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PubMed1983

Patterns of diagnostic testing in the academic setting: the influence of medical attendings' subspecialty training.

Internists with subspecialty training (subspecialists) constitute the majority of the medical faculty members and the test-ordering behavior of these subspecialists influences how house officers and students solve clinical problems. To assess whether test-ordering patterns are influenced by the ward attendings' subspecialty status, we identified the number of gastrointestinal endoscopic procedures, bone marrow procedures and exercise stress tests that were ordered on 9608 patients admitted to a medical service during a 3 year period. The patient management was supervised by attendings, 8 of whom were generalists and 37 of whom were subspecialists. House officers supervised by generalists ordered 23% fewer gastrointestinal procedures, 47% fewer bone marrow procedures, 43% fewer exercise stress tests and 29% fewer total procedures than house staff supervised by subspecialists (P--not significant, P less than 0.001, P less than 0.05 and P less than 0.01, respectively). House officers perceive a difference between the test-ordering patterns of subspecialists and generalists. They attribute this difference to post-residency training and believe that the use of more tests indicates a greater compulsion toward an exhaustive evaluation.

Diagnostic Services↗
PubMed1998

Moderate-intensity aerobic training improves glucose tolerance in aging independent of abdominal adiposity.

OBJECTIVE: To test the hypothesis that training-related improvements in glucose and insulin responses to an oral glucose tolerance test (OGTT) are independent of changes in abdominal adiposity. DESIGN: Adiposity and responses to an OGTT were measured before and after a 4-month randomized, controlled aerobic training program. SETTING: An academic medical institution. PARTICIPANTS: Sixteen healthy older (73+/-1 year) men and women. INTERVENTION: Both the training (T) (n=9) and control (C) (n=7) groups exercised 4 times a week for 60-minute sessions. T exercised on mini-trampolines at 55 to 65% of HRmax (determined from a graded treadmill test) for 1 month and then at 75% for 3 months; C engaged in supervised stretching and yoga. MEASUREMENTS: At baseline and follow-up, we estimated abdominal fat (from computed tomography and anthropometry), plasma glucose, and serum insulin responses to the OGTT and fasting concentrations of free fatty acids (FFA). RESULTS: Aerobic training resulted in a 16% increase in VO2 peak and a 24% decrease in FFA in the T group (P < .05), but training had no effect on abdominal fat. In the T group, the glucose response curve shifted to the left, and the incremental area under the glucose curve decreased by 25% (P < .05). This improvement in glucose response occurred, however, only in those with impaired glucose tolerance at baseline and without any observed change in insulin response. No change in any variables occurred in the C group. CONCLUSIONS: Our data suggest that moderate-intensity aerobic training has a favorable effect on glucose tolerance in older people, independent of changes in abdominal adiposity.

Abdomen↗
PubMed2006

Disorganized junior doctors fail the MRCP (UK).

Career progression during undergraduate and early postgraduate years is currently determined by successfully passing examinations. Both academic factors (secondary school examination results, learning style and training opportunities) and non-academic factors (maturity, ethnic origin, gender and motivation) have been identified as predicting examination outcome. Few studies have examined organization skills. Disorganized medical students are more likely to perform poorly in end-of-year examinations but this observation has not been examined in junior doctors. This study asked whether organization skills relate to examination outcome amongst junior doctors taking the clinical Part II examination for the Membership of the Royal College of Physicians (Practical Assessment of Clinical Examination Skills). The study was conducted prospectively at four consecutive clinical courses that provided clinical teaching and practice to prepare trainees for the examination. Arrival time at registration for the course was the chosen surrogate for organization skills. Trainees were advised that they should arrive promptly at 8.00 a.m. for registration and it was explained that the course would start at 8.30 a.m. Recorded arrival times were compared with the pass lists published by the Royal College of Physicians. The mean arrival time was 8.17 a.m. A total of 81 doctors (53.3%) passed the examination with a mean arrival time of 8.14 a.m. However, 71 doctors failed the exam and arrived, on average, six minutes later than doctors who passed (p?=?0.006). Better-prepared junior doctors were more likely to pass the final examination. Arriving on time represents a composite of several skills involved in the planning of appropriate travel arrangements and is therefore a valid marker of organization skills and preparation. This novel study has shown that good time-keeping skills are positively associated with examination outcome.

