Editors' Comments

High Overall Satisfaction: 2000/2001 Survey Results. People Visiting TPJ Web Site in Thousands Each Month Tom Janisse, MD, Editor-in-Chief

In our continuing effort to meet the needs of KP clinicians, The Permanente Journal Editorial Team once again surveyed our readership for feedback and comments between November 2000, and March 1st, 2001.

Survey Method
The initial survey appeared as an insert in the Fall 2000 issue with a duplicated survey on our TPJ Web site. We complemented these in January with a follow-up electronic mail reminder, encouraging one of several response options. People returned their surveys in the following ways: 63% paper mail, 26% fax, 6% Web, 5% e-mail. I cite these methods to demonstrate how our readers, following national trends, are increasingly utilizing electronic communication. Keeping pace with the most desirable and convenient methods that people employ to learn new information and to communicate with each other is essential.

Overall Satisfaction
In answer to the question, "Overall, how would you rate your satisfaction with The Permanente Journal?" clinicians were 85% highly satisfied (30% excellent and 55% good) versus 6% dissatisfied (3% fair and 3% poor). Ten percent cited average, which we designated neutral; however, given our national competitor general and specialty journals, we consider average as favorable. Our readers were more highly satisfied (85%) in 2000/2001 than in 1998 (71%), a 14% increase.

Sample Size and Confidence
The sample size of 610 on a clinician readership base of 15,700 gives the survey results a 95% confidence level of representing our population. Each region responded in a near equivalent percentage of 4%, except for the Northwest, which had a 20% response rate. (I attribute this to my ability to reach all NW clinicians more readily by electronic reminders and our extra step of mailing a second hardcopy of the survey to each clinician.) The high NW response rate is of particular note when viewed alongside the national statistics. The satisfaction/dissatisfaction rates in the NW so closely reflects the interregional rates, it confirms a high degree of confidence in the overall results. In addition, this cross-regional similarity suggests a common set of needs and practices of Permanente clinicians.

General Comments and Sections
Looking specifically at the "General Comments," clinicians were most satisfied with "The look" (graphics, photography, and art) (87%), and as a "Forum for clinicians to express their talents in the humanities" (84%). It is gratifying that Permanente clinicians create "the look" and "the humanity" with their photographs and paintings, and their poetry and stories. Readers were also highly satisfied with "Best practices" (82%), "Fosters a spirit of Permanente community" (81%), "Practical information" (74%), and "New information" (71%) (Figure 1).

In the "Sections" area of the survey, clinicians were most satisfied with "Permanente Abstracts" (82%), followed by "Clinical Contributions" (79%), "Soul of the Healer" (78%), "Editors' Comments" (76%), "Health Systems" (73%), "Original Research" (72%), and "External Affairs" (67%) (Figure 2).

Who Reads TPJ?
Using the survey respondents as a readership proxy, 85% of our readers are physicians and 15% affiliated clinicians; 73% are specialists, and 27% are primary care. Eighty-five percent of clinicians say TPJ is published often enough, 10% too often, and 5% not often enough. Eighty-six percent say the issues are the right length, 12% too long, and 2% too short. TPJ also has a readership which is largely a mystery to us--those who access us on-line in growing numbers.

TPJ Online
One of the more surprising survey comments we heard was "Something online might be read more." Since we have been online with a TPJ Web site, since 1997, and linked to the KP home page and to PKC, we must conclude that we haven't marketed our Web site well enough. Many people access our site, as evidenced from two automatic site reports we receive: "Daily Unique Visitors" (Figure 3) and a "Web Site Search Engine Activity Report." The first report captures each instance a different (unique) person visits the site, not just how many "hits" (clicks) the site receives (which could involve one person clicking on six or seven pages on one visit to the site). The report notes daily activity charted by month (2470 unique visitors in March), and a previous month, running-average comparison (and 2433 visitors in February). The most common TPJ Web site use is on weekdays, with use consistently falling 60% on the weekends. We don't have a way yet of identifying who is visiting the site, however we can track how people are arriving at our site, for example search engines, direct links from other web sites, and domains (ie, AOL.com, Pacbell.com, Earthlink.net, and Home.com).

The second report, "Web Site Search Engine Activity Report," notes the daily number of queries (Table 1), and keywords queried (Table 2: "Top 20 Keywords for February/March"). Because of the domain identification, we know that many of the people accessing our site are from outside KP. This is a measure of the health care consumers' interest in medical information and in Permanente Medicine. The same remarkable tracking technology we used might, with some imagination, someday be used to help clinicians learn more about the desires and interests of patients in their own practices.

In addition, TPJ is now listed on "MedNets"--"an international research site with proprietary search engines for every specialty in medicine searching only medical databases."

Current TPJ Web site capabilities are addressed later in this editorial.

Most Common Comments
Ninety-seven clinicians (16%) made comments on their surveys. The most common comment (24%) is a variation of "The journal gives us pride that Permanente produces such a nice piece of work. It clearly elevates PMG."

