i l a r e a s i s p a r t i a l l y e x p l i c a b l e i n terms o f z o n i n g c o n t r o l s . I n many c i t i e s h o s p i t a l s are zoned as c o n d i t i o n a l u s e s - i n r e s i d e n t i a l a r e a s whereas a p h y s i c i a n ' s o f f i c e i s zoned as a commercial use and as such i s r e s t r i c t e d t o a r e a s t h a t a re zoned f o r commercial u s e s . T h i s however, does n o t h e l p e x p l a i n the d i f f e r e n t i a l c l u s t e r i n g s f o u n d w i t h i n these more g e n e r a l r e t a i l a r e a s . Much o f the re m a i n -der o f t h i s c h a p t e r a t t e m p t s to o u t l i n e a p o s s i b l e p r o c e s s o f l o c a t i o n a l c h o i c e t h a t produces the p a t t e r n o b s e r v e d . The m e d i c a l s o c i o l o g i c a l l i t e r a t u r e . A r e v i e w of the r e l e v a n t m e d i c a l s o c i o l o g y l i t e r a t u r e s u g g e s t s t h a t p h y s i c i a n s can be s t e r e o t y p e d i n t o c a t e g o r i e s t h a t w i l l have i m p o r t a n t consequences f o r the s i t e c h a r a c t e r i s t i c s o f medi-c a l p r a c t i c e . • S c o t t and V o l k a r t say "Perhaps the f i r s t p o i n t t o be made i s t h a t a l t h o u g h one can l o o s e l y r e f e r t o the ' r o l e o f the  d o c t o r ' t h e r e i s i n f a c t n o t one r o l e b u t many w h i c h are as d i - v e r s e as are the ty p e s o f p h y s i c i a n s , types of p r a c t i c e i n w h i c h  t h e y are engaged and k i n d s o f s e t t i n g w i t h i n w h i c h t h e y work" ( S c o t t and V o l k a r t , 1966, p. 83). Hughes makes a s i m i l a r p o i n t . "By the same t o k e n o n l y some s m a l l p o r t i o n o f m e d i c a l know-led g e and s k i l l can be mastered by each member of the p r o f e s s i o n i t s e l f w h i c h l e a d s to t h e i r b e i n g s u b c u l t u r e s w i t h i n the p r o f e s s i o n a l m e d i c a l c u l t u r e . T h i s i s more than a matter of t e c h n i q u e and knowledge, i t has i t s r o o t s i n i d e a s and assumptions" (Hughes, 1 9 5 6 , p. 2 1 ) . Hanley and Grunberg d i s c u s s s p e c i f i c a l l y the r e s e a r c h minded p h y s i c i a n . "The detached p h y s i c i a n i s much r a r e r . He i s a bloodhound among the b u l l d o g s and c o c k e r s p a n i e l s of the s p e c i e s . H i s main i n t e r e s t i s i n the i n t e l l e c t u a l e x e r c i s e o f m e d i c i n e . He i s , i n f a c t , a f r u s t r a t e d d e t e c t i v e , a d i a g n o s t i c i a n  r a t h e r t h a n a t h e r a p i s t . T h i s i s the r e s e a r c h minded p h y s i c i a n whose c o n s u l t i n g room i s h i s l a b o r a t o r y . He e n t e r s  i n t o a m i n i m a l r e l a t i o n s h i p w i t h h i s p a t i e n t , and t h i s i s  e n t i r e l y - o n e way. What he can accumulate on the h i s t o r y page i s i m p o r t a n t to him. The g e n e r a l p r a c t i t i o n e r who r e f e r s p a t i e n t s t o him w i l l r e c e i v e i n r e t u r n l o n g l e t t e r s o f d e t a i l e d d e s c r i p t i o n and i n f i n i t e i n s t r u c t i o n s " (Hanley and Grunberg, 1 9 6 2 , p. 1 0 2 3 ) . Bucher and S t r a u s s make the p o i n t even more f o r c i b l e . "The s p l i t between r e s e a r c h  m i s s i o n s and c l i n i c a l p r a c t i c e runs c l e a r t h r o u g h m e d i c i n e  and i t s s p e c i a l i t i e s . P e d i a t r i c s has one of the most r a p i d l y growing f i e l d s o f p r a c t i c e , b u t i t has a l s o a t t r a c t e d a number of young p e o p l e , p a r t i c u l a r l y a t some c e n t r e s i n the N o r t h E a s t , s p e c i f i c a l l y f o r r e s e a r c h . They are p e o p l e who  have no c o n c e p t i o n o f themselves as f a m i l y p e d i a t r i c i a n s a t  a l l ; t h e y are i n t h i s f i e l d because of what t h e y can do i n the way o f r e s e a r c h . I n the two o l d e s t s p e c i a l i t i e s , s u r g e r y and i n t e r n a l m e d i c i n e , one f i n d s t hroughout the l i t e r a t u r e c o n s i d e r a b l e e v i d e n c e o f t h i s k i n d of s p l i t . One f i n d s an o l d surgeon c o m p l a i n i n g t h a t the young men are too much i n t e r e s t e d i n r e s e a r c h and i n i n t e r n a l medicine t h e r e are e x h o r t a t i o n s t h a t t hey s h o u l d be d o c t o r s n o t s c i e n t i s t s . T h i s l a t t e r lament i s p a r t i c u l a r l y i n t e r e s t i n g i n view of the t r a d i t i o n a l m i s s i o n o f the i n t e r n i s t t o e x e m p l i f y the f i n e s t i n the ' a r t of m e d i c i n e ' ; i t i s a r e a l b e t r a y a l when one of them shows too much i n t e r e s t i n c o n t r o l l e d r e s e a r c h " (Bucher and S t r a u s s , 1 9 ^ 1 , p. 3 2 7 ) . The d i a g n o s t i c i a n - t h e r a p i s t dichotomy. P h y s i c i a n s , i t a p p e a r s , can be c a t e g o r i z e d i n t o d i s t i n c t ' f u n c t i o n a l groups'; each w i t h a d i s t i n c t b e h a v i o r a l p a t t e r n r e s u l t i n g f r o m d i f f e r i n g 'need c o n s t r u c t s ' . F i e l d i n v e s t i g a t i o n s uggests however t h a t i n the case of m e d i c a l p r a c t i c e the dichotomy between ' r e s e a r c h o r i e n t e d ' and 'therapy o r i e n t e d ' p h y s i c i a n s i s f a l s e and what i s p r e s e n t i s a continum r a n g -i n g f r o m the neighbourhood P r i m a r y Care P h y s i c i a n a t the t h e r a p i s t extreme t h r o u g h s p e c i a l i s t s such as G e n e r a l Surgeons and I n t e r n i s t s t o the r e s e a r c h o r i e n t e d s p e c i a l t i e s such as N e u r o s u r g e r y and C a r d i o l o g y . I t i s suggested here t h a t ' i n t e r n a l needs' dominate the l o c a t i o n a l b e h a v i o r o f those p h y s i c i a n s toward the ' d i a g n o s t i c i a n / r e s e a r c h e r ' end of the continuum and t h a t ' e x t e r n a l needs' i . e . , those of the p a t i e n t s , dominate i n the ' p a t i e n t / t h e r a p i s t ' group. I n t h i s f o r m u l a t i o n m e d i c a l p r a c t i c e emerges as an a c t i v i t y i n w h i c h t h e r e e x i s t s a s p l i t dominance of need c o n s t r u c t , i . e . , i n t e r n a l needs are dominant f o r h i g h l y s p e c i a l i z e d p h y s i c i a n s b u t ' e x t e r n a l needs' f o r p a t i e n t o r i e n t a t e d p h y s i c i a n s . The i m p l i c a t i o n s o f t h i s w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s o f m e d i c a l p r a c t i c e must now be con-s i d e r e d . S i t e c h a r a c t e r i s t i c s of m e d i c a l p r a c t i c e . B e f o r e t h i s l i n e o f argument can be f r u i t f u l l y c o n t i n u e d the concept of ' s i t e c h a r a c t e r i s t i c s ' must be c l a r i f i e d . S i t e c h a r a c -t e r i s t i c s , i n the sense used h e r e , comprise two groups of v a r i a b l e s : - One group c o n c e r n i n g i t s e l f w i t h the ' r e l a t i v e l o c a t i o n ' o f a s i t e w i t h r e g a r d t o o t h e r m e d i c a l p r a c t i c e s i t e s and f a c i l i t i e s and the o t h e r w i t h the i n t r i n s i c n a t u r e of the s i t e i t s e l f . Examples of v a r i a b l e s f a l l i n g i n the f i r s t c a t e g o r y would be ' d i s t a n c e t o n e a r e s t h o s p i t a l ' or ' d i s t a n c e t o n e a r e s t d i a g n o s t i c r a d i o l o g y f a c i l i t y ' . Examples f r o m the second group are 'the number of p h y s i c i a n s who p r a c t i c e m e d i c i n e a t the s i t e ' and 'the number of p a r k i n g spaces a v a i l a b l e a t the s i t e . ' I t i s a s s e r t e d t h a t c e r t a i n v a r i a b l e s w i t h i n the two groups are s i g n i f i c a n t l y r e l a t e d to the 'need c o n s t r u c t ' o f a p h y s i c i a n o p e r a t i n g f r o m the s i t e . The r e l a t i o n s h i p s h y p o t h e s i z e d w i l l be d i s c u s s e d i n the f o l l o w i n g s e c t i o n and s t a t e d e x p l i c i t l y i n the R e s e a r c h Model. The i m p l i c a t i o n s of s p l i t dominance f o r the s i t e  c h a r a c t e r i s t i c s o f m e d i c a l p r a c t i c e s i t e s . As was e a r l i e r s u g g e s t e d M e d i c a l P r a c t i c e i s an a c t i v i t y i n w h i c h d i f f e r e n t s e c t o r s are dominated by e i t h e r i n t e r n a l or e x t e r n a l need s t r u c t u r e s . The ' d i a g n o s t i c i a n / r e s e a r c h ' o r i e n t e d s p e c i a l i s t p h y s i c i a n i s dominated by i n t e r n a l needs w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s of h i s p r a c t i c e s i t e . The s i t e f u l f i l l s a complex f u n c t i o n i n h i s p r a c t i c e and he makes heavy demands of i t w i t h r e g a r d t o a c c e s s i b i l i t y t o h o s p i t a l s , c l i n i c a l l a b o r a t o r i e s , d i a g n o s t i c r a d i o l o g y f a c i l i t i e s and o t h e r s p e c i a l i s t p h y s i c i a n s . Through f u n c t i o n and f u n c t i o n i n g he w i l l a ttempt t o s a t i s f y h i s 'need c o n s t r u c t ' r e g a r d i n g s i t e by a d o p t i n g a s i t e s a t i s f y i n g the a c c e s s i b i l i t y c r i t e r i a . As Hanley and Grunberg (1962, p. 1023) and Morgan and M a n s f i e l d (1969, p. 27) n o t e , the ' d i a g n o s t i c i a n / r e s e a r c h e r ' o n l y e n t e r s i n t o a m i n i m a l r e l a t i o n s h i p w i t h h i s p a t i e n t s and so h i s ' i n t e r n a l needs' dominate h i s c h o i c e o f p r a c t i c e s i t e . I n the case of the ' t h e r a p i s t ' the ' e x t e r n a l needs' o f h i s p a t i e n t s are dominant. The p h y s i c i a n ' s g o a l becomes t o s a t i s f y the ' e x t e r n a l need c o n s t r u c t ' of the p a t i e n t . Thus i n f u n c t i o n and f u n c t i o n i n g i n an attempt t o s a t i s f y h i s g o a l s he adopts a s i t e f r o m w h i c h he can m i n i m i z e i n c o n v e n -i e n c e t o h i s p a t i e n t s . I n g e n e r a l i t i s argued t h a t as the degree of t e c h -n i c a l t r a i n i n g and knowledge r e q u i r e d t o p e r f o r m a p a r t i c u l a r m e d i c a l s p e c i a l t y i n c r e a s e s then a) the f u n c t i o n s a p r a c t i t -i o n e r o f t h a t s p e c i a l t y r e q u i r e s h i s p r a c t i c e s i t e t o f u l -f i l l become more complex, and b) h i s in t e r d e p e n d e n c e w i t h o t h e r p h y s i c i a n s and m e d i c a l s e r v i c e s i n c r e a s e s , i . e . , the more ' s p e c i a l i z e d ' a p r a c t i t i o n e r becomes then the h i g h e r h i s demand f o r i n t e r n a l and e x t e r n a l s i t e l i n k a g e s becomes. Some j u s t i f i c a t i o n f o r t h i s r e l a t i o n s h i p between i n c r e a s i n g s p e c i a l i z a t i o n and i n c r e a s i n g l i n k a g e s i s found i n the l i t e r a t u r e . Lyon says " I n today's c o n t e x t , i t must be remembered, however, t h a t the f r a g m e n t a t i o n of m e d i c i n e i n t o a g r e a t many s p e c i a l t i e s i s one o f the s t r o n g e s t r e a s o n s f o r the f o r m a t i o n o f groups, i n o r d e r t o r e i n t e g r a t e t h i s know-ledge i n t o one o p e r a t i n g whole, and t h e r e f o r e the m a j o r i t y o f young d o c t o r s j u s t g r a d u a t i n g f r o m m e d i c a l s c h o o l may f e e l t h a t t h i s I s the most i m p o r t a n t o p e r a t i v e f a c t o r i n f o r m i n g a group f r o m the f i r s t day a f t e r g r a d u a t i o n . The s t u d e n t who i s g o i n g t o s p e c i a l i z e may t h i n k more i n terms o f group p r a c t i c e as the 'normal' way t o p r a c t i c e t h a n d i d h i s f o r e b e a r s . There i s s t i l l the o p t i o n o f w o r k i n g i n a l a r g e m e d i c a l b u i l d i n g however w i t h o u t f o r m a l group t i e s w i t h r e s p e c t t o income and o t h e r arrangements. T h i s i s the 'geographic group' r a t h e r t h a n the ' f o r m a l group', and i t may a p p e a l t o a g r e a t many s p e c i a l i s t s i n the f u t u r e , p a r t i -c u l a r l y as more and more m e d i c a l b u i l d i n g s are b u i l t " (Lyon, 1967, p. 45). I I . THE RESEARCH MODEL Natu r e o f the Model The r e s e a r c h model o f the s t u d y i s b ased on the p r o p osed r e l a t i o n s h i p s between the 'need c o n s t r u c t ' and 'the degree of s p e c i a l i s m ' o f an a c t o r and the ' s i t e c h a r a c t e r -i s t i c s ' o f the m e d i c a l p r a c t i c e u n i t f r o m w h i c h the a c t o r o p e r a t e s . The p r o blem of the s t u d y was t o measure the 'need c o n s t r u c t ' and 'degree of s p e c i a l i s m ' o f a sample of M e d i c a l P r a c t i t i o n e r s and r e l a t e t h i s t o the ' s i t e c h a r a c t e r i s t i c s ' o f t h e i r p r a c t i c e s i t e s . The f o l l o w i n g h y p o t h e t i c a l r e l a t i o n s h i p s s h o u l d e x i s t i f the c o n c e p t u a l paradigm i s to be f r u i t f u l . The 'degree of s p e c i a l i s m ' s c o r e of an a c t o r s h o u l d be h i g h l y r e l a t e d t o the 'need c o n s t r u c t ' o f an a c t o r . The "need c o n s t r u c t ' o f an a c t o r s h o u l d be h i g h l y r e l a t e d t o the ' s i t e c h a r a c t e r i s t -i c s ' o f h i s m e d i c a l p r a c t i c e s i t e and l o g i c a l l y a s t r o n g r e l a t i o n s h i p s h o u l d e x i s t between the 'Degree of S p e c i a l i s m ' s c o r e of an a c t o r and the s i t e c h a r a c t e r i s t i c s o f h i s medi-c a l p r a c t i c e s i t e . F i g u r e 1.1 i l l u s t r a t e s the h y p o t h e s i z e d r e l a t i o n s h i p s between the d a t a o f the s t u d y i n a h y p o t h e s i s t e s t i n g -c o r r e l a t i o n f o r m a t . Only those r e l a t i o n s h i p s w h i c h s h o u l d y i e l d s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s and are of t h e o r e t i -c a l i n t e r e s t are i n c l u d e d . I n t e r v i e w Schedule Need C o n s t r u c t S i t e C h a r a c t e r i s t i c s R e l a t i v e Degree of L o c a t i o n Need Measures S p e c i a l i s m C o n s t r u c t S c a l e 5 S c a l e I n t e r n a l S i t e Measures 1 i F i g u r e 1.1. The R e s e a r c h Model o f the Study. As so f a r s p e c i f i e d the h y p o t h e s i z e d r e l a t i o n s h i p s are v e r y vague and so the n e x t s e c t i o n p r e s e n t s an e x p l i c i t s t atement o f the hypotheses of the s t u d y . The H y p o t h e s i z e d R e l a t i o n s h i p s There are f o u r 'major h y p o t h e s e s ' o f the s t u d y o f w h i c h t h r e e , hypotheses 2, 3> and 4 c o n s i s t s of groups of n i n e sub-hypotheses. The s i t e v a r i a b l e s are e x p r e s s e d as S I , S2, e t c . , i n the statement o f the h y p o t h e s e s . F o r i d e n t i f i c a t i o n o f the s i t e v a r i a b l e s , see Appendix A. H y p o t h e s i s One That the 'need c o n s t r u c t ' o f ' a n a c t o r w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s o f h i s p r a c t i c e i s s i g n i f i c a n t l y c o r r e l a t e d w i t h h i s 'Degree of S p e c i a l i s m ' s c a l e s c o r e . H y p o t h e s i s Two That t h e , ' s i t e c h a r a c t e r i s t i c s ' of an a c t o r ' s p r a c t i c e s i t e as measured on the