Appointments and Schedules↗
PubMed1996

Comparing the hospitalizations of transfer and non-transfer patients in an academic medical center.

BACKGROUND: By accepting and caring for patients transferred from other institutions, academic medical centers have been able to develop comprehensive training and research programs. Whether academic institutions can continue to do this in the future is questionable. To the extent that transfer patients are more complex and severely ill than non-transfer patients, they are likely to consume more resources, and in managed care payment systems, they could place accepting hospitals in financial jeopardy. METHOD: Between July 1989 and December 1993, the internal medicine, surgery, and pediatrics services of the 880-bed University Hospital of the University of Michigan accepted 8,740 patients from other hospitals. The hospitalizations of these patients were compared with those of the 76,047 non-transfer patients on these services. The statistical methods used were Student's t-test, chi-square, Cochran-Mantel-Haenszel chi-square, and analysis of variance. RESULTS: The hospitalizations of the transfer patients were more complex and resource-use intensive. The transfer patients were more likely (p<.0000) to be length-of-stay outliers as defined by Medicare standards (28% vs 10%) and to suffer in-hospital death (9.4% vs 2.5%). After case-mix adjustment and exclusion of length-of-stay outliers, transfer patients on the three services (surgery, medicine, and pediatrics) remained in the hospital 1.62, 1.15, and 0.84 days longer (p<.0001) than non-transfer patients. Ancillary-service resource use was assessed using a relative-value-unit (RVU) scale based on direct-cost dollars. The transfer patients' case-mix-adjusted resource use exceeded that of the non-transfer patients by 1,155,850 and 957 RVUs for surgery, pediatrics, and medicine (p<.0001). Although the transfer patients were more likely to have Medicaid insurance, the differences in lengths of stay and use of ancillary services persisted throughout all insurance groups. Indeed, transfer status, compared with age, sex, and insurance status, was the best predictor of high resource use. CONCLUSION: The transfer patients stayed longer and consumed more hospital resources than did the non-transfer patients. Age, sex, case-mix, and insurance status did not account for these differences. To limit the financial liability that transfer patients pose, academic medical centers could be forced to abandon their traditional role of caring for such patients. The consequences of this possibility should be explored.

Academic Medical Centers↗
PubMed2004

Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers.

OBJECTIVE: To determine the current state of bedside emergency physician-performed ultrasonography in terms of prevalence, training, quality assurance, and reimbursement at emergency medicine residency programs. METHODS: The link to a 10-question Web-based survey was e-mailed to ultrasound/residency directors at 122 emergency medicine residency programs in the United States. RESULTS: The overall response rate was 84%. Ninety-two percent of programs reported 24-hour emergency physician-performed ultrasonography availability. Fifty-one percent of programs reported that a credentialing/privileging plan was in place at their hospital, and 71% of programs had a quality assurance/image review procedure in place. Emergency medicine specialty-specific guidelines of 150 ultrasonographic examinations and 40 hours of didactic instruction were met by 39% and 22% of residencies, respectively, although only 13.7% of programs were completing the 300 examinations recommended by the American Institute of Ultrasound in Medicine. Sixteen programs (16%) reported that they were currently billing for emergency physician-performed ultrasonography; of those not billing, 10 (12%) planned to bill within 1 year, and 32 (37%) planned to bill at some point in the future. CONCLUSIONS: Performance and training in emergency physician-performed ultrasonography at academic medical centers continues to increase. The number of emergency medicine residency programs meeting specialty-specific guidelines has more than doubled in the last 4 years, but only a small number are meeting American Institute of Ultrasound in Medicine guidelines. Although only 16% of programs reported that they were currently billing for emergency physician-performed ultrasonography, most had plans to bill in the future.

Academic Medical Centers↗
PubMed1999

Pioneering efforts for minority appointments and academic surgery. A narrative.