Bookends of the comments we received range from "I am surprised at how many articles are meaningful to me in each issue," to "In my opinion, we should cease publication because the journal makes a negligible contribution to medical science," and "Stop this magazine; spend the money on more staff and patient care." In addition, there are always several comments on the physical aspects of the journal, ie, about the "fancy" paper we use. Surprisingly, the perceived "thicker, slicker" paper we use costs the same from our printer as the thinner paper more common in other national journals. In any case, we are constantly re-exploring paper options to reduce costs, while maintaining the quality.

There are thousands of clinicians served by the journal, and almost as many opinions and perspectives. While responding to the opinions of our readers and integrating their ideas, we will continue to work to create a high quality publication, both in print and on-line.

We are pleased with comments like: "Especially like the blend of medicine and the humanities."

Most desired topics for the future
The most requested topic area for future articles relates to daily medical practice:

• "More focus on coping with the everyday challenges of being a busy clinician."
• "Ways to improve your practice (not really covered in 'best practices,') more along the lines of 'continuing improvement team': clinical, nursing, reception, quality of life."
• "Coping with a fast-paced practice with too many patients."
• "Electronic charting."
• "Advice by experienced MD to junior doctors on handling difficult patients."
• "Patient-physician communication."
• "How to behave in the exam room."
• "Techniques to improve efficiencies of a physician's practice in daily activities."
• "Computers and PDAs in medical practice."

On time (or lack of time):

• "Not enough time to read journals because my practice is so busy."
• "I only have time to scan it."
• "I put it in my reading pile and never look at it again."

On daily practice area:

• "Pharmaceutical issues."
• "Prescribing patterns."
• "Dealing with direct-to-consumer advertising."

On complementary and alternative medicine:

• "Spirituality, mindfulness, patient care"
• "Value of 'alternative medical therapies' for specific medical conditions."
• "More 'healing' articles."

On Permanente:

• "History of the PMGs."
• "Personalities of the past."
• "Outstanding physicians."
• "Permanente people: profiles of interesting, inspiring, off-beat, cutting-edge people."

On pediatrics:

• "More Pediatrics articles."
• "More Pediatrics topics."
• "More Pediatrics care."

On specialties:

• "More specialty emphasis."
• "A section each issue devoted to specialty areas."
• "Information on online sites that provide easily utilized clinical information based on specialty."
• "Every issue should have a review article by a specialist geared toward primary care."
• "Surgical issues."
• "From each specialty: 'what every clinician should know about '"

On clinician well-being:

• "More on the human side of being a doc."
• "Cultivate nurturing work environment."
• "Culturally competent care."
• ·"Physician burn-out."
• "Over a year ago, I saw an article for "Care for Caregivers" about Lisa Beesley-Lippman and the Southern California caregivers. I contacted Lisa, we brought the program to Northern California. It was a marvelous experience. It would never have happened without TPJ. Thanks!"
• "Medical ethics."
• "Anger management."

On pain:

• "Chronic pain."
• "Pain management."
• "Pelvic pain."
• "New research on chronic pain."
• "Pain control."
• "Treatment of chronic pain."

On the psychosocial:

• "More mental health issues."
• "Psychosomatic illness."
• "Stress illness."
• "Psychological assessment."
• "Obesity and eating disorders."
• "Addiction medicine."
• "Integration of counseling in everyday practice."

What's Coming in TPJ
Here is our list of future theme issues based on listening to clinicians and responding to survey comments:

• Summer 2001: Patient Safety
• Fall 2001: Clinician Work Environment
• Winter 2002: Pediatrics
• Spring 2002: Annual Vohs Awards for Quality
• Summer 2002: Complementary & Alternative Medicine
• Fall 2002: Sub-Specialty Reviews

We would like to thank all of you who not only suggested a topic but also suggested an author. We have already sent a list of topics and authors to each respective section editor. This is a great help to us to give you what you want, and by experts you recognize who are credible.

TPJ Web Site Capabilities
For clinicians and patients alike the Web offers options that print can't. The most powerful option is the ability to search multiple journal issues using keywords to find exactly the explanation or pertinent study you need at the time you need it. Click on hypertext and link immediately to another site for additional information. A clinician can read articles online and complete the post-test for CME credit.

Patients are increasingly using the TPJ site for specific medical information, Permanente medical practices, guidelines appearing in articles, and to learn clinician perspectives on health care and health systems. They are comparing approaches across systems, and use what they find to prepare for their office visit. Medical knowledge helps them to better understand their condition, treatment approaches, medication use, and the inevitable shared decision process.

Conclusions
Physicians and clinicians strongly support The Permanente Journal and cite high overall satisfaction with its content, format, appearance, and periodicity. Our evolution toward a best practice publication, and a best practice communication and learning tool, is enhanced with clinician use and advice.

How clinicians and patients best access information and learn new knowledge using print versus electronic forums is still not understood, and continues to evolve. Print and electronic communication vehicles each have unique advantages and shortcomings. Both have a place and often complement each other when integrated. TPJ will maintain, and enhance, both forums looking for the greatest advantages for clinicians and patients.

When clinicians can offer their patients medical literature, authored and published by Permanente, to confirm their treatment recommendations, it can be a powerful inducement to patient adherence and improved efficacy and medical outcomes.

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