s i t e v a r i a b l e s S I , S 2 , S3,' S5, S6, and S 7 are s i g n i f i c a n t l y c o r r e l a t e d w i t h the 'need c o n s t r u c t ' o f the a c t o r w i t h r e g a r d to the s i t e c h a r a c t e r i s t i c s of h i s p r a c t i c e b u t t h a t no s i g n i f i c a n t c o r r e l a t i o n e x i s t s between the s i t e v a r i a b l e s S4, S 8 , and S 9 , and the a c t o r s need c o n s t r u c t . H y p o t h e s i s Three That the ' s i t e c h a r a c t e r i s t i c s ' o f an a c t o r ' s p r a c t i c e s i t e as measured on the s i t e v a r i a b l e s S I , S 2 , S 3 , S5j S6, S 7 a r e s i g n i f i c a n t l y c o r r e -l a t e d w i t h the "Degree o f S p e c i a l i s m ' s c a l e s c o r e of the a c t o r b u t t h a t no s i g n i f i c a n t c o r r e l a t i o n e x i s t s between s i t e c h a r a c t e r i s t i c s S4, S 8 , S 9 and the Degree of S p e c i a l i s m s c o r e of the p h y s i c i a n . H y p o t h e s i s Four That the s i t e c h a r a c t e r i s t i c s of P r i m a r y Care p h y s i c i a n s s i t e s as measured on s i t e v a r i a b l e s S I , S 2 , S 3 , S5, S6, S 7 are s i g n i f i c a n t l y d i f f e r e n t f r o m the s i t e c h a r a c t e r i s t i c s o f S p e c i a l i s t P h y s i c i a n s ' s i t e s b u t t h a t no-s i g n i f i c a n t d i f f e r e n c e e x i s t s f o r s i t e c h a r a c t e r i s t i c s S4, S8, S9 between the two groups. These hypothese are c e n t r a l t o the t h e s i s and r e s u l t s are d i s c u s s e d a t l e n g t h i n Chapter I I I . THE METHODOLOGICAL APPROACH OF THE STUDY T h i s s t u d y uses a c o g n i t i v e - b e h a v i o r a l model t o s t u d y the l o c a t i o n a l d e c i s i o n s of a p r o f e s s i o n a l group w i t h i n an urban a r e a . T h i s approach f o c u s e s on the i n d i v i d u a l a c t o r , and the c h a r a c t e r i s t i c s of h i s p r a c t i c e s i t e as the u n i t s o f a n a l y s i s . S t r u c t u r a l , o r E c o l o g i c a l , a n a l y s e s are n o t p r e s e n t e d . I . THE SAMPLE OF ACTORS The P o p u l a t i o n The p o p u l a t i o n o f a c t o r s f o r t h i s s t u d y c o m p r i s e d a l l p h y s i c i a n s who p r a c t i c e d m e d i c i n e w i t h i n the C i t y o f Vancouver. P h y s i c i a n s who h e l d f u l l time i n s t i t u t i o n a l p o s i t i o n s were e x c l u d e d f r o m the p o p u l a t i o n under c o n s i d e r a -t i o n . The p o p u l a t i o n c o n s i s t e d of 1048 p h y s i c i a n s of whom 467 were P r i m a r y Care P h y s i c i a n s and 581 S p e c i a l i s t P h y s i -c i a n s ( S O U H B : C o l l e g e of P h y s i c i a n s and Surgeons of B. C , 1969). The enumeration o f p h y s i c i a n s i n the source i s complete i n as much as e v e r y r e g i s t e r e d p h y s i c i a n i n B r i t i s h C olumbia must be l i s t e d i n o r d e r t o l e g a l l y p r a c t i c e m e d i c i n e w i t h i n the p r o v i n c e . The o n l y o m i s s i o n s a re those p h y s i c i a n s who s t a r t e d t o p r a c t i c e m e d i c i n e w i t h i n the C i t y o f Vancouver a f t e r the d i r e c t o r y was c o m p i l e d . I t i s thought t h a t these o m i s s i o n s w i l l n o t s i g n i f i c a n t l y b i a s the r e s u l t s . The Sample A sample o f 40 p h y s i c i a n s p r o v i d e d the a c t o r s s t u d i e d i n t h i s t h e s i s . Twenty o f the p h y s i c i a n s s e l e c t e d were p r i m a r y c a r e p h y s i c i a n s and twenty were s p e c i a l i s t s . W i t h i n the two groups p h y s i c i a n s were s e l e c t e d a t random. T h i s sample c o n s t i t u t e s r o u g h l y a 4 per c e n t sample o f the popu-l a t i o n o f a c t o r s w h i c h i s a s m a l l sample. The s i z e o f the sample was de t e r m i n e d l a r g e l y f o r the p r a c t i c a l r e a s o n s o f time and budget l i m i t a t i o n s and a l a r g e r sample would have been more s a t i s f a c t o r y . The r e a s o n the sample was s p l i t between the two groups o f p r i m a r y c a r e and s p e c i a l i s t p h y s i c i a n s was because the hypotheses o f the s t u d y s u g g e s t e d t h a t s i g n i f i c a n t d i f f e r e n c e s would e x i s t between the groups. The d e c i s i o n t o make the two sample groups o f e q u a l s i z e was made f o r convenience and based on the f a c t t h a t the two p o p u l a t i o n groups were not of d i s s i m i l a r s i z e . I I . THE INTERVIEW SCHEDULE C o n s t r u c t i o n o f the P r e l i m i n a r y I n s t r u m e n t s and the P r e - T e s t One o f the problems o f the s t u d y was t o dev e l o p i n s t r u m e n t s t o v a l i d l y and r e l i a b l y measure the 'degree o f s p e c i a l i s m ' o f an i n d i v i d u a l p h y s i c i a n . A p r e l i m i n a r y i n s t r u m e n t was d e v e l o p e d as the f i r s t s t age i n the d e v e l o p -merit, o f s e n s i t i v e i n s t r u m e n t s t o be used I n the f i n a l s t u d y . The ' p r e l i m i n a r y i n s t r u m e n t ' was a p p l i e d t o t e n p h y s i c i a n s f r o m the s t u d y p o p u l a t i o n ; f i v e P r i m a r y Care P h y s i c i a n s and f i v e S p e c i a l i s t P h y s i c i a n s - . The purpose of t h i s ' p r e - t e s t ' was t o g a i n i n s i g h t i n t o the s t r e n g t h s and weaknesses of the i n s t r u m e n t so as t o a l l o w a p p r o p r i a t e m o d i f i c a t i o n s t o be made b e f o r e the i n s t r u m e n t was a p p l i e d t o the f u l l s t u d y sample. It e m A n a l y s i s of the P r e l i m i n a r y I n s t r u m e n t U s i n g the d a t a o b t a i n e d i n the p r e - t e s t an i t e m a n a l y s i s of the o r i g i n a l i n s t r u m e n t was made r e g a r d i n g the i n s t r u m e n t i n terms o f p s y c h o l o g i c a l t e s t t h e o r y . T e s t t h e o r y , w h i c h d e r i v e s a ' s c a l e - s c o r e ' f r o m the summation o f i t e m s c o r e s , assumes t h a t each i t e m c o n t r i b u t e s t o the p r e -d i c t i o n of the s c a l e s c o r e . The items of the s c a l e c o n s i s t e d of c o n t i n u o u s and dichotomous v a r i a b l e s and as s c o r i n g was a l r e a d y a d i f f i c u l t p r o b l e m due t o l a c k o f s t a b l e c r i t e r i a a g a i n s t w h i c h t o compare the s t a t e d performance o f the r e s -pondents a s i m p l e 0, 1, dichotomous s c o r i n g system was adopted. Dichotomous s c o r e s were a s s i g n e d on the b a s i s o f n a t u r a l or l o g i c a l b r e a k s i n the re s p o n s e s among the sample o f r e s p o n -d e n t s . F o r many items d i c h o t o m i z a t i o n was c l e a r b u t f o r o t h e r s d i c h o t o m i z a t i o n was made about the median. When i t e m s c o r e s a re d i c h o t o m i z e d 0, 1 and the i n t e r n a l c r i t e r i o n o f t o t a l s c a l e s c o r e i s b e i n g used, the p o i n t - b i s e r i a l r i s the a p p r o p r i a t e s t a t i s t i c t o determine the c o n t r i b u t i o n of each i t e m t o the t o t a l s c o r e ( G u i l f o r d , 1956, p. 427). The p o i n t -b i s e r i a l c o r r e l a t i o n s o b t a i n e d are l i s t e d i n Appendix P. The p o i n t - b i s e r i a l c o r r e l a t i o n i s u s e f u l when i t i s d e s i r e d t o c o n s t r u c t a s c a l e f r o m a l a r g e number of i t e m s . Items w i t h low c o e f f i c i e n t s can be e l i m i n a t e d f r o m the r e v i s e d i n s t r u -ment. They a l s o p r o v i d e a b a s i s f o r the i n c l u s i o n o f f u r t h e r items by i n d i c a t i n g those ' s e c t i o n s ' o f the s c a l e t h a t d i s -c r i m i n a t e most e f f i c i e n t l y w i t h r e g a r d t o the c r i t e r i o n measure. Based on the r e s u l t s o f the i t e m a n a l y s i s and on e x p e r i e n c e g a i n e d t h r o u g h the a d m i n i s t r a t i o n o f the p r e - t e s t the i n s t r u m e n t was m o d i f i e d f o r use i n the sample s t u d y . The r e v i s e d i n s t r u m e n t i s p r e s e n t e d i n Appendix B and the 'degree of s p e c i a l i s m ' s c a l e items enumerated i n Appendix C. The r e v i s e d i n s t r u m e n t was used i n the sample s t u d y . The Method of D a t a C o l l e c t i o n The ' i n t e r v i e w ' d a t a f o r the s t u d y was o b t a i n e d by a p e r s o n a l a d m i n i s t r a t i o n o f the i n s t r u m e n t t o each sample a c t o r . Each sample a c t o r was a d m i n i s t e r e d the i n s t r u m e n t by the a u t h o r . The s i t e o f the i n t e r v i e w was i n a l l b u t s i x cases the p h y s i c i a n ' s p r a c t i c e s i t e . Of the s i x e x c e p t i o n s f o u r were i n t e r v i e w e d i n t h e i r own homes and two were i n t e r -v iewed a t the Vancouver G e n e r a l H o s p i t a l . The p r a c t i c e s i t e s o f the s e p h y s i c i a n s were s u b s e q u e n t l y v i s i t e d by the autho r i n a l l c a s e s . The f o r m of the i n t e r v i e w c o n s i s t e d o f an a d m i n i s t r a t i o n of the i n s t r u m e n t f o l l o w e d by i n f o r m a l d i s c u s s i o n . O n l y the f o r m a l ' i n s t r u m e n t 1 p r o v i d e d d a t a f o r the s t u d y ; the i n f o r m a l d i s c u s s i o n b e i n g t o p r o v i d e i n t u i t i v e i n s i g h t s r a t h e r t h a n h a r d f a c t s . I I I . THE SITE DATA The S i t e V a r i a b l e s The s i t e v a r i a b l e s used i n t h i s s t u d y f a l l n a t u r a l l y i n t o two groups. One group of v a r i a b l e s i s concerned w i t h the ' r e l a t i v e l o c a t i o n ' o f a M e d i c a l P r a c t i c e S i t e t o o t h e r m e d i c a l f a c i l i t i e s and w i t h the s t r u c t u r a l c h a r a c t e r i s t i c s of the immediate urban environment. The second group of v a r i a b l e s r e l a t e s t o the i n t r i n s i c n a t u r e of the p r a c t i c e s i t e . The v a r i a b l e s i n c l u d e d i n b o t h groups were s e l e c t e d on the b a s i s o f e x i s t i n g l i t e r a t u r e and on e x p e r i e n c e g a i n e d i n the a d m i n i s t r a t i o n of the p r e - t e s t . The v a r i a b l e s c o m p r i s i n g the r e l a t i v e l o c a t i o n group a r e : 51 D i s t a n c e t o the d i a g n o s t i c l a b o r a t o r i e s used by the p h y s i c i a n , 52 D i s t a n c e t o the d i a g n o s t i c r a d i o l o g y f a c i l i t i e s used by the p h y s i c i a n , 55 D i s t a n c e t o the h o s p i t a l most f r e q u e n t l y used by the p h y s i c i a n , 56 I s the p r a c t i c e s i t e l o c a t e d i n a r e s i -d e n t i a l a r e a , S8 I s the p r a c t i c e s i t e l o c a t e d on a p u b l i c t r a n s i t r o u t e . The v a r i a b l e s c o m p r i s i n g the second group a r e : 53 What d i a g n o s t i c f a c i l i t i e s e x i s t a t the s i t e , 54 For how many c a r s i s p a r k i n g p r o v i d e d a t the s i t e , S7 I s the p r a c t i c e s i t e a s i n g l e p r a c t i c e s i t e , S9 How many s e a t s are t h e r e i n the p a t i e n t w a i t i n g room. The s i t e r a t i n g i n s t r u m e n t used i n c o n j u n c t i o n w i t h the i n t e r v i e w s c h e d u l e i s p r e s e n t e d i n Appendix A. The Method of D a t a C o l l e c t i o n The s i t e d a t a was o b t a i n e d f r o m two b a s i c s o u r c e s : the i n t e r v i e w s c h e d u l e and z o n i n g maps o f G r e a t e r Vancouver. A two-stage p r o c e s s was used on some of the v a r i a b l e s . V a r i a b l e s S6 and S8 were 'measured' f r o m c a r t o g r a p h i c s o u r c es and y i e l d e d i n f o r m a t i o n o f a n o m i n a l n a t u r e . V a r i a b l e s S3> S 4 , SJ, and S9 were a s s e s s e d t h r o u g h d i r e c t q u e s t i o n i n g of the p h y s i c i a n and y i e l d e d i n f o r m a t i o n o f a n o m i n a l n a t u r e f o r v a r i a b l e s S3 and SJ, and o f an o r d i n a l n a t u r e f o r S4 and S9. The r e m a i n i n g v a r i a b l e s , S I , S2, and S5 were a s s e s -sed by a two-stage p r o c e s s . The p h y s i c i a n was asked to i n d i c a t e w h i c h f a c i l i t i e s he used and t h i s was n o t e d by the i n t e r v i e w e r . The d i s t a n c e f r o m the p h y s i c i a n ' s o f f i c e t o the a p p r o p r i a t e f a c i l i t y l o c a t i o n was l a t e r o b t a i n e d f rom c a r t o g r a p h i c s o u r c e s . DATA ANALYSIS AND RESULTS I . THE GENERAL APPROACH TO THE ANALYSIS The d a t a c o l l e c t i o n i n t h i s s t u d y was of two major t y p e s : the s i t e d a t a and the i n t e r v i e w s c h e d u l e d a t a . The g e n e r a l approach t o the a n a l y s i s was t o f i r s t i n v e s t i g a t e each d a t a s e t by i t s e l f , p a y i n g s p e c i a l a t t e n t i o n t o the s c a l e s c o n t a i n e d i n the i n t e r v i e w s c h e d u l e d a t a , and t h e n to t e s t the hypotheses of the s t u d y u t i l i z i n g the r e l e v a n t d a t a f r o m b o t h groups. I I . THE SITE DATA The L e v e l o f Measurement o f the S i t e V a r i a b l e s The l e v e l of measurement o f the s i t e v a r i a b l e s was e i t h e r n o m i n a l or i n t e r v a l . The i n t e r v a l v a r i a b l e s are the v a r i a b l e s S I , S2, S4, S5, and S9, w h i c h are the v a r i a b l e s r e l a t e d t o the d i s t a n c e t o o t h e r m e d i c a l f a c i l i t i e s and t o the s i z e of the w a i t i n g room and number of c a r p a r k i n g spaces a v a i l a b l e t o the p h y s i c i a n (see Chapter I I and Appendix A f o r a l i s t i n g of the s i t e v a r i a b l e s ) . The n o m i n a l v a r i a b l e s are the v a r i a b l e s S3, S6, S7, and S8, w h i c h are a l l d i c h o t o -mous n o m i n a l v a r i a b l e s . The i n t e r v a l v a r i a b l e s were t r e a t e d as o r d i n a l v a r i a b l e s i n the a n a l y s i s as th e y d e v i a t e d d r a s t i -c a l l y f r o m the 'normal' d i s t r i b u t i o n , and i n some cases were b i m o d a l . I t was c o n s i d e r e d a d v i s a b l e t o c o n s i d e r the v a r i -a b l e s as o r d i n a l and use n o n - p a r a m e t r i c t e s t s r a t h e r t h a n m a i n t a i n an i n t e r v a l l e v e l o f measurement, w h i c h c o n t a i n s more i n f o r m a t i o n , and v i o l a t e the assumptions o f many p a r a -m e t r i c t e s t s . The D i s t r i b u t i o n s o f the S i t e V a r i a b l e s As mentioned i n the l a s t s e c t i o n , the d i s t r i b u t i o n s o f v a r i a b l e s S I , S2, S4, S 5 , and S9 d i f f e r e d r a d i c a l l y f r o m n o r m a l i t y as can be seen i n F i g u r e s 3.1 to 3.5 i n c l u s i v e . T h i s was t o be e x p e c t e d f o r v a r i a b l e s S I , S2, and S5 , as i t was h y p o t h e s i z e d i n Chapter I t h a t p h y s i c i a n s , and e s p e c i a l l y s p e c i a l i s t p h y s i c i a n s , tended to l o c a t e so as t o be r e a s o n a b l y a c c e s s i b l e t o o t h e r m e d i c a l f a c i l i t i e s . T h i s would t e n d to produce a ' d i s t a n c e decay' e f f e c t w h i c h can i n f a c t be seen i n the h i s t o g r a m s , (shown on pages 36 t o 40 i n c l u s i v e l y ) . D i f f e r e n c e s a l s o seem t o e x i s t between the g e n e r a l p r a c t i t -i o n e r and s p e c i a l i s t p h y s i c i a n groups as p r e d i c t e d by H y p o t h e s i s 4. T h i s s u g g e s t i o n i s t e s t e d i n a l a t e r s e c t i o n . D i f f e r e n c e s between the g e n e r a l p r a c t i t i o n e r and s p e c i a l i s t groups can a l s o be seen i n the v a r i a b l e s S3., S6, S7JJ and S8 c o n t i n g e n c y t a b l e s w h i c h are p r e s e n t e d i n T a b l e s 3.1 t o 3.4 i n c l u s i v e . Once a g a i n t e s t s f o r the s i g n i f i c a n c e of these d i f f e r e n c e s are p r e s e n t e d i n the s e c t i o n on hypo-t h e s i s t e s t i n g . 