The author gives a narrative chronologic explanation for the early inclusion of African Americans and other minorities into the Yale University Orthopaedic Surgical Residency Training Program. The author's early isolation from racial problems living in rural Nebraska and the paucity of racial friction at the University of Nebraska gave him a more neutral or positive view of other cultures. Sudden exposure to the racial tension and police brutality toward African Americans in Boston followed by the well defined racial bias in the Southern city of Baltimore showed the plight of minorities. At that same time the author encountered many gentle and extremely intelligent African Americans who performed outstanding medical tasks for the Johns Hopkins Hospital hospital with little educational background. The author's experience with Shirley Moore and Augustus White at Yale made it possible to recruit a diverse group of gifted and loyal resident staff. The high number of academic appointments in minority and majority residents has evolved from the Academic Training and Research Program and a special selection process for choosing residents.

Black or African American↗
PubMed1994

The history and future of operative laparoscopy.

Laparoscopic sterilization was first performed in the United States in 1941. During the 1950s and 1960s hospitals procured the relatively inexpensive basic laparoscopic instrumentation, and education for physicians learning the techniques was provided mostly by academic centers during residency training. Interest in expansion of laparoscopic procedures was slight until the mid-1980s when operative laparoscopic management of ectopic pregnancies began to spread from academic centers to the private sector. Major technologic developments in instrumentation greatly simplified the endoscopic procedures and provided the first impetus for an explosive growth of operative laparoscopic applications in surgery. The great financial resources of private hospitals enabled them to adapt and retool quickly for operative endoscopy. Lacking these resources, academic institutions lagged behind; thus a growing divergence began between academic and private institutions in their influence on the development, use, and acceptance of the new technology. The development of expensive disposable instruments, with costs passed on to patients by private hospitals, further priced academic institutions out of the market. Two concerns today are paramount regarding operative laparoscopy: (1) The majority of laparoscopic techniques and procedures being performed by surgeons in this country have not been taught in the controlled setting of a residency or fellowship training program; (2) the legitimacy of the procedures themselves is questionable because of lack of sufficient data in the literature to support them. Academic institutions, working in tandem with the private sector, must assume the responsibility for answering these concerns.

Female↗
PubMed1999

Radiation oncology training in the United States: report from the Radiation Oncology Resident Training Working Group organized by the Society of Chairman of Academic Radiation Oncology Programs (SCAROP).

PURPOSE: In response to the major changes occurring in healthcare, medical education, and cancer research, SCAROP addressed issues related to post-graduate education that could enhance existing programs and complement the present system. METHODS AND MATERIALS: SCAROP brought together a Working Group with a broad range of representatives organized in subcommittees to address: training, curriculum, and model building. RESULTS: The Working Group emphasized the importance of training physicians with the necessary clinical, scientific, and analytical skills, and the need to provide expert radiation oncology services to patients throughout the United States. Opportunities currently exist for graduates in academic medicine, although there may be limited time and financial resources available to support academic pursuits. CONCLUSIONS: In the face of diminishing resources for training and education and the increased scope of knowledge required, a number of models for resident training are considered that can provide flexibility to complement the present system. This report is intended to initiate dialogue among the organizations responsible for radiation oncology resident education so that resident training can continually evolve to meet the needs of cancer patients and take advantage of opportunities for progress through innovative cancer care and research.

Curriculum↗
PubMed1984

Electroencephalographic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting.

Six children were provided with long-term biofeedback and academic treatment for attention deficit disorders. Their symptoms were primarily specific learning disabilities, and, in some cases, there were varying degrees of hyperkinesis. The training consisted of two sessions per week for 10 to 27 months, with a gradual phase-out. Feedback was provided for either increasing 12- to 15-Hz SMR or 16- to 20-Hz beta activity. Inhibit circuits were employed for blocking the SMR or beta when either gross movement, excessive EMG, or theta (4-8 Hz) activity was present. Treatment also consisted of combining the biofeedback with academic training, including reading, arithmetic, and spatial tasks to improve their attention. All children increased SMR or beta and decreased slow EEG and EMG activity. Changes could be seen in their power spectra after training in terms of increased beta and decreased slow activity. All six children demonstrated considerable improvement in their schoolwork in terms of grades or achievement test scores. None of the children are currently on any medications for hyperkinetic behavior. The results indicate that EEG biofeedback training, if applied comprehensively, can be highly effective in helping to remediate children who are experiencing attention deficit disorders.

Adolescent↗
PubMed2000

The future general practitioner: out of date and running out of time.