2(0 N u m b e r o f B l o c k s Specialists N = 20 I 5 10 N u m b e r o f P a r k i n g S p a c e s 20 Specialists N = 20 GP's N = 20 c 0) 0 10 20 30 4 0 5 0 6 0 N u m b e r o f B l o c k s • C o n t i n g e n c y Table of S i t e V a r i a b l e Three .(.Do. . D i a g n o s t i c F a c i l i t i e s E x i s t a t the. P r a c t i c e S i t e ) Response GP's N 20 S p e c i a l i s t s N 20 A l l N 40 Yes 8 17 25 No 12 3 15 TABLE 3.2 C o n t i n g e n c y Table o f S i t e V a r i a b l e S i x ( I s the P r a c t i c e S i t e L o c a t e d i n a R e s i d e n t i a l Neighbourhood) Response GP's N 20 S p e c i a l i s t s N 20 A l l N 40 Yes No 13 5 18 7 15 22 TABLE 3-3 ( I C o n t i n g e n c y Table o f S i t e V a r i a b l e Seven s the P r a c t i c e S i t e a S i n g l e P r a c t i c e S i t e ) Response GP's N 20 S p e c i a l i s t s N 20 A l l N 40 Yes No 9 0 9 11 ' 20 31 C o n t i n g e n c y Table of S i t e V a r i a b l e E i g h t ( I s the P r a c t i c e S i t e L o c a t e d on a P u b l i c T r a n s p o r t Route) Response GP's N 20 S p e c i a l i s t s N 20 A l l N 40 Yes 20 20 40 No 0 0 0 I I I . THE INTERVIEW SCHEDULE DATA The I n s t r u m e n t The i n s t r u m e n t used to c o l l e c t the d a t a o f t h i s s e c t i o n i s p r e s e n t e d i n Appendix B. Many of the q u e s t i o n s c o n t a i n e d i n the i n s t r u m e n t are not i n c l u d e d i n e i t h e r the 'Need' s c a l e o r the 'Degree of S p e c i a l i s m ' s c a l e and were i n c l u d e d i n the s c h e d u l e f o r purposes o t h e r t h a n t e s t i n g the hypotheses o f t h i s s t u d y . We now t u r n t o a c o n s i d e r a t i o n of the 'Need' s c a l e . Need The measurement t e c h n i q u e . I n o r d e r t o o b t a i n a q u a n t i t i v e . m e a s u r e of the 'need' c o n s t r u c t o f a p h y s i c i a n w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s of a m e d i c a l p r a c t i c e s i t e a s c a l e was d e v i s e d u t i l i z i n g the p s y c h o m e t r i c method o f rank o r d e r (see G u i l f o r d , 1954, pp. 178-I96). Seven s t i m u l i r e l a t e d t o the s i t e c h a r a c t e r i s t i c s o f m e d i c a l p r a c t i c e s i t e s were p r e s e n t e d to the s u b j e c t s who were asked t o r a n k them i n the o r d e r t h a t t h e y made a h y p o t h e t i c a l s i t e ' a t t r a c t i v e ' t o the p h y s i c i a n as a s i t e f r om w h i c h t o conduct t h e i r p r a c -t i c e . The s t i m u l i a re p r e s e n t e d i n Table 3.5-TABLE 3.5 S t i m u l i P r e s e n t e d i n the Need S c a l e S t i m u l u s A L a b o r a t o r y F a c i l i t i e s w i t h i n 5 b l o c k s o f p r a c t i c e . s i t e . ) S t i m u l u s B H o s p i t a l w i t h i n 5 minutes w a l k i n g d i s t a n c e of p r a c t i c e s i t e . S t i m u l u s C P r a c t i c e s i t e l o c a t e d a t the c e n t r e o f a l a r g e r e s i d e n t i a l a r e a . S t i m u l u s D Good p a r k i n g a v a i l a b l e on or near the p r a c t i c e s i t e . S t i m u l u s E Other GP's or S p e c i a l i s t s l o c a t e d on or near the s i t e . S t i m u l u s F P r a c t i c e s i t e e a s i l y a c c e s s i b l e by p u b l i c t r a n s p o r t . S t i m u l u s G D i a g n o s t i c r a d i o l o g y f a c i l i t i e s w i t h i n 5 b l o c k s of p r a c t i c e s i t e . From t h i s d a t a i t i s p o s s i b l e t o produce a r a n k o r d e r f r e q u e n c y m a t r i x i n w h i c h the columns r e p r e s e n t s t i m u l i and the rows r a n k s . The elements of t h i s m a t r i x are the f r e -q u e n c i e s w i t h w h i c h the s u b j e c t s a s s i g n e d a s p e c i f i c r a n k t o a s p e c i f i c s t i m u l u s . I n t h i s s t u d y , two such r a n k o r d e r f r e q u e n c y m a t r i c e s were o b t a i n e d ; one f o r s p e c i a l i s t p h y s i c i a n s and one f o r p r i m a r y c a r e p h y s i c i a n s . The r e a s o n f o r s p l i t t i n g the r e s -ponses i n t o the two groups was to a s c e r t a i n on the i n t u i t i v e l e v e l whether the s c a l e .rwould d i s c r i m i n a t e between the two groups o f p h y s i c i a n s . The m a t r i c e s are p r e s e n t e d i n T a b l e s 3.6 and 3.7. TABLE 3-6 Rank Order Frequency M a t r i x of P r i m a r y Care P h y s i c i a n s S t i m u l i ( s j ) r i R i A B C D E F G r i 1 7 6 2 5 1 0 5 1 20 2 6 1 2 2 2 2 4 7 20 3 5 0 1 2 5 4 5 3 20 •H 4 4 5 0 0 5 3 3 4 20 m 5 3 6 2 2 2 4 1 3 20 rt 6 2 2 4 5 4 2 1 2 20 7 1 0 9 4 l 5 1 0 20 20 20 20 20 20 20 20 140 f j i R i 90 54 77 79 65 102 93 c r ^ 3 7 5 4 6 1 2 Rank Order, Frequency M a t r i x of S p e c i a l i s t Physic:.ans S t i m u l i (Sj) r i R i A B C D E F G r i 1 7 1 9 0 3 1 3 3 20 2 6 7 1 0 3 2 3 4 20 3 5 4 2 0 3 4 2 5 20 U 4 4 3 3 1 5 3 2 3 20 Ranks 5 6 3 2 2 2 2 1 0 5 4 l 5 4 4 5 3 2 20 20 7 l 1 2 14 1 l 1 0 20 f j i 20 20 20 20 20 20 20 140 ' f j i R i 92 101 28 89 75 80 95 c r ^  3 1 7 4 6 5 2 From such m a t r i c e s i t i s p o s s i b l e t o o b t a i n a 1 com-p o s i t e r a n k i n g 1 o f the s t i m u l i f o r each of the groups. T h i s i s done by c o n v e r t i n g the 'r a n k s ' , r-j_, a s s i g n e d t o the s t i m u l i i n t o 'rank v a l u e s ' , Rj_. T h i s i s done u s i n g the s i m p l e e q u a t i o n : R-L s n - r j _ - 1 where: n «* number o f s u b j e c t s A term i s then c a l c u l a t e d by m u l t i p l y i n g each r a n k v a l u e by the f r e q u e n c y t h a t t h a t r a n k v a l u e was a s s i g n e d t o the s t i m u l u s under c o n s i d e r a t i o n . These terms are then summed f o r each s t i m u l u s t o produce the term f j i ^ i - F i n a l l y f r o m these v a l u e s f j i ^ i one- can o b t a i n the 'composite rank' of the s t i m u l u s , cr-j_. The v a l u e of c r j _ i s 1 f o r the l a r g e s t fj±R±, 2 f o r the second l a r g e s t , and so on f o r a l l the s t i m u l i . The ^ j i ^ i a n c ^ c r l v a l u e s of the s t i m u l i are p r e s e n t e d w i t h the r a n k o r d e r f r e q u e n c y m a t r i c e s i n T a b l e s 3.6 and 3.7. As had been suggested e a r l i e r , d i f f e r e n c e s were found between the cr j _ o f the two groups. These d i f f e r e n c e s were, i n t u i t i v e l y a t l e a s t , o f the type suggested by the r e s e a r c h h y p o t h e s i s o f the s t u d y . The two s e t s of composite r a n k i n g s are p r e s e n t e d i n Tab l e s 3«8 and 3«9« As can be seen s p e c i a l i s t p h y s i c i a n s showed a marked p r e f e r e n c e f o r s i t e s t h a t f a c i l i t a t e d a h i g h degree of l i n k a g e w i t h o t h e r m e d i c a l f a c i l i t i e s . O n l y s t i m u l u s E, a c c e s s i b i l i t y t o o t h e r p h y s i c i a n s , was fo u n d t o have a low composite r a n k i n g . S t i m u l i concerned w i t h the a c c e s s i b i l i t y o f the p r a c t i c e s i t e t o the g e n e r a l p u b l i c r e c e i v e d g e n e r a l l y low r a n k i n g s . T h i s i n d i c a t e s t h a t s p e c i a l i s t p h y s i c i a n s ' 'need' c o n s t r u c t s r e g a r d i n g the s i t e c h a r a c t e r i s t i c s o f m e d i c a l p r a c t i c e s i t e s i s l a r g e l y dominated by h i s ' i n t e r n a l needs' f o r h i g h l i n k a g e f a c i l i t i e s . TABLE 3-8 Composite Rankings o f S p e c i a l i s t P h y s i c i a n s : , . . S t i m u l u s c r j A L a b o r a t o r y f a c i l i t i e s w i t h i n 5 b l o c k s o f p r a c t i c e s i t e 3 B H o s p i t a l w i t h i n 5 minutes w a l k i n g d i s t a n c e o f p r a c t i c e s i t e 1 C P r a c t i c e s i t e l o c a t e d a t c e n t r e o f l a r g e r e s i d e n t i a l a r e a 7 D Good p a r k i n g a v a i l a b l e on or near the p r a c t i c e s i t e 4 E Other GP's or s p e c i a l i s t s l o c a t e d on or near the p r a c t i c e s i t e 6 F P r a c t i c e s i t e e a s i l y a c c e s s i b l e by p u b l i c t r a n s p o r t 5 G D i a g n o s t i c r a d i o l o g y f a c i l i t i e s w i t h i n 5 b l o c k s o f p r a c t i c e s i t e 2 TABLE 3.9 Composite R a n k i n g s o f P r i m a r y Care P h y s i c i a n s S t i m u l u s c r ^  A L a b o r a t o r y f a c i l i t i e s w i t h i n 5 b l o c k s o f p r a c t i c e s i t e 3 B H o s p i t a l w i t h i n 5 minutes w a l k i n g d i s t a n c e of p r a c t i c e s i t e 7 C P r a c t i c e s i t e l o c a t e d a t c e n t r e o f l a r g e r e s i d e n t i a l a r e a 5 D Good p a r k i n g a v a i l a b l e on or near the p r a c t i c e s i t e 4 E Other GP's or s p e c i a l i s t s l o c a t e d on or near the p r a c t i c e s i t e 6 F P r a c t i c e s i t e e a s i l y a c c e s s i b l e by p u b l i c t r a n s p o r t 1 G D i a g n o s t i c r a d i o l o g y f a c i l i t i e s w i t h i n 5 b l o c k s of p r a c t i c e s i t e - . ,, , . , ,2 P r i m a r y Care P h y s i c i a n s showed a v e r y d i f f e r e n t composite r a n k s t r u c t u r e . S t i m u l i P and C, a c c e s s i b i l i t y o f s i t e by p u b l i c t r a n s p o r t and l o c a t i o n of s i t e i n a l a r g e r e s i d e n t i a l a r e a , were b o t h r a n k e d h i g h e r moving f r o m r a n k 5 t o r a n k 1 and r a n k 7 t o r a n k 5 r e s p e c t i v e l y . S t i m u l u s B, a c c e s s i b i l i t y o f p r a c t i c e s i t e t o h o s p i t a l , dropped f r o m r a n k 1 t o r a n k 7 w h i l e s t i m u l i A, D, B, and G h e l d the same r a n k s . T h i s i n d i c a t e s t h a t the 'need' c o n s t r u c t o f p r i m a r y c a r e p h y s i c i a n s i s dominated more by the ' e x t e r n a l ' needs of the p h y s i c i a n s ' p a t i e n t s f o r 'c o n v e n i e n t ' l o c a t i o n s than i s the ' i n t e r n a l l y 1 dominated need s t r u c t u r e of the s p e c i a l i s t p h y s i c i a n . The composite r a n k s o f the p r i m a r y c a r e p h y s i -c i a n s are p r e s e n t e d i n Table 3.9 The g r o u p i n g a n a l y s i s . As was seen i n the l a s t s e c t i o n the Need s c a l e , d i d d i s c r i m i n a t e i n the aggregate sense between P r i m a r y Care and S p e c i a l i s t p h y s i c i a n s . How-e v e r , the purpose of the s c a l e was t o q u a n t i t a t i v e l y 'measure' the Need c o n s t r u c t of the i n d i v i d u a l p h y s i c i a n . To a t t a i n t h i s end a h i e r a r c h i c a l g r o u p i n g a n a l y s i s was performed on the i n d i v i d u a l . p h y s i c i a n s 1 r a n k i n g s o f the seven s t i m u l i p r e s e n t e d i n the Need s c a l e . Veldman (1967) d i s c u s s e s h i e r a r c h i c a l g r o u p i n g a n a l y s i s as f o l l o w s : G i v e n a s e t o f N o b j e c t s ( p e r s o n s , t e s t i t e m s , and so. f o r t h ) , each measured on K d i f f e r e n t v a r i a b l e s , one may ask t o what e x t e n t t h e r e e x i s t n a t u r a l groups among the N o b j e c t s - - g r o u p s w h i c h are s i m i l a r i n t h e i r s c o r e s on the K v a r i a b l e s used to d e s c r i b e them. T h e o r e t i c a l l y , an optimum g r o u p i n g of the o b j e c t s can be d e f i n e d f o r each p a r t i c u l a r number of groups f r o m 2 to N-l,....Such an optimum group-i n g s h o u l d maximize the average i n t e r - g r o u p d i s t -ance w h i l e m i n i m i z i n g the average i n t r a - g r o u p d i s t a n c e . U n f o r t u n a t e l y the c o m p u t a t i o n a l burden . . . . i s p r o h i b i t i v e even w i t h the a i d of a computer. S i n c e e v e r y p o s s i b l e g r o u p i n g of the 20 o b j e c t s i n t o f o u r s e t s would have t o be used as a b a s i s f o r c a l -c u l a t i n g an i n d e x o f c l u s t e r s e p a r a t i o n . Ward (I963) has p r o v i d e d a compromise approach t o the g o a l o f d e t e r m i n i n g optimum g r o u p i n g s . The method b e g i n s by d e f i n i n g each o r i g i n a l o b j e c t as a 'group'. These N groups are then r e d u c e d i n number by a s e r i e s of s t e p - d e c i s i o n s u n t i l a l l N p ersons have been c l a s s i f i e d i n t o one o r the o t h e r o f two groups. A t each s t e p some p a i r of groups i s combined, thus r e d u c i n g the number of groups by one. The d e c i s i o n r e g a r d i n g the p a r t i c u l a r p a i r t o be combined a t any s t a g e i s made on the b a s i s o f some p a r t i c u l a r 'value r e f l e c t i n g ' f u n c t i o n : the t o t a l w i t h i n group v a r i -a t i o n w h i c h i s t o be m i n i m a l l y i n c r e a s e d a t each s t e p i n the p r o c e s s . . . . T h i s p r o c e d u r e i s a compro-mise w i t h the t h e o r e t i c a l i d e a l of optimum g r o u p i n g d e s c r i b e d e a r l i e r , s i n c e a t each stage of the p r o -c e s s the p r e v i o u s g r o u p i n g i s a c c e p t e d as the b a s i s f o r d e t e r m i n i n g the n e x t r e d u c t i o n . One can imagine t h i s p r o c e s s l e a d i n g g r a d u a l l y t o a s o l u t i o n w h i c h i s not optimum, b u t o n l y under c i r c u m s t a n c e s where the ' n a t u r a l ' c l u s t e r i n g o f the o b j e c t ' s p r o f i l e s i s q u i t e weak. (Veldman, 1967, pp. 308-309) I n t h i s case the N o b j e c t s are the 40 p h y s i c i a n s and the K v a r i a b l e s the seven s t i m u l i o f the need s c a l e . As s t a t e d i n the l a s t p a r a g r a p h , the Ward a l g o r i t h m s t a r t s w i t h each o b j e c t as i t s own group and s u c c e s s i v e l y combines them u n t i l a l l o b j e c t s are i n one group. For our purposes we r e q u i r e d the g r o u p i n g to i s o l a t e the ' n a t u r a l ' c l u s t e r i n g s of p h y s i c i a n s based on t h e i r 'need' p r o f i l e s . The g r o u p i n g s o b t a i n e d can be seen i n the Tree Graph p r e s e n t e d i n Appendix G. The q u e s t i o n was a t w h i c h l e v e l o f g r o u p i n g s h o u l d one a c c e p t the number o f groups as b e i n g ' n a t u r a l ' ? I n t h i s case the e r r o r f u n c t i o n , the sum o f the squared d i f f e r e n c e s between c o r r e s p o n d i n g s c o r e s i n the p r o f i l e d i v i d e d by the number o f o b j e c t s i n the p o t e n t i a l group summed over a l l groups, d i d n o t r i s e s h a r p l y a t any p a r t i c u l a r s tage i n the g r o u p i n g , thus i n d i c a t i n g t h a t the p r e v i o u s g r o u p i n g con-t a i n e d a g r e a t d e a l more i n f o r m a t i o n t h a n the n e x t s t a g e , and so the d e c i s i o n t o u t i l i z e the g r o u p i n g c o n t a i n i n g f o u r groups was made on i n t u i t i v e grounds. The s p e c i a l t i e s o f the p h y s i c i a n s w i t h i n the f o u r groups are p r e s e n t e d i n Table 3.10. I n t u i t i v e l y t hese groups 'make sense' i n t h a t they s e p a r a t e P r i m a r y Care and S p e c i a l i s t p h y s i c i a n s w i t h o n l y f o u r e x c e p t i o n s . Of the s e one of the two i n t e r n i s t s i n Group One i s e x p l i c a b l e i n t h a t a l t h o u g h p o s s e s s i n g s p e c i a l -i s t q u a l i f i c a t i o n s the n a t u r e o f h i s p r a c t i c e I s e s s e n t i a l l y t h a t o f a P r i m a r y Care p h y s i c i a n . Only 5 per cen t o f h i s p a t i e n t s are r e f e r r e d t o him by P r i m a r y Care p h y s i c i a n s , the o t h e r 95 per cen t b e i n g p a t i e n t s f o r whom he a c t s as a ' f a m i l y d o c t o r ' . The f o u r groups were l a b e l l e d as f o l l o w s : Group 1, the P r i m a r y Care M e d i c a l B u i l d i n g group; Group 2, the P r i m a r y Care Neighbourhood group; Group 3, the S p e c i a l i s t H o s p i t a l L i n k a g e group; Group 4, the S p e c i a l i s t Non H o s p i t a l L i n k a g e group. These f o u r groups between them account f o r a l l the 40 p h y s i c i a n s used i n the s t u d y and as such member-TABLE 3.10 S p e c i a l t i e s o f P h y s i c i a n s i n the Four Need Groups Group 1 N=9 Group 2 N = l l Group 3 N-14 Group 4 N=6 Pr Imary Care P r i m a r y Care P r i m a r y Care ( U r o l o g y Pr imar y Care 1 Pr imary Care P r i m a r y Care Dermatology Pr imary Care Pr imary Care I n t e r n a l M e d i c i n e O t o l a r y n g o l o g y Pr imary Care Pr imar y Care I n t e r n a l M e d i c i n e O t o l a r y n g o l o g y Pr imary Care Pr imary Care I n t e r n a l M e d i c i n e Ophthalmology P r i m a r y Care Pr imary Care I n t e r n a l M e d i c i n e Ophthalmology P r i m a r y Care P r i m a r y Care I n t e r n a l M e d i c i n e Ophthalmology I n t e r n a l . M e d i c i n e P r i m a r y Care P l a s t i c S u r g e r y I n t e r n a l M e d i c i n e P r i m a r y Care P l a s t i c S u r g e r y P r i m a r y Care T h o r a c i c S u r g e r y P r i m a r y Care U r o l o g y A l l e r g y N e u r o s u r g e r y O r t h o p a e d i c S u r g e r y s h i p o f a group i s e q u i v a l e n t to b e i n g a s s i g n e d a s c o r e on a n o m i n a l v a r i a b l e measuring the 'need' of a p h y s i c i a n , i . e . , a f o u r group- polycotomous 'need' v a r i a b l e has been g e n e r a t e d f r o m the i n d i v i d u a l s t i m u l i p r o f i l e s o f the p h y s i c i a n s . As we have seen the groups produced are i n t u i t i v e l y a p p e a l i n g b u t i t i s n o t u n t i l the s e c t i o n on h y p o t h e s i s t e s t i n g t h a t the u s e f u l n e s s o f t h i s c o n s t r u c t w i l l be ful3y i n v e s t i g a t e d . The Degree o f S p e c i a l i s m S c a l e The s c a l e i t e m s . C e n t r a l t o the r e s e a r c h h y p o t h e s i s o f the s t u d y i s the concept o f the 'Degree of S p e c i a l i s m ' o f a p h y s i c i a n . One o f the major 'problems' o f the s t u d y was t o d e v i s e a s c a l e t o q u a n t i t a t i v e l y measure t h i s c o n c e p t . As was d i s c u s s e d i n Chapter I I , a p r e l i m i n a r y i n s t r u m e n t to measure t h i s concept was s u b j e c t e d t o a p r e - t e s t and i t e m a n a l y s i s and m o d i f i e d i n the l i g h t o f the r e s u l t s o b t a i n e d . D i s c u s s i o n i n t h i s - s e c t i o n concerns i t s e l f s o l e l y w i t h the i n s t r u m e n t as used i n the f i n a l s t u d y . The items i n c l u d e d i n the f i n a l s c a l e c o m p r i s e d items t h a t b e l o n g e d t o those dimensions of the t o t a l s c a l e t h a t showed the h i g h e s t p r e d i c t i v e v a l i d i t y i n the p r e - t e s t a n a l y s i s . The dimensions i n c l u d e d were as f o l l o w s : a) Items concerned w i t h the e d u c a t i o n a l h i s t o r y o f the p h y s i c i a n b) Items concerned w i t h the o r g a n i z a t i o n a l n a t u r e o f the p h y s i c i a n ; ' s p r a c t i c e c) Items concerned w i t h the p h y s i c i a n ' s a t t e n d a n c e a t m e d i c a l c o n f e r e n c e s and h i s c h o i c e o f p r o f e s s i o n a l j o u r n a l s d) Items concerned w i t h the physician;''.s t e a c h i n g and r e s e a r c h a c t i v i t i e s and h i s p a s t c o n t r i -b u t i o n s to m e d i c a l r e s e a r c h e) Items concerned w i t h the 'time budget' of the p h y s i c i a n f ) Items concerned w i t h the ' t u r n o v e r ' c h a r a c t e r -i s t i c s o f the p h y s i c i a n ' s ' p a t i e n t s ' . The e x a c t n a t u r e o f the items used can be f o u n d i n Appendix C. The s c o r i n g system adopted f o r the f i n a l s c a l e was the same as i n the p r e l i m i n a r y s c a l e , i . e . , a dichotomous 0, 1 system f o r each i t e m w i t h the f i n a l s c a l e s c o r e b e i n g the sum o f the i n d i v i d u a l i t e m r e s p o n s e s . F o r a d i s c u s s i o n o f the system used the r e a d e r i s r e f e r r e d to Chapter I I . Item v a l i d i t y . I n o r d e r t o a s c e r t a i n the i t e m v a l i d i t y o f the items c o m p r i s i n g the 'degree of s p e c i a l i s m ' s c a l e an i t e m a n a l y s i s was p e r formed on a l l s c a l e i t e m s . The i n t e r n a l c r i t e r i o n of ' t o t a l s c o r e ' was used and as the i n d i -v i d u a l items had been d i c h o t o m i z e d the P o i n t B i s e r i a l c o r r e -l a t i o n c o e f f i c i e n t was the a p p r o p r i a t e i n d e x o f i t e m v a l i d i t y ( G u i l f o r d , 1954, p. 427). The P o i n t B i s e r i a l c o r r e l a t i o n s between i t e m r e s p o n s e s and t o t a l s c o r e are p r e s e n t e d i n Appendix D. G e n e r a l l y the r e s u l t s o f the i t e m a n a l y s i s were e n c o u r a g i n g w i t h h i g h c o r r e l a t i o n s r e p o r t e d f o r most dimen-s i o n s . The e d u c a t i o n d i m e n s i o n was the weakest w i t h s e v e r a l 'poor' i t e m s . The ' o r g a n i z a t i o n ' and ' p a r t i c i p a t i o n ' d imensions showed g e n e r a l l y h i g h c o r r e l a t i o n s . E x c e l l e n t r e s u l t s were o b t a i n e d f o r .the o t h e r d i m e n s i o n s . The r e s u l t s o f the i t e m a n a l y s i s i n d i c a t e d t h a t the 'degree o f s p e c i a l i s m ' s c a l e c o n s i s t e d o f a s e t o f items w i t h h i g h v a l i d i t y t o p r e d i c t the f i n a l s c a l e s c o r e . Our a t t e n t i o n w i l l now be d i r e c t e d t o the p r oblem o f t e s t r e l i -a b i l i t y . S c a l e r e l i a b i l i t y . Whereas ' v a l i d i t y ' i s concerned w i t h 'what' an i t e m measures or what an i t e m c o n t r i b u t e s toward a f i n a l s c a l e s c o r e , ' r e l i a b i l i t y ' i s concerned w i t h the s t a b i l i t y o f a s c o r e o b t a i n e d a f t e r one a d m i n i s t r a t i o n o f a t e s t . There have been t h r e e s t a n d a r d approaches t o r e l i a b i l i t y known as the ' s p l i t h a l f , ' a l t e r n a t e forms' and ' r e t e s t ' methods o f r e l i a b i l i t y e s t i m a t i o n (see G u i l f o r d , 1954, pp. 373-398). " A l l have i n common the g o a l o f d e r i v i n g two s e t s o f s c o r e s f r o m the 'same' t e s t a d m i n i s t e r e d t o the 'same' sample f o r the purpose of c o r r e l a t i o n t o f i n d r^^." ( G u i l f o r d , 1954, p. 373). I n t h i s case r^-^. ranges f o r 0 t o 1 and can be c o n s i d e r e d as the p r o b a b i l i t y o f o b t a i n i n g the same s c o r e s on a second a d m i n i s t r a t i o n of the 'same' t e s t to the 'same' sample, i . e . , i t i s an i n d e x o f the s t a b i l i t y o f the s c a l e s c o r e s o b t a i n e d . I n t h i s s t u d y the r e l i a b i l i t y o f the s c a l e was e s t i m a t e d by the use o f the K u d e r - R i c h a r d s o n F o r m u l a 20. The c a l c u l a t i o n f o r m u l a used was: where n = number of items i n the s c a l e p = p r o p o r t i o n o f the r e s p o n d e n t s r e s p o n d i n g i n the keyed manner q * 1-p <r.. t o t a l v a r i a n c e o f the t e s t G u i l f o r d (1954, p. 380) p o i n t s out t h a t i n e f f e c t t h i s f o r m u l a s p l i t s the t e s t i n t o 'n' p a r t s of one i t e m each. The f o r m u l a assumes t h a t the s c a l e i s o f a u n i f a c t o r n a t u r e w i t h p a r a l l e l i t e m s ; an a s s u m p t i o n not met i n t h i s s i t u a t i o n . Brogden (1946) however, i n v e s t i g a t e d the e f f e c t of v i o l a t i n g t h e s e assumptions and c o n c l u d e d t h a t b i a s was v e r y s m a l l u n l e s s 'speeding' was i n v o l v e d i n s c a l e a d m i n i s t r a t i o n . The use o f the f o r m u l a would appear t o be j u s t i f i e d i n t h i s s i t u -a t i o n . The v a l u e o f the r ^ o b t a i n e d when a p p l y i n g Kuder-R i c h a r d s o n f o r m u l a 20 t o the degree of s p e c i a l i s m s c a l e was 0.9275j a v e r y h i g h f i g u r e , i n d i c a t i n g t h a t the s c o r e s o b t a i n e d i n t h i s s t u d y have a h i g h degree o f r e l i a b i l i t y . The o r d i n a l degree of s p e c i a l i s m s c o r e . As we have seen i n the l a s t t h r e e s e c t i o n s a s c a l e was d e v i s e d t o v a l i d l y and r e l i a b l y measure the 'Degree o f S p e c i a l i s m 1 o f an i n d i -v i d u a l p h y s i c i a n . T h i s s c a l e w i l l be c o n s i d e r e d t o have produced an o r d i n a l r a t h e r t h a n an i n t e r v a l l e v e l of measure-ment, f o r a l t h o u g h the s c a l e s c o r e s may seem t o b e l o n g t o the l a t t e r l e v e l of measurement we heed S i e g e l ' s w a r n i n g t h a t "Many p e r s o n a l i t y i n v e n t o r i e s and t e s t s of a b i l i t y or a p t i -tude r e s u l t i n s c o r e s w h i c h have the s t r e n g t h of r a n k s . A l t h o u g h the s c o r e s may appear to be more p r e c i s e t h a n r a n k s , g e n e r a l l y t h e s e s c a l e s do not meet the r e q u i r e m e n t s of any h i g h e r l e v e l o f measurement and may p r o p e r l y be viewed as o r d i n a l " ( S i e g e l , 1956, p. 24). What then are the ' r a n k i n g s ' o f p h y s i c i a n s produced by t h i s o r d i n a l degree o f s p e c i a l i s m s c a l e . The s p e c i a l i s m s o f the p h y s i c i a n s r a n k e d f r o m one to f o r t y on the 'degree of s p e c i a l i s m ' s c a l e are g i v e n i n Table 3.H. I n t u i t i v e l y the r a n k i n g s o b t a i n e d on the s c a l e are v e r y a p p e a l i n g . A l l s p e c i a l i s t p h y s i c i a n s are r a n k e d h i g h e r t h a n P r i m a r y Care p h y s i c i a n s and w i t h i n the s p e c i a l i s t s surgeons dominate the f i r s t seven r a n k s , f o l l o w e d by the non-s u r g i c a l s p e c i a l t i e s . The i n t e r n a l m e d i c i n e s p e c i a l i s t s o c c u p y i n g r a n k s e i g h t e e n and twenty are the only, two i n t e r n a l m e d i c i n e s p e c i a l i s t s who do not have a s u b - s p e c i a l t y w i t h i n i n t e r n a l m e d i c i n e and b o t h o p e r a t e as ' f a m i l y p h y s i c i a n s ' t o a l a r g e p r o p o r t i o n of t h e i r p a t i e n t s ; 40 per c e n t i n the case of the p h y s i c i a n r a n k e d e i g h t e e n and 95 per c e n t i n the case of the l a t t e r . These r a n k i n g s suggest on the i n t u i t i v e l e v e l t h a t the Degree of S p e c i a l i s m s c a l e has h i g h e x t e r n a l v a l i d -i t y , i . e . , i t i s measuring what i t i s i n t e n d e d t o . A more r i g o r o u s t e s t o f the e x t e r n a l v a l i d i t y of the s c a l e , however, TABLE 3-11 Rank on Degree of S p e c i a l i s m S c a l e and S p e c i a l t y o f Sample P h y s i c i a n s Rank S p e c i a l t y Rank S p e c i a l t y Rank S p e c i a l t y Rank . - S p e c i a l t y 1 U r o l o g y 11 O r t h o p a e d i c S u r g e r y 21 P r i m a r y Care 31 Pr imary Care 2 C a r d i o l o g y 22 Pr imary Care 32 P r i m a r y Care 12 D i a b e t i c s 3 T h o r a c i c 23 P r i m a r y Care 33 P r i m a r y Care S u r g e r y 13 Ophthalmology 14 24 Pr imar y Care 34 P r i m a r y Care 4 P l a s t i c Surg. U r o l o g y 25 Pr imar y Care 35 P r i m a r y Care 5 N e u r o s u r g e r y 15 O t o l a r y n g o l o g y 16 26 Pr imary Care 36 P r i m a r y Care 6 Dermatology Halmatology 27 Pr imary Care 37 P r i m a r y Care 7 P l a s t i c Surg. 17 O t o l a r y n g o l o g y 18 28 P r i m a r y Care 38 Pr imary Care 8' Rheumatics I n t e r n a l M e d i c i n e 29 Pr imary Care 39 P r imary Care 9 A l l e r g y 19 Ophthalmology 30 Pr imary Care 40 Pr imary Care 10 N u c l e a r M e d i c i n e 20 I n t e r n a l M e d i c i n e i s n o t p o s s i b l e as no r e a d i l y a c c e p t a b l e e x t e r n a l c r i t e r i o n f o r the Degree of S p e c i a l i s m i f a p h y s i c i a n e x i s t s . The r e l a -- t i o n s h i p s between the Degree of S p e c i a l i s m s c a l e and the o t h e r c o n s t r u c t s o f the s t u d y w i l l be examined i n the n e x t s e c t i o n i n w h i c h the h ypotheses o f the s t u d y are e x p l i c i t l y t e s t e d . I V . THE HYPOTHESES H y p o t h e s i s One Statement o f the h y p o t h e s i s . I n Chapter I , H y p o t h e s i s One was s t a t e d as f o l l o w s : That the 'need c o n s t r u c t ' o f an a c t o r w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s o f h i s p r a c t i c e i s s i g n i f i c a n t l y c o r r e l a t e d w i t h h i s 'degree of s p e c i a l i s m ' s c a l e s c o r e . T h i s h y p o t h e s i s i n v o l v e s c a l c u l a t i n g an a p p r o p r i a t e co-e f f i c i e n t o f c o r r e l a t i o n and t e s t i n g f o r the s i g n i f i c a n c e o f the c o r r e l a t i o n o b t a i n e d . The t e s t used. As the l e v e l o f measurement o b t a i n e d on the need s c a l e was o f a n o m i n a l n a t u r e and as the 'degree o f s p e c i a l i s m ' s c a l e i s o f an o r d i n a l n a t u r e , the a p p r o p r i a t e c o r r e l a t i o n c o e f f i c i e n t t o use i n t h i s case i s Freeman's C o e f f i c i e n t of D e t e r m i n a t i o n , 9 (Freeman, 1965, pp. 108-119). The a p p r o p r i a t e t e s t f o r the s i g n i f i c a n c e of the c o r r e l a t i o n o b t a i n e d i s the x 2 t e s t w i t h (n-l)(m- 1 )d.f. where n i s the . number of d i s t i n c t r a n k s i n the o r d i n a l s c a l e and m the l e v e l o f the n o m i n a l v a r i a b l e . The r e s u l t s of the t e s t . The r e s u l t s o f the t e s t u s i n g the method above are p r e s e n t e d i n Table 3.12. As can be seen f r o m the above t a b l e the r e l a t i o n s h i p between a c t o r 'need' and 'degree of s p e c i a l i s m ' i s s i g n i f i c a n t a t the 1 p e r c e n t l e v e l . We t h e r e f o r e a c c e p t h y p o t h e s i s one o f the s t u d y . TABLE 3.12 R e l a t i o n s h i p Between A c t o r Need C o n s t r u c t and Degree o f S p e c i a l i s m C o e f f i c i e n t C o r r e l a t i o n T e st P r o b a b i l i t y N Freeman 1s 6 0.7136 x^ t e s t 0.0074 40 H y p o t h e s i s Two Statement of the h y p o t h e s i s . H y p o t h e s i s Two was s t a t e d i n Chapter I as f o l l o w s : That the ' s i t e c h a r a c t e r i s t i c s ' o f an a c t o r ' s p r a c t i c e s i t e as measured on the s i t e v a r i a b l e s S I , S2, S3, S5, S6, S7 are s i g n i f i c a n t l y c o r r e l a t e d w i t h the 'need c o n s t r u c t ' o f the a c t o r w i t h r e g a r d to the s i t e c h a r a c t e r i s t i c s of h i s p r a c t i c e , b u t t h a t no s i g n i f i c a n t c o r r e l a t i o n e x i s t s between the s i t e v a r i a b l e s S4, S8, S9 and the a c t o r ' s need c o n s t r u c t . To t e s t t h i s h y p o t h e s i s i t i s n e c e s s a r y t o t e s t the hypotheses t h a t a s i g n i f i c a n t c o r r e l a t i o n e x i s t s between the 'need' of an a c t o r and the s i t e v a r i a b l e s S I , S2, S3, S5, S6, S7 t a k e n i n d i v i d u a l l y . The s i t e v a r i a b l e s are enumerated i n Appendix A. The t e s t s used. As d i s c u s s e d i n an e a r l i e r s e c t i o n the l e v e l o f measurement of the s i t e v a r i a b l e s was e i t h e r n o m i n a l or o r d i n a l . The 'need' s c a l e measures a t the n o m i n a l l e v e l . The a p p r o p r i a t e c o e f f i c i e n t of c o r r e l a t i o n between a n o m i n a l and an o r d i n a l s c a l e i s , as i n H y p o t h e s i s One, 2 Freeman's c o e f f i c i e n t of d e t e r m i n a t i o n , 0/, w i t h the x t e s t p r o v i d i n g the t e s t of s i g n i f i c a n c e (Freeman, 1965, pp. 108-119). The a p p r o p r i a t e c o e f f i c i e n t of c o r r e l a t i o n between two n o m i n a l s c a l e s i s Guttman's Symmetric C o e f f i c i e n t o f P r e d i c t a b i l i t y , X , w i t h the x t e s t w i t h (n-1)(m-1) d . f . p r o v i d i n g the t e s t of s i g n i f i c a n c e where n i s the l e v e l of one of the n o m i n a l v a r i a b l e s and m the l e v e l of the second. R e s u l t s of the t e s t s . The r e s u l t s of the t e s t of H y p o t h e s i s Two are p r e s e n t e d i n Table 3.13-As can be seen f r o m the above s t u d y H y p o t h e s i s Two i s o n l y p a r t i a l l y v e r i f i e d by the d a t a of the s t u d y . The t h r e e v a r i a b l e s h y p o t h e s i z e d as h a v i n g no s i g n i f i c a n t r e l a -t i o n t o the need of the a c t o r s are i n f a c t not s i g n i f i c a n t l y r e l a t e d . However, of the s i x v a r i a b l e s h y p o t h e s i z e d as b e i n g s i g n i f i c a n t l y r e l a t e d , o n l y t h r e e are s i g n i f i c a n t l y r e l a t e d a t the 5 per c e n t l e v e l o r b e t t e r - - S 3 a t the 5 Per c e n t l e v e l , S6 a t the 5 per c e n t l e v e l and S7 a t the 1 per c e n t l e v e l . V a r i a b l e s S I , S2, and S5 would o n l y be s i g n i f i c a n t l y r e l a t e d i f the l e v e l of s i g n i f i c a n c e of the t e s t were s e t a t the 20 per c e n t l e v e l . However, these t h r e e v a r i a b l e s are more TABLE 3.13 R e l a t i o n s h i p Between A c t o r Need C o n s t r u c t and A c t o r P r a c t i c e S i t e C h a r a c t e r i s t i c s V ar i a b l e L e v e l of Measurement C o e f f i c i e n t C o r r e l a t i o n T e s t P r o b a b i l i t y N S I O r d i n a l Freeman's e 0.4322 X2 O.I565 40 S2 O r d i n a l Freeman 1s © 0.4288 x 2 0.1805 40 S3 Nominal Guttman 1s X 0.3488 X2 0.0525 4o S4 Nominal Guttman's X 0.0357 x 2 0.2900 4o S5 O r d i n a l Freeman's 9 0.5300 x 2 O.1767 40 S6 Nominal Guttman's X 0.2955 •X2 0.0231 4o S7 Nominal Guttman's X 0.2571 x 2 0.0020 4o s8 Nominal Guttman's X 0.0000 X2 1.0000 40 S9 O r d i n a l Freeman's 6 0.3568 . . x 2 , . . 0.3075 4o OA H s i g n i f i c a n t l y r e l a t e d than are the t h r e e v a r i a b l e s hypo-t h e s i z e d as not b e i n g s i g n i f i c a n t l y r e l a t e d . T h i s p o s s i b l y i n d i c a t e s t h a t the l a c k o f s i g n i f i c a n c e may be due t o the crude n a t u r e of measurement of the 'need' c o n s t r u c t and not t o a l a c k o f r e l a t i o n s h i p between the v a r i a b l e s . I n the l i g h t o f t h i s o b s e r v a t i o n and the f a c t t h a t s i x o f the n i n e sub-hypotheses were 'accepted' a t the 5 per c e n t c o n f i d e n c e l e v e l or b e t t e r , H y p o t h e s i s Two o f the s t u d y i s ' a c c e p t e d ' . H y p o t h e s i s Three Statement of the h y p o t h e s i s . H y p o t h e s i s Three was s t a t e d i n Chapter I as f o l l o w s : That the s i t e c h a r a c t e r i s t i c s of an a c t o r ' s p r a c t i c e s i t e as measured on the s i t e v a r i a b l e s S I , S2, S3; S5, S6, S7 are s i g n i f i c a n t l y c o r r e l a t e d w i t h the 'Degree of S p e c i a l i s m ' s c a l e s c o r e o f the a c t o r b u t t h a t no s i g n i f i c a n t c o r r e l a t i o n e x i s t s between s i t e c h a r a c t e r i s t i c s S4, S8, S9 and the 'Degree of S p e c i a l i s m ' s c o r e o f the p h y s i c i a n . As w i t h H y p o t h e s i s Two t h i s h y p o t h e s i s w i l l be t e s t e d as n i n e i n d i v i d u a l sub-hypotheses by t e s t i n g f o r the s i g n i f i -cance of the c o r r e l a t i o n between the 'Degree o f S p e c i a l i s m ' s c o r e and each o f the i n d i v i d u a l s i t e v a r i a b l e s . The t e s t s used. As the l e v e l of the s i t e v a r i a b l e s i s e i t h e r of the n o m i n a l or the o r d i n a l l e v e l and the 'Degree of S p e c i a l i s m ' s c a l e i s an o r d i n a l s c a l e , the a p p r o p r i a t e c o r r e l a t i o n c o e f f i c i e n t s are Freeman's 6 f o r the o r d i n a l -n o m i n a l c o r r e l a t i o n and Goodman and K r u s k a l ' s C o e f f i c i e n t of r a n k a s s o c i a t i o n , G, f o r the o r d i n a l - o r d i n a l c o r r e l a t i o n . The s i g n i f i c a n c e t e s t s f o r the c o r r e l a t i o n s are p r o v i d e d by the s i g n i f i c a n c e t e s t f o r G i n the o r d i n a l - o r d i n a l case and by the Mann Whitney U t e s t f o r the o r d i n a l - n o m i n a l c o r r e l a -t i o n s e x c e p t i n the case of S3, w h i c h has l e v e l t h r e e and 2 not two as have the o t h e r n o m i n a l v a r i a b l e s , where the x t e s t p r o v i d e s the t e s t o f s i g n i f i c a n c e (Freeman, 19^5^ pp. 109-120 and pp. 79-89). R e s u l t s o f the t e s t s . The r e s u l t s of the t e s t on H y p o t h e s i s Three are p r e s e n t e d i n Table 3.14. As can be seen f r o m the t a b l e shown on page 64, s t u d y h y p o t h e s i s t h r e e i s v e r i f i e d by the d a t a on a l l v a r i a b l e s e x c e p t S3. The c o r r e l a t i o n s between v a r i a b l e s S4, S8, S9 and the 'Degree of S p e c i a l i s m ' s c a l e s c o r e are not s i g n i f i -c a n t f o r any v a r i a b l e as was h y p o t h e s i z e d and the c o r r e l a -t i o n s between v a r i a b l e s S I , S2, S5, S6, S7 are s i g n i f i c a n t a t the 1 per c e n t l e v e l of s i g n i f i c a n c e . Only the r e l a t i o n -s h i p between S3 and the'Degree of S p e c i a l i s m ' s c o r e f a i l s t o be s i g n i f i c a n t . No e x p l a n a t i o n f o r the l a c k of r e l a t i o n s h i p i s f o r t h c o m i n g . I n the l i g h t of the above f i n d i n g s , r e s e a r c h H y p o t h e s i s Three of the s t u d y i s a c c e p t e d . H y p o t h e s i s Four Statement of the h y p o t h e s i s . I n Chapter I H y p o t h e s i s Four was s t a t e d as f o l l o w s : TABLE 3.14 R e l a t i o n s h i p Between A c t o r Degree of S p e c i a l i s m Score and A c t o r S i t e C h a r a c t e r i s t i c s V ar i a b l e L e v e l o f Measurement C o e f f i c i e n t C o r r e l a t i o n T e s t : P r o b a b i l i t y N S I O r d i n a l G 0.6077 s i g . t e s t f o r G 0.0014 40 S 2 O r d i n a l G 0.6321 s i g . t e s t f o r G 0.0006 4o S 3 Nominal e 0.5704 2 X 0.9857 4o S 4 Nominal e O.O263 U 0.9502 40 S 5 O r d i n a l G 0.4068 s i g . t e s t f o r G 0.0035 4o S 6 Nominal G 0.4399 U 0.0179 4o S 7 Nominal e 0.8037 U 0.0003 40 S 8 Nominal 0 0.0000 U 1.0000 4o S 9 O r d i n a l G - 0.1440 s i g . t e s t f o r G 0.3342 40 That the s i t e c h a r a c t e r i s t i c s o f P r i m a r y Care p h y s i c i a n s ' s i t e s as measured on s i t e v a r i a b l e s S I , S2, S3, S5, S6, S7 are s i g n i f i c a n t l y d i f f e r e n t f r o m the s i t e c h a r a c t e r i s t i c s o f S p e c i a l i s t p h y s i -c i a n s ' s i t e s but t h a t no s i g n i f i c a n t d i f f e r e n c e e x i s t s f o r s i t e c h a r a c t e r i s t i c s S4, S8, S9 between the two groups. As i n Hypotheses Two and Three,, n i n e sub-hypotheses are t e s t e d w i t h each s i t e c h a r a c t e r i s t i c b e i n g i n d i v i d u a l l y t e s t e d . The t e s t s used. U n l i k e Hypotheses One t h r o u g h Three w h i c h were hypotheses r e g a r d i n g the s i g n i f i c a n c e o f a c o r r e -l a t i o n between two s c a l e s , H y p o t h e s i s Four i s concerned w i t h the d i f f e r e n c e s between the s i t e c h a r a c t e r i s t i c s o f two groups o f p h y s i c i a n s : - namely P r i m a r y Care p h y s i c i a n s and S p e c i a l i s t p h y s i c i a n s . The a p p r o p r i a t e t e s t t o use t o t e s t f o r t h i s d i f f e r e n c e when the s i t e v a r i a b l e b e i n g c o n s i d e r e d has a c h i e v e d o r d i n a l measurement i s the Mann-Whitney U t e s t ( S i e g e l , 1956, pp. Il6-127), w h i l e the x t e s t p r o v i d e s the t e s t when the v a r i a b l e i s measured a t the n o m i n a l l e v e l ( S i e g e l , 1956, pp. 104-111). R e s u l t s o f the t e s t s . The r e s u l t s o f the Mann-Whitney U t e s t s on the o r d i n a l v a r i a b l e s w i l l be r e p o r t e d f i r s t f o l l o w e d by the r e s u l t s o f the t e s t s on the n o m i n a l v a r i a b l e s . The r e s u l t s o f the U t e s t s are p r e s e n t e d i n Table 3.15. Mann-Whitney U T e s t R e s u l t s . P r i m a r y Care v s . S p e c i a l i s t P h y s i c i a n s V a r i a b l e P r i m a r y Care Mean N=20 S p e c i a l i s t s Mean N=20 U z S I 10.80 4.20 285.5 2.3127* S2 12.85 4.20 296.0 2.5968** S4 0.30 0.1.0 200.5 0.0135 S5 26.45 8.30 293.0 3.1648** S9 8.55 7.25 264.0 1.7300* p < .05 * p <;.01 ** One t a i l e d t e s t s . As b o t h n-]_ and n2 were twenty, the normal a p p r o x i -m a t i o n , z, o f U was used to determine the s i g n i f i c a n c e l e v e l o f the d i f f e r e n c e between the two groups. As the a l t e r n a t e h y p o t h e s i s t o the n u l l h y p o t h e s i s o f e q u a l means was t h a t the means of the P r i m a r y Care group were g r e a t e r t h a n those of the S p e c i a l i s t group, one t a i l e d t e s t s were employed ( S i e g e l , 1956, p. 122). As can be seen f r o m the t a b l e the h y p o t h e s i z e d r e l a -t i o n s h i p were a l l v e r i f i e d by the d a t a o f the s t u d y w i t h the e x c e p t i o n o f the h y p o t h e s i z e d l a c k o f d i f f e r e n c e f o r v a r i a b l e S9, i . e . , t h e r e was no s i g n i f i c a n t d i f f e r e n c between the two groups f o r v a r i a b l e S4 b u t t h a t d i f f e r e n c e s s i g n i f i c a n t a t the 5 per c e n t or 1 per c e n t l e v e l were found f o r the o t h e r f o u r v a r i a b l e s . The s i g n i f i c a n t d i f f e r e n c e was as hypo-t h e s i z e d f o r v a r i a b l e s S I , S2, and S5 b u t c o n t r a r y t o the h y p o t h e s i s f o r v a r i a b l e S9. However, the d i f f e r e n c e , a l t h o u g h u n e x p e c t e d , i s i n t u i t i v e l y r e a s o n a b l e i n terms of the c o n c e p t u a l paradigm of the model f o r i f one group were t o p r o v i d e l a r g e r w a i t i n g rooms f o r t h e i r p a t i e n t s one would e x p e c t t h i s t o be the P r i m a r y Care group where fewer p a t i e n t s have appointments and ' d r o p - i n 1 p a t i e n t s i n c r e a s e the average w a i t i n g p e r i o d b e f o r e b e i n g seen by the p h y s i c i a n . We now c o n s i d e r the n o m i n a l v a r i a b l e s . , C o n t i n g e n c y t a b l e s of the n o m i n a l s i t e v a r i a b l e s b r o k e n down i n t o the two groups are p r e s e n t e d i n T a b l e s 3«1 t h r o u g h 3-4 and so o n l y the x v a l u e s and t h e i r s i g n i f i c a n t l e v e l s w i l l be r e p o r t e d i n t h i s s e c t i o n . Table 3.l6 p r o v i d e s a summary o f the t e s t r e s u l t s f o r the n o m i n a l v a r i a b l e s . TABLE 3.16 p x T e s t R e s u l t s . P r i m a r y Care v s . S p e c i a l i s t P h y s i c i a n s V a r i a b l e X 2 V a l u e Degrees of Freedom L e v e l o f S i g n i f i c a n c e S3 8.24 1 S6 4.95 1 % S7 9.18 1 S8 0 . 0 0 0 — As can be seen, the h y p o t h e s i z e d d i f f e r e n c e s are a l l s u p p o r t e d by the d a t a of the s t u d y . No d i f f e r e n c e was f o u n d between the two groups on v a r i a b l e S8. I n f a c t a l l p h y s i -c i a n s were l o c a t e d a t s i t e s s e r v e d by p u b l i c t r a n s i t f a c i l i -t i e s . The h y p o t h e s i z e d d i f f e r e n c e s between the two groups on the o t h e r v a r i a b l e s were found t o be s i g n i f i c a n t a t e i t h e r the 5 per c e n t or 1 per c e n t l e v e l s . Of the s i x h y p o t h e s i z e d s i g n i f i c a n t r e l a t i o n s h i p s a l l s i x p r o v e d to be s i g n i f i c a n t a t the 5 per c e n t or 1 per c e n t l e v e l . Of the t h r e e h y p o t h e s i z e d n o n - s i g n i f i c a n t r e l a -t i o n s h i p s two p r o v e d t o be n o n - s i g n i f i c a n t and one was s i g -n i f i c a n t a t the 5 per c e n t l e v e l , b u t t h i s was u n d e r s t a n d a b l e i n an ' a f t e r the f a c t ' f a s h i o n . I n the l i g h t o f these f i n d i n g s r e s e a r c h H y p o t h e s i s Four of the s t u d y i s a c c e p t e d . SUMMARY OP MAJOR FINDINGS AND RECOMMENDATIONS FOR FUTURE RESEARCH I . SUMMARY OF THE MAJOR FINDINGS Degree of S p e c i a l i s m Can Be Measured One o f the major problems o f t h i s s t u d y was t o de v e l o p a s c a l e t h a t r e l i a b i l i t y and v a l i d l y measured the 'Degree of S p e c i a l i s m ' o f a m e d i c a l p r a c t i t i o n e r . A p r e l i m i n a r y s c a l e was d e v e l o p e d t h a t was d e s i g n e d t o cover the major dimensions o f t h i s ' c o n s t r u c t ' and a p p l i e d t o a s m a l l ' p r e - t e s t ' sample. The i t e m r e s p o n s e s were d i c h o t o m i z e d t o a c h i e v e a s c a l e s c o r e f o r the i n d i v i d u a l r e s p o n d e n t s and an i t e m a n a l y s i s c o n d ucted. The r e s u l t s o f t h i s i t e m a n a l y s i s were t h e n used t o mo d i f y the s c a l e f o r use i n the s t u d y p r o p e r . The p r e l i m i n a r y i n -strument i s r e p r o d u c e d i n Appendix E and the i t e m a n a l y s i s r e s u l t s of t h i s s c a l e i n Appendix F. The r e v i s e d s c a l e was th e n i n c o r p o r a t e d i n t o a l a r g e r i n t e r v i e w s c h e d u l e and a d m i n i s t e r e d t o the s t u d y sample. Once a g a i n , i t e m r e s p o n s e s were d i c h o t o m i z e d and an i t e m a n a l y s i s conducted. The P o i n t -B i s e r i a l c o r r e l a t i o n s between i t e m r e s p o n s e s and the i n t e r n a l c r i t e r i o n o f s c a l e s c o r e were g e n e r a l l y h i g h i n d i c a t i n g t h a t the r e v i s e d s c a l e had h i g h i n t e r n a l c o n s i s t e n c y . To i n v e s t i -gate the r e l i a b i l i t y o f the s c a l e a K u d e r - R i c h a r d s o n f o r m u l a 20 • r e l i a b i l i t y c o e f f i c i e n t was c a l c u l a t e d y i e l d i n g an r^-j-v a l u e of . 9 2 7 5--a s a t i s f a c t o r i l y h i g h f i g u r e . The r e v i s e d s c a l e i s p r e s e n t e d i n Appendix C and the i t e m a n a l y s i s r e s u l t s i n Appendix D. The r e v i s e d 'Degree o f S p e c i a l i s m ' s c a l e t h e n had h i g h i n t e r n a l c o n s i s t e n c y and r e l i a b i l i t y i n d i c a t i n g t h a t some c o n f i d e n c e can be p l a c e d on i t as an a c c u r a t e 'measure' o f the 'Degree of S p e c i a l i s m ' o f an i n d i v i d u a l m e d i c a l p r a c t i t i o n e r . As d i s c u s s e d i n Chapter I I I , the l e v e l o f measurement a t t a i n e d by the s c a l e i s c o n s i d e r e d t o be t h a t o f an o r d i n a l v a r i a b l e . The 'Need C o n s t r u c t ' o f an A c t o r Can Be Measured The o t h e r major ' c o n s t r u c t ' u t i l i z e d i n t h i s s t u d y was t h a t o f the 'need c o n s t r u c t ' o f an i n d i v i d u a l p h y s i c i a n w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s o f h i s p r a c t i c e s i t e . I n o r d e r to 'measure' t h i s c o n s t r u c t , a r a n k - o r d e r methodology was adopted i n w h i c h seven s t i m u l i were p r e s e n t e d t o the r e s -pondent a c t o r s who were asked t o r a n k them i n terms o f the degree t o w h i c h t h e y made a h y p o t h e t i c a l p r a c t i c e s i t e a t t r a c t i v e t o them as a s i t e f r o m w h i c h t o conduct t h e i r p r a c t i c e . The s t i m u l i are p r e s e n t e d I n Table 3 . 4 . From the r e s p o n s e s o b t a i n e d two r a n k - o r d e r f r e q u e n c y m a t r i c e s were g e n e r a t e d , one f o r S p e c i a l i s t p h y s i c i a n s , Table 3 - 7 , and one f o r P r i m a r y Care p h y s i c i a n s , Table 3 . 6 . From these m a t r i c e s composite r a n k i n g s o f the seven s t i m u l i were c a l c u l a t e d f o r each o f the two groups and shown t o d i f f e r i n a p r e d i c t a b l e manner. A g r o u p i n g a n a l y s i s o f the p h y s i c i a n s ' r e s p o n s e s was t h e n p e rformed and a d e c i s i o n made t o a c c e p t the group-i n g c o n t a i n i n g f o u r c l a s s e s of p h y s i c i a n s . These groups were i n t u i t i v e l y a p p e a l i n g and c o n s t i t u t e d the n u m e r i c a l a s s i g n -ment r u l e f o r 'measuring' the 'need c o n s t r u c t ' of the i n d i v i d u a l p h y s i c i a n , i . e . membership o f a group was used t o a s s i g n the v a l u e o f a l e v e l f o u r n o m i n a l v a r i a b l e t o each p h y s i c i a n . The s p e c i a l t i e s of p h y s i c i a n s i n the f o u r groups are r e p r o d u c e d I n Table 3.10 and the Tree Graph of the group-i n g a n a l y s i s i s r e p r o d u c e d i n Appendix G. Need R e l a t e s to the Degree of S p e c i a l i s m I n the r e s e a r c h model of the s t u d y adopted i n Chapter I the 'Degree of S p e c i a l i s m ' o f a p h y s i c i a n was seen t o a f f e c t the 'need c o n s t r u c t ' o f the p h y s i c i a n w i t h r e g a r d t o the s i t e c h a r a c t e r i s t i c s of h i s p r a c t i c e s i t e w h i c h i n t u r n a f f e c t e d the l o c a t i o n a l d e c i s i o n s o f the p h y s i c i a n s w i t h r e g a r d t o h i s c h o i c e o f p r a c t i c e s i t e . Thus H y p o t h e s i s One of the s t u d y p o s i t e d a s i g n i f i c a n t r e l a t i o n s h i p between the 'Degree of S p e c i a l i s m ' o f a p h y s i c i a n and h i s 'need c o n s t r u c t ' w i t h r e g a r d t o p r a c t i c e s i t e c h a r a c t e r i s t i c s . U t i l i z i n g the 'measures' p r o v i d e d by the 'Degree of S p e c i a l i s m ' and 'need' s c a l e s a Freeman's c o r r e l a t i o n c o e f f i c i e n t was c a l c u l a t e d p and a x t e s t used t o t e s t the s i g n i f i c a n c e of the c o r r e l a t i o n . The v a l u e o f o b t a i n e d was 0 . 7 1 3 6 w h i c h was s i g n i f i c a n t a t the 1 per c e n t l e v e l . H y p o t h e s i s One o f the s t u d y was thus 'accepted' a t the 1 per c e n t l e v e l o f s i g n i f i c a n c e . Need R e l a t e s t o S i t e C h a r a c t e r i s t i c s The second h y p o t h e s i s o f the s t u d y p o s i t e d t h a t the 'need c o n s t r u c t ' o f an a c t o r was s i g n i f i c a n t l y c o r r e l a t e d w i t h c e r t a i n s i t e c h a r a c t e r i s t i c s o f h i s p r a c t i c e s i t e b u t t h a t no r e l a t i o n s h i p w o u l d be found between o t h e r s i t e c h a r a c t e r i s t i c s and the a c t o r ' s need. None o f the hypothe-s i z e d n o n - s i g n i f i c a n t r e l a t i o n s h i p s p r o v e d t o be s i g n i f i c a n t . Of the s i x h y p o t h e s i z e d s i g n i f i c a n t r e l a t i o n s h i p s t h r e e were s i g n i f i c a n t a t the 5 per c e n t o f 1 p e r c e n t l e v e l and the t h r e e t h a t were n o t s i g n i f i c a n t a t the 5 per c e n t l e v e l showed a s t r o n g e r r e l a t i o n s h i p t h a n the h y p o t h e s i z e d n o n - s i g n i f i c a n t r e l a t i o n s h i p s . The r e s u l t s are r e p r o d u c e d i n Table 3 . 1 3 . On the b a s i s o f t h e s e r e s u l t s H y p o t h e s i s Two o f the s t u d y was 'accepted'. Degree of S p e c i a l i s m R e l a t e s t o S i t e C h a r a c t e r i s t i c s H y p o t h e s i s Three of the s t u d y completed t e s t i n g of the r e l a t i o n s h i p s e x p r e s s e d i n the r e s e a r c h model of the s t u d y (see F i g u r e 1 . 1 ) p o s i t i n g s i g n i f i c a n t r e l a t i o n s h i p s between s i x s i t e c h a r a c t e r i s t i c s and a c t o r 'Degree of S p e c i a l i s m ' s c o r e s and n o n - s i g n i f i c a n t r e l a t i o n s h i p s . b e t w e e n the o t h e r t h r e e s i t e c h a r a c t e r i s t i c s and a c t o r 'Degree of S p e c i a l i s m ' s c o r e s . The t h r e e h y p o t h e s i z e d n o n - s i g n i f i c a n t r e l a t i o n s h i p s were found t o be n o n - s i g n i f i c a n t and f i v e of the s i x hypo-t h e s i z e d s i g n i f i c a n t r e l a t i o n s h i p s were found t o be s i g n i f i -c a n t a t the 5 per c e n t l e v e l . The r e s u l t s o f the t e s t s are p r e s e n t e d i n Table 3 . 1 4 . On the b a s i s o f the t e s t s made, H y p o t h e s i s Three of the s t u d y was a c c e p t e d . I I . SUGGESTIONS FOR FUTURE RESEARCH T h i s s t u d y has f o c u s e d on two a s p e c t s o f the l o c a t i o n a l d e c i s i o n s o f M e d i c a l P r a c t i t i o n e r s w i t h i n an urban a r e a ; namely the r e l a t i o n s h i p s between the 'Degree of S p e c i a l i s m ' o f a p h y s i c i a n , the 'need c o n s t r u c t ' o f a p h y s i c i a n and the-..-, s i t e c h a r a c t e r i s t i c s of the M e d i c a l P r a c t i c e s i t e o c c u p i e d by the p h y s i c i a n . No attempt was made t o e x p l i c i t l y a n a l y z e the s p a t i a l s t r u c t u r e of M e d i c a l P r a c t i c e s i t e s w i t h i n the s t u d y a r e a a l t h o u g h the c o n c e p t u a l paradigm of the s t u d y i m p l i e s t h a t c e r t a i n ' p r o p e r t i e s ' s h o u l d be found w i t h i n t h i s s t r u c -t u r e i f the paradigm adopted i s t o prove u s e f u l . S u g g e s t i o n s r e g a r d i n g the i n v e s t i g a t i o n o f t h i s a s p e c t o f the problem a re d i s c u s s e d i n the f o l l o w i n g s e c t i o n . The Need F or a S t r u c t u r a l A n a l y s i s The r e l a t i o n s h i p s h y p o t h e s i z e d i n the c o n c e p t u a l p a r a d i g m between the 'Degree of S p e c i a l i s m 1 o f a p h y s i c i a n and the s i t e c h a r a c t e r i s t i c s o f h i s p r a c t i c e i m p l y t h a t two ' s t r u c t u r a l ' c h a r a c t e r i s t i c s of the s p a t i a l p a t t e r n o f m e d i c a l c a r e s h o u l d be f o u n d a t the i n t r a - u r b a n l e v e l . These a r e : i ) That the 'Degree o f S p e c i a l i s m ' o f the p r a c t i t i o n e r s o f a c e r t a i n m e d i c a l s p e c i a l t y s h o u l d be r e l a t e d t o the 'degree o f a g g l o m e r a t i o n ' o f the s p a t i a l p a t t e r n o f t h a t p a r t i c u l a r s p e c i a l t y , i . e . , the h i g h e r the 'Degree of S p e c i a l i s m ' o f a c e r t a i n s p e c i a l t y the g r e a t e r .should be the ' c l u s t e r i n g ' found i n the s p a t i a l p a t t e r n o f t h a t s p e c i a l t y . I n terms o f the 'Degree o f S p e c i a l i s m ' r a n k i n g s g i v e n i n T a ble t h i s w ould mean t h a t surgeons would be the most ' c l u s t e r e d ' group, f o l l o w e d by o t h e r s p e c i a l i s t s w i t h P r i m a r y Care p h y s i c i a n s d i s p l a y i n g the l e a s t c l u s t e r e d s p a t i a l p a t t e r n o f p r a c t i c e . Some e v i d e n c e t h a t t h i s s i t u a t i o n i s the case f o r two major U.S. c i t i e s i s p r o v i d e d by Marsden (1966) f o r S e a t t l e and M o r r i l l and E a r i c k s o n (1966) f o r Ch i c a g o . A t e s t of t h i s h y p o t h e s i s u s i n g p o i n t p a t t e r n a n a l y s i s t e c h n i q u e s such as N e a r e s t Neighbour A n a l y s i s c o u l d y i e l d i n t e r e s t i n g r e s u l t s . i i ) That as S p e c i a l i s t p h y s i c i a n s become more h i g h l y s p e c i a l i z e d over time the s p a t i a l p a t t e r n o f s p e c i a l i s t p r a c t i c e s i t e s s h o u l d become more c l u s t e r e d . To t e s t t h i s h y p o t h e s i s i n any s t r i c t sense i s i m p o s s i b l e as i t i s n o t p o s s i b l e t o r e c o v e r the 'Degree of S p e c i a l i s m ' s c o r e s o f p h y s i c i a n s as t h e y were i n the p a s t . I t i s o n l y the p r e s e n t 'Degree o f S p e c i a l i s m ' t h a t we are a b l e t o measure. However, i f one i s p r e p a r e d t o a c c e p t t h a t i n c r e a s -i n g s p e c i a l i s m o c c u r s over time f o r the s p e c i a l i s t m e d i c a l community i n a g g r e g a t e , i t would be p o s s i b l e u t i l i z i n g p o i n t p a t t e r n s t a t i s t i c s , t o i n v e s t i g a t e the c l u s t e r i n g f o u n d w i t h i n the s p a t i a l p a t t e r n o f p r a c t i c e s i t e s a t p o i n t s i n the p a s t . I f c l u s t e r i n g had i n c r e a s e d over time t h i s would l e n d some s u p p o r t t o the h y p o t h e s i s and f u r t h e r v a l i d a t i o n of the c o n c e p t u a l paradigm. The Meed For An E x p l i c i t L i n k a g e A n a l y s i s Much o f the c o n c e p t u a l paradigm o f t h i s s t u d y was concerned w i t h the p h y s i c i a n s ' 'need c o n s t r u c t ' r e g a r d i n g the i n t e r n a l and e x t e r n a l l i n k a g e s of p o t e n t i a l p r a c t i c e s i t e s w i t h o t h e r m e d i c a l f a c i l i t i e s . E x t e r n a l s i t e l i n k a g e w i t h d i a g n o s t i c f a c i l i t i e s and a major h o s p i t a l were e s s e n -t i a l c h a r a c t e r i s t i c s f o r a S p e c i a l i s t p h y s i c i a n ' s p r a c t i c e s i t e i t was argued. The 'need c o n s t r u c t ' r a n k - o r d e r f r e -quency m a t r i x o f S p e c i a l i s t p h y s i c i a n s (Table 3 . 7 ) and the s i g n i f i c a n t d i f f e r e n c e s f o u n d between S p e c i a l i s t and P r i m a r y Care p h y s i c i a n s i n H y p o t h e s i s Four (see T a b l e s 3 . 1 5 and 3 - l 6 ) l e n d credance t o t h i s c o n c e p t . However, an e x p l i c i t L i n k a g e A n a l y s i s u t i l i z i n g ' t i m e - l o g ' d a t a f o r p h y s i c i a n s would be a v e r y u s e f u l s t u d y . I n t h i s way one c o u l d a n a l y z e the 'Degree of S p e c i a l i s m ' , L i n k a g e , S i t e c h a r a c t e r i s t i c s r e l a t i o n s h i p s e x p l i c i t l y r a t h e r t h a n i n the i m p l i c i t way w i t h w h i c h they have been h a n d l e d i n t h i s s t u d y . Such a s t u d y would be a v e r y v a l u a b l e a d d i t i o n t o the s t u d y r e p o r t e d i n t h i s t h e s i s . 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To r o n t o ' s c h a n g i n g r e t a i l complex. Chicago Department o f Geography R e s e a r c h Paper No.. 104, U n i v e r s i t y o f C h i c a g o , 1966. Tolman, E.- C. The d e t e r m i n a n t s of b e h a v i o r of a c h o i c e p o i n t . P s y c h o l o g i c a l Review, 1938, 45, l - 4 l . Veldman, D. J . F o r t r a n programming f o r the b e h a v i o r a l s c i e n c e s " New York: H o l t , R i n e h a r t and W i n s t o n , Ward, J . H. H i e r a r c h i c a l g r o u p i n g t o o p t i m i z e an o b j e c t i v e f u n c t i o n . American S t a t i s t i c a l A s s o c i a t i o n J o u r n a l , 19b3, 5», 23b-244. APPENDIX A THE SITE VARIABLES Number o f c i t y b l o c k s f r o m p r a c t i c e s i t e t o d i a g n o s t i c l a b o r a t o r y f a c i l i t i e s . Number o f c i t y b l o c k s f r o m p r a c t i c e s i t e t o d i a g n o s t i c r a d i o l o g y f a c i l i t i e s . Do d i a g n o s t i c r a d i o l o g y or l a b o r a t o r y f a c i l i t i e s e x i s t a t the p r a c t i c e s i t e . Number of c a r p a r k i n g spaces a v a i l a b l e t o the p h y s i c i a n a t the p r a c t i c e s i t e . Number o f c i t y b l o c k s f r o m p r a c t i c e s i t e t o the h o s p i t a l o f a f f i l i a t i o n o f the p h y s i c i a n . I s the p r a c t i c e s i t e l o c a t e d i n a r e s i d e n t i a l a r e a . I s the p r a c t i c e s i t e a s i n g l e p r a c t i c e s i t e . I s the p r a c t i c e s i t e l o c a t e d on a p u b l i c t r a n s i t r o u t e . Number o f s e a t s i n the p a t i e n t w a i t i n g room. APPENDIX B THE INTERVIEW SCHEDULE 1 0 0 CHARACTERISTICS OF THE PARTNERSHIP 110 S i z e o f the P a r t n e r s h i p 1 1 1 - No. o f p h y s i c i a n s i n p a r t n e r s h i p . 1 1 2 - T o t a l number o f p h y s i c i a n s i n c l i n i c ( not p a r t n e r s h i p ) . 1 1 3 - How many o f f i c e s do you/the p a r t n e r s h i p o p e r a t e ? 114 - Where are these o f f i c e s ? 1 2 0 H i s t o r y of the P r a c t i c e 1 2 1 - F o r how l o n g have you p r a c t i c e d m e d i c i n e ? 1 2 2 - F o r how l o n g have you p r a c t i c e d m e d i c i n e i n Vancouver? 1 2 3 - For how l o n g have you p r a c t i c e d m e d i c i n e a t the p r e s e n t s i t e ? 1 2 4 - Where e l s e i n Vancouver have you p r a c t i c e d m e d i c i n e ? 125 - How l o n g have the a u x i l i a r y o f f i c e s of the p a r t n e r -s h i p been open? 1 3 0 C a p i t a l i z a t i o n / E x p e n d i t u r e s of P r a c t i c e 1 3 1 - Do you/the p a r t n e r s h i p own your o f f i c e ( s ) ? 1 3 2 - Do you/the p a r t n e r s h i p l e a s e ' y o u r o f f i c e ( s ) ? 1 3 3 - Do you/the p a r t n e r s h i p r e n t your o f f i c e ( s ) ? 1 3 4 - I f the p a r t n e r s h i p owns the o f f i c e ( s ) , have you formed a c o r p o r a t i o n t h a t t e c h n i c a l l y owns the o f f i c e and t h a t charges you r e n t a l ? 1 3 5 - I f so, i s the s h a r i n g o f c a p i t a l i n the c o r p o r a t i o n the same as i n the p a r t n e r s h i p ? 1 3 6 ' - What i s the c a p i t a l i n v o l v e d i n the c l i n i c i f you/the p a r t n e r s h i p own i t i n : f a l R e a l c a p i t a l ( r e a l e s t a t e ) ? lb) F i x e d c a p i t a l (equipment, e t c . ) ? (c) W orking c a p i t a l ( s a l a r i e s , e t c . ) ? 140 L e g a l S t a t u s of P a r t n e r s h i p 141 - I s the p a r t n e r s h i p a f o r m a l l e g a l agreement? 142 - I f so, f o r how l o n g i s i t v a l i d ? 1 4 3 - What are the most i m p o r t a n t terms f o r s e p a r a t i n g f r om the c l i n i c ? 200 CHARACTERISTICS OF INDIVIDUAL PHYSICIAN 210 M e d i c a l E d u c a t i o n 211 - How many y e a r s d i d you spend i n u n i v e r s i t y / c o l l e g e p r i o r t o g o i n g .to m e d i c a l s c h o o l ? 212 - What s u b j e c t ( s ) d i d you major i n a t c o l l e g e ? 2 1 3 - How many y e a r s d i d you spend i n m e d i c a l s c h o o l ( e x c l u d i n g i n t e r n s h i p ) ? 214 - How many y e a r s s t r u c t u r e d p o s t - g r a d u a t e t r a i n i n g d i d you do? 215 - D i d you o b t a i n the degree of Ph.D.? 2 1 6 - Which u n i v e r s i t y / c o l l e g e d i d you a t t e n d ? 2 1 7 - Which m e d i c a l s c h o o l d i d you a t t e n d ? 2 1 8 - Where d i d you do your p o s t - g r a d u a t e t r a i n i n g ( i f any)? 2 1 9 - A t w h i c h h o s p i t a l d i d you do your i n t e r n s h i p ? 21A - I f t h i s was i n the U.S.A., d i d you serve a s p e c i a l i s t or r o t a t i n g i n t e r n s h i p ? 2IB - Date o f g r a d u a t i o n f r o m m e d i c a l s c h o o l . 21C - Were you i n the upper or lower h a l f o f the c l a s s i n m e d i c a l s c h o o l ? 2 2 0 G e n e r a l S o c i a l C h a r a c t e r i s t i c s 2 2 1 - Were you b o r n i n Canada? 2 2 2 - I f s o , w h i c h p r o v i n c e ? 2 2 3 - I f not B.C., when d i d you come t o B.C.? 2 2 4 - I f n o t , what c o u n t r y ? 225 - I f n o t , when d i d you come t o Canada? 2 2 6 - What i s your r e l i g i o n ( i f any)? 2 2 7 - Are you m a r r i e d ? 2 3 0 P a s t M e d i c a l E x p e r i e n c e 2 3 1 - How l o n g have you been i n m e d i c a l p r a c t i c e ? 2 3 2 - Where and f o r how l o n g were you i n m e d i c a l vu p r a c t i c e p r e v i o u s t o your p r e s e n t l o c a t i o n ? 2 3 3 - For how l o n g have you p r a c t i c e d m e d i c i n e as a r e g i s t e r e d s p e c i a l i s t ? 2 3 4 - How d i d you e n t e r the p r e s e n t p a r t n e r s h i p ? 2 4 0 H o s p i t a l A f f i l i a t i o n 2 4 1 - To w h i c h h o s p i t a l s are you a f f i l i a t e d ? 2 4 2 - What i s the n a t u r e of your a f f i l i a t i o n ? 2 5 0 F u n c t i o n a l C h a r a c t e r i s t i c s o f P r a c t i c e 2 5 1 - Do you use an an s w e r i n g s e r v i c e ? 2 5 2 - Do you make house c a l l s ? 2 5 3 - Do you make house c a l l s a t n i g h t ? 2 5 4 - How many days a week do you h o l d s u r g e r y ? 255 - What are your s u r g e r y hours? 2 5 6 - What p r o p o r t i o n of your p a t i e n t s a re r e f e r r e d t o you? 2 5 7 - What p r o p o r t i o n o f your p a t i e n t s are f r o m 'out o f town'? 2 6 0 Income 2 6 1 - What i s your g r o s s income? 2 6 2 - What p e r c e n t a g e of your g r o s s income i s consumed by overheads? 2 7 0 P r o f e s s i o n a l Group Membership • 2 7 1 - Of how many p r o f e s s i o n a l b o d i e s are you a member? 2 7 2 - How many m e d i c a l j o u r n a l s do you s u b s c r i b e t o ? 2 7 3 - How many of these are of a s p e c i a l i s t n a t u r e ? 2 7 4 - How many ' . p r o f e s s i o n a l m e d i c a l c o n f e r e n c e s ' do you a t t e n d a n n u a l l y ? 3 0 0 PERSONNEL CHARACTERISTICS OF THE PRACTICE 310 D i v i s i o n o f Labour o f M e d i c a l P a r t n e r s 3 1 1 - Do each o f the d o c t o r s w i t h i n the p a r t n e r s h i p f u l f i l l the same a d m i n i s t r a t i v e f u n c t i o n ? 312 - I f n o t , what are the s p e c i a l i s m s o f the p a r t n e r s ? 3 1 3 - What are the most i m p o r t a n t s p e c i a l t i e s n o t i n c l u d e d i n the p a r t n e r s h i p ? 3 2 0 A d m i n i s t r a t i v e S t r u c t u r e o f the P r a c t i c e 3 2 1 - Do each o f the d o c t o r s w i t h i n the p a r t n e r s h i p f u l f i l l the same a d m i n i s t r a t i v e f u n c t i o n ? 3 2 2 - I f n o t , what i s the ' d i v i s i o n of l a b o u r ' ? 4 0 0 DECISION MAKING PROCESS 4 1 0 Use o f F i n a n c i a l A d v i s o r s 4 1 1 - Do you use p r o f e s s i o n a l a c c o u n t a n t s to s c r u t i n i z e your f i n a n c i a l r e c o r d s ? 4 2 0 Use o f Other O u t s i d e P r o f e s s i o n a l A d v i s o r s 4 2 1 - D i d you c o n s u l t a r e a l t o r when d e c i d i n g whether t o own, r e n t or l e a s e your p r e s e n t o f f i c e ( s ) ? 4 2 2 - W i t h whom d i d you d i s c u s s the pr o b l e m o f d e c i d i n g where t o l o c a t e your o f f i c e ( s ) ? 4 2 3 - D i d you b u i l d o r remodel your p r e s e n t o f f i c e ? 4 2 4 - I f s o , d i d you o b t a i n the s e r v i c e s of an a r c h i t e c t e x p e r i e n c e d i n w o r k i n g w i t h m e d i c a l f a c i l i t i e s ? 4 3 0 Major D e c i s i o n Making F a c t o r s 4 3 2 - Note any o t h e r f a c t o r s t h a t you c o n s i d e r s h o u l d be i m p o r t a n t i n the d e c i s i o n o f where t o l o c a t e a p h y s i c i a n ' s o f f i c e ? 4 3 3 - What were the major f a c t o r s t h a t i n f l u e n c e d you i n your c h o i c e of s i t e ? 5 0 0 QUANTITY OF INFORMATION 5 1 0 R e c o r d K e e p i n g 5 1 1 - I f you have more th a n one o f f i c e , do you ( p e r s o n a l l y ) keep s e p a r a t e f i n a n c i a l r e c o r d s f o r each o f f i c e ? 5 1 2 - I f you have more th a n one o f f i c e , do you ( p e r s o n a l l y ) keep s e p a r a t e m e d i c a l ( i n terms o f p a t i e n t s ' r e c o r d s ) r e c o r d s f o r each o f f i c e ? 5 1 3 - I f the p a r t n e r s h i p o p e r a t e s s e v e r a l o f f i c e s , are the r e c o r d s k e p t s e p a r a t e l y f o r each o f f i c e ? 5 1 4 - Are s e p a r a t e r e c o r d s k e p t f o r each member o f the p a r t n e r s h i p i f you op e r a t e from the same s i t e ? 5 1 5 - Do you r e c e i v e i n f o r m a t i o n r e g a r d i n g the d e v e l o p -ment o f m e d i c a l c e n t r e s w i t h i n Vancouver? 5 1 6 - Do you s o l i c i t such m a t e r i a l ? 5 1 7 - Do you know the c o s t of m a i n t a i n i n g an o f f i c e i n a major m e d i c a l c e n t r e such as the F a i r m o n t B u i l d i n g ? 5 1 8 - Do you know the range o f f a c i l i t i e s a v a i l a b l e i n the major m e d i c a l c e n t r e s ? 5 2 0 C l a s s i f i c a t i o n o f I n f o r m a t i o n 5 2 1 - How do you c l a s s i f y your i n f o r m a t i o n r e g a r d i n g : (a) your p r a c t i c e - - i . e . , between o f f i c e s / p a r t -ner s ? (b) p o s s i b l e a l t e r n a t i v e s i t e s f o r your p r a c t i c e ? 5 3 0 Use of Computer F a c i l i t i e s 5 3 1 - Do you use computer f a c i l i t i e s f o r any purpose? 5 3 2 - I f s o , f o r what purpose? 5 3 3 - I f s o , where are they l o c a t e d ? 5 3 4 - I f s o , have you a remote t e r m i n a l a t the p r a c t i c e ? 6 0 0 QUALITY OF INFORMATION 610 Sources o f I n f o r m a t i o n 6 1 1 - What are your sources of d a t a r e : fa) the m e d i c a l c e n t r e s ? f b j o t h e r p o s s i b l e p r a c t i c e s i t e s ? (c) s u c c e s s e s and f a i l u r e s o f o t h e r p h y s i c i a n s ? 6 1 2 - I f any o f the above i n f o r m a t i o n i s c o l l e c t e d f o r m a l l y , i n d i c a t e the methods used. 6 2 0 Age o f I n f o r m a t i o n 6 2 1 - I n what year was your l a t e s t d a t a c o l l e c t e d r e g a r d i n g the c l a s s e s o f i n f o r m a t i o n i n d i c a t e d above? 8 0 0 FUNCTIONAL SPECIALISM OF PHYSICIAN 8 1 0 A t t i t u d e s Toward R e s e a r c h 8 1 1 - What were the p r i m a r y m o t i v a t i o n s t h a t l e d you i n t o G P / s p e c i a l i s t p r a c t i c e ? 8 1 2 - What were the p r i m a r y m o t i v a t i o n s t h a t l e d you i n t o your p a r t i c u l a r s p e c i a l t y ? 8 1 3 - Are you engaged i n a c t i v e ' b a s i c r e s e a r c h ' ? 814 - Are you engaged i n a c t i v e ' c l i n i c a l r e s e a r c h ' ? 8 1 5 - I f s o , does t h i s r e s e a r c h r e q u i r e s p e c i a l f a c i l i t i e s ? 8 1 6 - I f y e s , where are th e y l o c a t e d ? 817 - Have you had any papers p u b l i s h e d i n p r o f e s s i o n a l j o u r n a l s ? 8 1 8 - I f s o , how many? 8 1 9 - Were the s e papers concerned w i t h : (a) B a s i c r e s e a r c h ? f b j C l i n i c a l r e s e a r c h ? (c) M e d i c a l economics? (d) Other t o p i c s ( s p e c i f y ) ? 8 2 0 R e f e r r a l P a t t e r n s 8 2 1 - What p e r c e n t a g e of your p a t i e n t s are r e f e r r e d t o you by o t h e r p h y s i c i a n s ? 8 2 2 - On what grounds do you r e f e r a p a t i e n t t o an a p p r o p r i a t e s p e c i a l i s t (e.g. by r e p u t a t i o n , ease of a c c e s s , p e r s o n a l f r i e n d ) ? 8 2 3 - Do you r e f e r p a t i e n t s c o n s i s t e n t l y t o the same group of a p p r o p r i a t e s p e c i a l i s t s ? 8 2 5 - How would you r e g a r d a r a p i d p r o l i f e r a t i o n o f : f a } GP's o f f i c e s (b) S p e c i a l i s t s ' o f f i c e s i n the l o c a t i o n o f your p r a c t i c e ? 8 3 0 Use o f Time 8 3 1 - What do you c o n s i d e r t o be the 'most c h a r a c t e r i s t i c ' a c t o f your s p e c i a l t y ( e . g . d i a g n o s i s , s u r g e r y , t r e a t m e n t , t e a c h i n g , r e s e a r c h ) ? 8 3 2 - What do you c o n s i d e r t o be your most c h a r a c t e r i s t i c a c t ? 8 3 3 - What p e r c e n t a g e of each 'work week' do you spend: 'a) I n your o f f i c e ? 'b) I n the h o s p i t a l ? c) Elsewhere? 8 3 4 - When you are not s e e i n g p a t i e n t s i n the o f f i c e or on du t y a t the h o s p i t a l b u t s t i l l engaged i n m e d i c a l a f f a i r s , what f u n c t i o n s take up most of your time: a) Reading? (b) Research? ^c) Teaching? 840 A t t i t u d e Toward P r e s e n t S i t e 8 4 1 - Do you c o n s i d e r your s i t e t o be adequate? 8 4 2 - What are the major d i s a d v a n t a g e s o f the s i t e ? 843 - Do you c o n s i d e r t h e r e are.more advantageous s i t e s i n Vancouver f o r your p r a c t i c e ? 844 - I f s o , where? 845 - I f so, on what grounds do you r e g a r d them as b e i n g s u p e r i o r t o your p r e s e n t s i t e ? 8 5 0 A s p i r a t i o n L e v e l 8 5 1 - What income do you hope t o be e a r n i n g a t the peak of your c a r e e r ? 8 5 2 - What f u n c t i o n do you hope t o be f u l f i l l i n g a t the peak o f your c a r e e r ? 8 6 0 Mature of C l i e n t e l e 8 6 1 - What p r o p o r t i o n o f your p a t i e n t s are a t r a n s i e n t c l i e n t e l e ( i . e . , non f a m i l y p a t i e n t s ) ? 8 6 2 - Do you p r e f e r r e g u l a r t o t r a n s i e n t p a t i e n t s ? 8 6 3 - I f s o , why? 864 - Do you have a h i g h t u r n o v e r r a t e of p a t i e n t s on your l i s t ? 8 6 5 - Do you p r e f e r a h i g h or a low t u r n o v e r r a t e o f p a t i e n t s ? 8 6 6 - Why? 8 6 7 - Where do you f e e l you make your b i g g e s t c o n t r i b u t i o n t o s o c i e t y ? APPENDIX C THE DEGREE OP SPECIALISM SCALE The f o l l o w i n g items f r o m the i n t e r v i e w s c h e d u l e were i n c l u d e d i n the Degree of S p e c i a l i s m S c a l e . Readers s h o u l d r e f e r t o the I n t e r v i e w Schedule i n Appendix B f o r the c o n t e n t of the i t e m s . Numbers of the Items i n the Degree of S p e c i a l i s m S c a l e 1 1 1 1 1 2 2 1 1 2 1 2 2 1 3 2 1 4 215 2 1 8 2 1 A 2 IB 2 3 3 2 4 l 2 4 2 2 5 2 2 5 3 2 5 6 2 5 7 2 7 1 2 7 2 2 7 3 2 7 4 4 3 3 8 1 1 8 1 2 8 1 3 8l4 8 1 7 8 1 8 8 1 9 8 3 1 8 3 2 8 3 3 8 3 4 845 8 6 1 864 APPENDIX D POINT BISERIAL CORRELATIONS BETWEEN DEGREE OP SPECIALISM SCALE ITEM RESPONSES AND SCALE SCORE It e m Number P q r p b i 111 0.800 0.200 0.1798 112 0.625 0.375 0.5262 211 0.725 0.275 - 0.3329 212 0.750 0.250 - 0.1226 213 1.000 0.000 u n d e f i n e d 214 0.500 0.500 0.9025 215 0.200 0.800 0.6440 218 0.500 0.500 0.9025 21A 0.000 1.000 0.0000 21B 0.090 0.950 0.1642 233 0.075 0.925 0.4056 241 1.000 0.000 u n d e f i n e d 242 0.825 0.175 0.4320 252 0.350 0.650 0.7784 253 0.350 0.650 0.7784 256 o.4oo 0.600 0.7614 257 0.300 0.700 0.7441 271 0.125 1.875 0.4884 272 0.150 0.850 O.4767 273 0.500 0.500 0.9239 274 0.425 0.575 0.7909 433 0.325 0.675 0.7148 811 o.4oo 0.600 O.9834 812 o.4oo 0.600 O.9834 813 0.075 0.925 0.4455 8l4 0.275 0.725 0.6804 817 0.425 0.575 0.8720 818 0.275 0.725 0.7587 819 0.400 0.600 0.8100 831 0.300 0.700 O.7851 832 0.300 0.700 0.7851 833 0.300 0.700 0.7971 834 0.275 0.725 O.7169 845 0.050 0.950 - O.0596 861 0.475 0.525 O.9103 864 0.450 0.550 0.9103 -p = p r o p o r t i o n of a c t o r s s c o r i n g 1 on i t e m q = 1 - p r. h • = the p o i n t b i s e r i a l c o r r e l a t i o n c o e f f i c i e n t APPENDIX E THE PRELIMINARY INSTRUMENT USED IN THE PRE-TEST A b i l i t y t o A c t Dimensions 1 0 0 CHARACTERISTICS OF THE PARTNERSHIP 110 S i z e of the P a r t n e r s h i p 1 1 1 - Number of p h y s i c i a n s i n p a r t n e r s h i p . 1 1 2 - How many o f f i c e s does the p a r t n e r s h i p o p e r a t e a) i n Vancouver b) elsewhere? 1 2 0 L i f e C y c l e C h a r a c t e r i s t i c s 1 2 1 - How l o n g has the p r e s e n t p a r t n e r s h i p been l o c a t e d i n (a) Vancouver (b) p r e s e n t s i t e ? 1 2 2 - How l o n g has the p r e s e n t p r a c t i c e been l o c a t e d i n the p r e s e n t s i t e ? 1 2 3 - A t what dates d i d you open a u x i l i a r y o f f i c e s ( i f any)? 1 3 0 C a p i t a l i z a t i o n / E x p e n d i t u r e s 1 3 1 - Does the p a r t n e r s h i p own your o f f i c e ( s ) ? 1 3 2 - Does the p a r t n e r s h i p l e a s e your o f f i c e ( s ) ? 1 3 3 - Does the p a r t n e r s h i p r e n t your o f f i c e ( s ) ? 1 3 4 - What are the main a r e a s of c a p i t a l o u t l a y i n your p r a c t i c e ? 135 - I s the b u i l d i n g o c c u p i e d by the p a r t n e r s h i p owned by a c o r p o r a t i o n the s t o c k of w h i c h i s h e l d by the members o f the p a r t n e r s h i p ? 1 3 6 - I f so i s the p e r c e n t a g e of s t o c k h e l d by the p a r t n e r s i n the c o r p o r a t i o n the same as the p e r c e n t a g e t h e y own i n the p a r t n e r s h i p ? 1 3 7 - What i s the c a p i t a l the p a r t n e r s h i p has i n (a) R e a l c a p i t a l ( r e a l e s t a t e ) ? f b j F i x e d c a p i t a l (equipment, e t c ) ? (c) Working c a p i t a l ( s a l a r i e s , e t c . ) ? 1 3 8 - What p e r c e n t a g e o f t o t a l income does the p a r t n e r s h i p spend on: (a) S a l a r i e s ? f b j S u p p l i e s and drugs? (c) Others ( t r a v e l , l a u n d r y , l e g a l f e e s , e t c . ) ? 1 4 0 L e g a l S t a t u s o f P a r t n e r s h i p 1 4 1 - I s the p a r t n e r s h i p a f o r m a l l e g a l agreement? 1 4 2 - I f so, f o r how l o n g i s i t v a l i d ? 143 - I s i t p o s s i b l e f o r a p a r t n e r t o l e a v e the p a r t n e r s h i p i f he so d e s i r e s w i t h o u t the consent o f the o t h e r p a r t n e r s ? 2 0 0 CHARACTERISTICS OF THE INDIVIDUAL DECISION MAKER 2 1 0 E d u c a t i o n (Type/Time/Place) 2 1 1 - How many y e a r s d i d you spend i n c o l l e g e p r i o r t o m e d i c a l s c h o o l ? 2 1 2 - How many y e a r s d i d you spend i n m e d i c a l s c h o o l ( e x c l u d i n g i n t e r n s h i p ) ? 2 1 3 - Which c o l l e g e d i d you a t t e n d ? 2 1 4 - Which m e d i c a l s c h o o l d i d you a t t e n d ? 215 - Date o f g r a d u a t i o n : fa) f r o m c o l l e g e (b) f r o m m e d i c a l s c h o o l . 2 1 6 - D i d you s e r v e a r o t a t i n g o r a s p e c i a l i s t i n t e r n s h i p ? 217 - Was the type o f i n t e r n s h i p you s e r v e d the type f o r w h i c h you a p p l i e d ? 2 l 8 - Were you i n the upper or lower h a l f o f the c l a s s i n m e d i c a l s c h o o l ? 2 2 0 R a c i a l / S o c i a l Background 2 2 1 - Were you b o r n i n Canada? 2 2 2 - I f s o , w h i c h p r o v i n c e ? 2 2 3 - I f n o t , w h i c h c o u n t r y ? 2 2 4 - To w h i c h census e t h n i c group do you be l o n g ? 2 2 5 - What i s your r e l i g i o n ( i f any)? 2 3 0 P a s t M e d i c a l E x p e r i e n c e 2 3 1 - I s the p r e s e n t p r a c t i c e the f i r s t i n w h i c h you have been i n v o l v e d ? 2 3 2 - D i d you e n t e r the p r e s e n t p r a c t i c e (a) by e n t e r i n g i n t o p a r t n e r s h i p w i t h an e s t a b l i s h e d p h y s i c i a n ? b) e s t a b l i s h i n g a new p r a c t i c e ? c) t a k i n g over a v a c a n t p r a c t i c e ? 2 3 3 - Where and f o r how l o n g have you p r a c t i c e d m e d i c i n e (a) Vancouver? (b) r e s t of B.C.? (c) r e s t o f Canada ( s p e c i f y p r o v i n c e ( s ) ) ? fd) U.S.A. ( s p e c i f y s t a t e ) ? (e) e l s e w h e r e ( s p e c i f y ) ? 2 4 0 H o s p i t a l A f f i l i a t i o n 2 4 1 - To w h i c h h o s p i t a l ( s ) a re you a f f i l i a t e d ? 2 4 2 - Are your p a t i e n t s s e n t t o the same h o s p i t a l i r r e s p e c t i v e of the t r e a t m e n t r e q u i r e d ? 2 5 0 Income L e v e l / S o u r c e 2 5 1 - Do you o b t a i n your income f r o m (a) f e e s f o r s e r v i c e ? (b) a c a p i t a t i o n agreement? (c) a s a l a r y ? 2 5 2 - I n t o w h i c h income group do you f a l l ? 'a) $10,000 - $ 1 5 , 0 0 0 [bj 8 15 , 0 0 0 - $ 2 0 , 0 0 0 \c) $ 2 0 , 0 0 0 + 2 6 0 P r a c t i t i o n e r P a t i e n t R e l a t i o n s ( F a c t u a l ) 2 6 1 - Do you use an a n s w e r i n g s e r v i c e ? 2 6 2 - I f so, can you be r e a c h e d a t a l l times by a p a t i e n t ? 2 6 3 - I f n o t , can a p a t i e n t a t a l l times g e t i n c o n t a c t w i t h a n o t h e r member of your p a r t n e r s h i p ? 2 6 4 - How many h o s p i t a l a d m i s s i o n s d i d you have per hundred p a t i e n t s l a s t year fa) f o r s u r g e r y ? fb) f o r o b s e r v a t i o n ? (c) f o r i n t e n s i v e c a r e (non s u r g i c a l ) ? 2 6 5 - Do you make house c a l l s ? a t n i g h t ? 2 6 6 - I f s o , how many per week? 2 7 0 Group Membership 2 7 1 - Of what p r o f e s s i o n a l b o d i e s are you a member? 2 7 2 - I n w h i c h o f these are you an a c t i v e member? 2 7 3 - To w h i c h m e d i c a l j o u r n a l s do you s u b s c r i b e ? 3 0 0 INTERNAL STRUCTURE OF FIRM 3 1 0 D i v i s i o n o f M e d i c a l Labour o f P r a c t i t i o n e r s 3 1 1 - Do each of the d o c t o r s w i t h i n the p a r t n e r s h i p f u l f i l l the same p r o f e s s i o n a l f u n c t i o n ? 3 1 2 - I f n o t , what a r e the s p e c i a l i s m s o f the p a r t n e r s ? 3 1 3 - What i s the most i m p o r t a n t s p e c i a l t y n o t i n c l u d e d i n the p a r t n e r s h i p ? 3 2 0 D i v i s i o n o f A d m i n i s t r a t i v e Labour o f P r a c t i t i o n e r s 3 2 1 - Do each o f the d o c t o r s w i t h i n the p a r t n e r s h i p f u l f i l l the same a d m i n i s t r a t i v e f u n c t i o n ? 3 2 2 - I f n o t , what i s t h e ' d i v i s i o n of l a b o u r 1? 3 3 0 Other Permanent P e r s o n n e l 3 3 1 - Does the p a r t n e r s h i p employ a b u s i n e s s manager t o d e a l w i t h o r g a n i z a t i o n a l , f i n a n c i a l and p e r s o n n e l q u e s t i o n s ? 400 DECISION MAKING PROCESS 410 Use of O u t s i d e A d v i s o r s on F i n a n c i a l M a t t e r s 411 - Do you use p r o f e s s i o n a l a c c o u n t a n t s t o s c r u t i n i z e your f i n a n c i a l r e c o r d s ? 412 - Do you work i n c o n j u n c t i o n w i t h p r o f e s s i o n a l a d v i s o r s when making f i n a n c i a l d e c i s i o n s ? 4 2 0 Use o f O u t s i d e A d v i s o r s r e S u i t a b i l i t y o f S i t e s , e t c 4 2 1 - D i d you c o n s u l t a r e a l t o r when d e c i d i n g whether t o own, l e a s e or r e n t your o f f i c e ? 4 2 2 - Who d i d you t a l k t o when d e c i d i n g where t o l o c a t e your o f f i c e ? 4 2 3 - D i d you b u i l d o r remodel your p r e s e n t o f f i c e ? 4 2 4 - I f s o , d i d you o b t a i n the s e r v i c e s of an a r c h i t e c t e x p e r i e n c e d i n w o r k i n g w i t h m e d i c a l f a c i l i t i e s ? 4 3 0 I n t e r n a l Segmentation o f D e c i s i o n Making 4 3 1 - Do 'committees' of the p a r t n e r s e x i s t t o d e a l w i t h d i f f e r e n t a r e a s of p o l i c y d e c i s i o n making? 4 3 2 - I f s o , are the d e c i s i o n s o f these committees f i n a l or do th e y m e r e l y make recommendations t o a l l the p a r t n e r s ? 4 3 3 - Do a l l the p a r t n e r s have an e q u a l v o i c e i n making major p o l i c y d e c i s i o n s o r i s t h e r e a r a n k i n g by s e n i o r i t y , e t c . ? 4 4 0 Method o f A p p r a i s a l 4 4 1 - What are the major c o n s i d e r a t i o n s t h a t s h o u l d be c o n s i d e r e d when c h o o s i n g the s i t e o f your m e d i c a l p r a c t i c e u n i t ? 4 4 2 - D i d you c o n s c i o u s l y l o c a t e your o f f i c e w i t h i n c o n v e n i e n t d i s t a n c e o f : (&) major t r a f f i c a r t e r i e s ? (b) p u b l i c t r a n s p o r t ? 443 - D i d you l o c a t e your o f f i c e so as to a v o i d n o i s e p o l l u t i o n from: 'a) t r a f f i c a r t e r i e s ? [bj r a i l r o a d y a r d s ? c) i n d u s t r y ? 444 - D i d you l o c a t e your o f f i c e so as t o a v o i d i n d u s t r i a l a i r p o l l u t i o n ? 445 - D i d you l o c a t e your o f f i c e so as t o a v o i d a r e a s of p r e s e n t or p o s s i b l e f u t u r e d e t e r i o r a t i o n of v i s u a l b u i l d i n g s t a n d a r d s ? 446 - How t o you a s s e s s a r e a s of 'growth' and ' d e c l i n e ' i n the c i t y ? I n f o r m a t i o n D i mension 5 0 0 QUANTITY OF INFORMATION 5 1 0 O r i e n t a t i o n and P e r s p e c t i v e 5 1 1 - I f you have more t h a n one o f f i c e do you keep s e p a r a t e f i n a n c i a l r e c o r d s f o r each o f f i c e or a g g r e g a t e d r e c o r d s f o r the whole p a r t n e r s h i p ? 5 1 2 - Do you keep i n t o u c h w i t h p u b l i c s o u r c e s of i n f o r -m a t i o n r e g a r d i n g a r e a s o f p o p u l a t i o n change i n : 'a") Vancouver? (b) Lower M a i n l a n d ? [c\ B.C.? 'd) e l s e w h e r e ? 5 1 3 - Do you o b t a i n i n f o r m a t i o n on new comm e r c i a l d e v e l o p -ment i n : 'a") Vancouver? 'b) Lower M a i n l a n d ? \c) B.C.? 'dj e l s e w h e r e ? 514 - Do you r e c e i v e i n f o r m a t i o n r e g a r d i n g the development of new m e d i c a l complexes i n : fa) Vancouver? (b) elsewhere ( s p e c i f y ) ? 515 - Do you know the c o s t o f m a i n t a i n i n g an o f f i c e i n the major m e d i c a l c e n t r e s ? 516 - Do you know the range of f a c i l i t i e s a v a i l a b l e i n the major m e d i c a l c e n t r e s ? 517 - Do you o b t a i n i n f o r m a t i o n on o t h e r p h y s i c i a n s ' p r a c t i c e s i n terms o f : 'a) number of p a t i e n t s ? 'b) income? 520 Format f o r . O r g a n i z a t i o n o f I n f o r m a t i o n 521 - How do you c l a s s i f y your i n f o r m a t i o n r e g a r d i n g : a) o t h e r p r a c t i c e s ? 'b) the m e d i c a l c e n t r e s ? 'cj s o c i o - e c o n o m i c c h a r a c t e r i s t i c s o f Vancouver? 530 S t o r a g e and R e t r i e v a l of I n f o r m a t i o n 531 - Do you use a computer d a t a bank? 532 - What i n f o r m a t i o n do you s t o r e i n the d a t a bank ( i f any)? 533 - I f you use computer f a c i l i t i e s , where are th e y s i t u a t e d ? 534 - Do you have a computer t e r m i n a l a t the p r a c t i c e ? 600 QUALITY OF INFORMATION 610 Sources o f D a t a 611 - What are your sources o f d a t a r e : a) o t h e r p h y s i c i a n s ? 'b) the m e d i c a l c e n t r e s ? [c) s o c i o - e c o n o m i c c h a r a c t e r i s t i c s o f Vancouver? 612 - I f any o f the above i n f o r m a t i o n i s c o l l e c t e d p r i v a t e l y i n d i c a t e the c o l l e c t i o n methods used? 6 2 0 Age of D a t a 6 2 1 - I n what year was your l a t e s t d a t a c o l l e c t e d r e g a r d i n g the c l a s s e s o f i n f o r m a t i o n i n d i c a t e d above? B e h a v i o r a l C h a r a c t e r i s t i c s of P h y s i c i a n s 7 0 0 CHARACTERISTICS OF INDIVIDUAL DECISION MAKER 7 1 0 O r g a n i z a t i o n a l Membership See 2 0 0 . 8 0 0 CHARACTERISTICS OF INDIVIDUAL DECISION MAKER (ATTITUDE'S") 8 1 0 A t t i t u d e s Towards R e s e a r c h 8 1 1 - What were the p r i m a r y m o t i v a t i o n s t h a t l e d you i n t o s p e c i a l i s t p r a c t i c e ? 8 1 2 - Are you engaged i n a c t i v e m e d i c a l r e s e a r c h ? 8 1 3 - I f - s o , does t h i s r e s e a r c h r e q u i r e s p e c i a l f a c i l i t i e s ? 814 - Do you devote the m a j o r i t y o f your time t o : 'a) s e e i n g p a t i e n t s ? j (b) t e a c h i n g and r e s e a r c h ? 815 - Have you had any papers p u b l i s h e d i n p r o f e s s i o n a l j o u r n a l s ? 8 1 6 - I f s o , how many? 817 - Were these papers concerned w i t h : (a) r e s e a r c h ( b a s i c ) ? (b) r e s e a r c h ( c l i n i c a l ) ? (c) m e d i c a l e t h i c s ? (d) o t h e r t o p i c s ? 8 1 8 - What i s the n a t u r e o f your a s s o c i a t i o n w i t h the h o s p i t a l w i t h w h i c h you work i n c o n j u n c t i o n ? 8 2 0 A t t i t u d e s Towards Other P h y s i c i a n s 8 2 1 - What p e r c e n t a g e o f your p a t i e n t s are r e f e r r e d t o you by o t h e r p h y s i c i a n s ? 8 2 2 - Do you r e f e r p a t i e n t s t o s p e c i a l i s t s whose o f f i c e s are near your own o f f i c e ? 8 2 3 - I f n o t , on what grounds do you choose between p r o f e s s i o n a l c o l l e a g u e s t o whom you r e f e r p a t i e n t s ? 8 2 4 - Do you have any f e e - s h a r i n g arrangements w i t h s p e c i a l i s t s t o whom you r e f e r p a t i e n t s ? 8 2 5 - Do you r e f e r p a t i e n t s who r e q u i r e t r e a t m e n t beyond your c a p a b i l i t i e s c o n s i s t e n t l y t o the same s p e c i a l i s t i n the a p p r o p r i a t e f i e l d ? 8 2 6 - Which o f the f o l l o w i n g i s the most a c c u r a t e r e p r e s e n t a t i o n of what you c a l l a c o l l e a g u e ? a) a nother p r a c t i c i n g p h y s i c i a n [bl a p h y s i c i a n w i t h the same s p e c i a l t y c) a p h y s i c i a n you know p e r s o n a l l y 'd) a p h y s i c i a n t o whom you r e f e r p a t i e n t s [e) a p a r t n e r ? 8 2 7 - How would you r e g a r d a r a p i d p r o l i f e r a t i o n of p h y s i c i a n s 1 o f f i c e s i n the immediate v i c i n i t y of your o f f i c e . 8 3 0 A t t i t u d e s Re S p e c i a l i s m 8 3 1 - What do you c o n s i d e r t o be the 'most c h a r a c t e r i s t i c a c t ' o f your s p e c i a l t y ? 8 3 2 - What i s your 'most c h a r a c t e r i s t i c a c t ' ? 8 3 3 - What do you c o n s i d e r t o be the major m o t i v a t i o n s i n your c h o i c e o f s p e c i a l i s m ( o t h e r t h a n those t h a t m o t i v a t e d b e i n g a s p e c i a l i s t i n g e n e r a l ) ? 840 A t t i t u d e s Towards P r e s e n t S i t e 8 4 1 - Do you c o n s i d e r your s i t e t o be adequate? 8 4 2 - Do you c o n s i d e r t h a t your p a t i e n t s would r e c e i v e b e t t e r c a r e i f you were l o c a t e d n e a r e r a h o s p i t a l w i t h I t s a d d i t i o n a l d i a g n o s t i c f a c i l i t i e s ? 843 - Do you c o n s i d e r t h a t t h e r e e x i s t more advantageous s i t e s i n Vancouver f o r your p r a c t i c e ? 844 - I f so, where? are these more advantageous i n terms o f : p r o x i m i t y t o r e s e a r c h f a c i l i t i e s ? p r o x i m i t y t o o t h e r p h y s i c i a n s ? a c c e s s t o h o s p i t a l f a c i l i t i e s ? a c c e s s t o s p e c i a l i s t l i b r a r i e s ? ease of p a t i e n t a c c e s s ? p r e s t i g e ? economic r e t u r n ? 8 5 0 A s p i r a t i o n L e v e l 8 5 1 - What do you e x p e c t t o e a r n a t the peak of your c a r e e r ? 8 5 2 - What f u n c t i o n do you hope t o be f u l f i l l i n g a t the peak of your c a r e e r ? 8 5 3 - Where do you f e e l you make your most i m p o r t a n t c o n t r i b u t i o n t o s c i e n c e ? I f so, a] V ' d ! 'e 'f' APPENDIX P \ POINT BISERIAL CORRELATIONS BETWEEN ITEM RESPONSES AND SCALE SCORE ON THE PRELIMINARY INSTRUMENT -Item P o i n t .Bls.er.ial . . C o r r e l a t i o n C o e f f i c i e n t 1 2 1 u n d e f i n e d 1 3 1 0 . 1 8 1 2 1 3 2 O . 7 8 5 2 1 3 3 0 . 4 3 4 9 134 0 . 0 0 0 0 141 - 0 . 2 2 1 3 1 4 2 0 . 7 2 4 8 1 4 3 0 . 9 2 6 1 2 1 1 - 0 . 2 2 1 4 2 1 2 - 0 . 1 2 0 6 2 1 3 u n d e f i n e d 2 1 4 u n d e f i n e d 2 1 5 - O . 5 8 3 8 2 1 8 0 . 8 5 0 7 2 3 1 0 . 3 6 2 4 2 3 2 - O . O 2 6 3 2 4 l - 0 . 2 8 1 7 2 4 2 0 . 0 0 0 0 2 5 2 0 . 3 8 2 2 2 6 l - 0 . 3 2 1 9 2 7 1 0 . 9 2 7 4 2 7 2 0 . 1 2 0 8 2 7 3 0 . 7 2 4 8 3 2 1 - 0 . 1 0 5 4 3 3 1 0 . 0 0 0 0 4 1 1 u n d e f i n e d 4 1 2 u n d e f i n e d 4 2 1 0 . 2 8 1 7 4 2 2 0 . 2 8 1 7 4 2 4 0 . 0 0 0 0 4 3 1 0 . 1 8 1 1 4 3 2 0 . 3 6 2 4 4 3 3 0 . 0 0 0 0 4 4 1 0 . 7 6 4 4 4 4 2 0 . 5 7 3 8 . 4 4 3 0 . 0 0 0 0 4 4 4 0 . 0 0 0 0 4 4 5 0 . 4 8 2 9 446 0 . 0 0 0 0 4 4 7 0 . 0 0 0 0 Item numbers r e f e r t o the items on the P r e l i m i n a r y I n s t r u m e n t p r e s e n t e d i n Appendix E. ) APPENDIX G ITEMS GROUPED STEP I J 15 38 26 24 40 19 25 37 11 21 3 1 30 16 18 10 28 EBBOB 20 14 12 32 35 13 23 33 36 1 24 31 0.00000100 * I I I I I 1 1 2 35 36 0.00000100 * 1 1 1 1 1 1 1 3 9 14 1.00000000 • 1 1 1 1 1 u 4 30 34 1.00000000 • M i l l 1 5 9 13 1.66666603 * 1 1 1 1 1 l_ 6 1 37 2.00000000 * l_l 1 1 1 7 2 7 2 .00000000 * 1 I I I 8 6 19 2.00000000 * T i i i 9 22 29 2.00000000 * i i l l 10 6 18 2.66666603 * i i l l 1 1 8 15 3.00000000 * i i l l 12 24 35 3.99999714 * i i i 13 2 16 4.00000000 • i l l 14 21 32 4 .00000000 * i i i 15 25 28 4.00000000 * i i i 16 2 3 5.50000000 * i i i 17 24 40 5.59999180 * i i i 18 11 12 6.00000000 * i i i 19 4 10 7.00000000 * i i i 20 9 38 7.83332634 * i i i 21 25 27 8.00000000 * i i i 22 21 33 8.66666603 • i l l 23 8 9 9.4999771 1 * i i i 24 5 17 10.0000000 * i i | 25 23 26 10.0000.000 • i i i 26 1 20 1 1.3333330 • i i i 27 24 30 1 1. 3999786 * 7 i 28 25 39 13.0000000 * i i 29 2 6 15.2618618 • i i 30 11 23 18.4999847 • i i 3 1 1 8 2 0 . 1 109619 • i i 32 21 24 21 .3332367 * i 33 2 5 33 .9046936 * | 34 22 25 35.6666260 * i 35 1 1 21 47 .6425476 * i 36 2 4 63.6665039 * i 37 2 22 111.214752 * | 38 1 11 162.280685 * i 39 1 2 326.645264 * * l_l I I l_l 34 I I I I I I l_ l 22 27 17 29 l__l * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 39 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 

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