In the late 1960s a Royal College of General Practitioners' working party produced a job description for the 'Future General Practitioner', together with an educational programme for vocational training. Despite the perceived success of vocational training, general practice remains academically disadvantaged compared with hospital medicine. Most general practitioners (GPs) have no contact with research or academic general practice, few achieve higher degrees compared with hospital consultants, and there are few academic posts in general practice. Junior doctors perceive general practice as offering less intrinsic job satisfaction than hospital medicine and recruitment is falling. Registrars who have completed vocational training are reluctant to commit themselves to general practice and often drift away from it. Schemes with an academic content, designed to retain doctors in general practice, have been well received but there are few career posts in academic general practice. Primary care groups and clinical governance will radically change the nature of general practice. GPs will no longer be at the centre of the primary health care team. Primary care trusts, serving populations of 100,000 or more at multiple sites, will still employ doctors but much of the traditional GP workload will be undertaken by nurses. Present day vocational training produces GPs without the skills that future 'community generalists' will need. Their training will be longer and their careers more structured than at present. They will use evidence-based practice routinely and be experts in information management, interpreting and managing complex diagnostic and therapeutic problems in the context of rapidly changing health technology.

Career Choice↗
PubMed2000

Prediction of genetic structure in eukaryotic DNA using reference point logistic regression and sequence alignment.

MOTIVATION: Current software tools are moderately effective in predicting genetic structure (exons, introns, intergenic regions, and complete genes) from raw DNA sequence data. Improvements in accuracy and speed are needed to deal with the increasing volume of data from large scale sequencing projects. RESULTS: We present a two-stage computer program to predict genetic structure in eukaryotic DNA. The first stage makes use of a novel statistical technique, called reference point logistic (RPL) regression, to calculate scores for potential functional sites. These site scores are combined with interval content, length, and state scores, via a Generalized Hidden Markov Model, to determine a combined score for each possible parse of a given DNA sequence into exons, introns, and intergenic regions. An optimal parse is found using a dynamic programming algorithm. In the second stage, protein sequence alignment methods are applied to improve the accuracy of the initial parse. Computation in the first stage of the program is very fast (1 s on a 360 MHz CPU for a 16 kb sequence) and its predictive accuracy typically matches or exceeds the best results reported for other methods (Sensitivity = 0.93 and Specificity = 0.93 for the Burset/Guigótest set). Computation in the second stage is slower, but the final predictions are more accurate (Sn = 0.97, Sp = 0.97). The program (called GRPL) can handle partial, single, and multi-gene sequences. The program is also capable of predicting the genetic structure of vertebrate, invertebrate, and plant DNA with nearly equal accuracy. Statistical techniques have also been introduced to model the effects of varying C+G content in a continuous manner and to control overfitting of parameters for smaller training sets. AVAILABILITY: An academic implementation of GRPL, compiled for SUN workstations, is available by anonymous ftp from snipe.pharmacy. ualberta.ca/pub. The training and test sets used in this work, together with supplementary material, can be found at the same location. A commercial implementation is available as a component of GeneTool (BioTools Inc., http://biotools.com).

Algorithms↗
PubMed1975

Primary care within the academic tradition.

In the rush to train primary-care physicians, the bioscience tradition must remain inviolate. At the same time, however, academic medicine should recognize that the actual practice of medicine has a special content and operational philosophy that is indispensable for patient care and in which, therefore, every student should be versed.

Delivery of Health Care↗
PubMed1996

Integrating health sciences librarians into biomedicine.

Vanderbilt University Medical Center (VUMC) developed a model training program to prepare current and future health sciences librarians for roles that are integrated into the diverse fabric of the health care professions. As a complement to the traditional and theoretical aspects of a librarian's education, this mixture of supplemental coursework and intensive practical training emphasizes active management of information, problem-solving skills, learning in context, and direct participation in research, while providing the opportunity for advanced academic pursuits. The practical training will take place under the auspices of an established Integrated Advanced Information Management Systems (IAIMS) library that is fully integrated with the Health Center Information Management Unit and Academic Biomedical Informatics Unit. During the planning phase, investigators are analyzing the model's aims and requirements, concentrating on (a) refining the current understanding of the roles health sciences librarians occupy; (b) developing educational strategies that prepare librarians to fulfill expanded roles; and (c) planning for an evaluation process that will support iterative revision and refinement of the model.

Certification↗
PubMed1981

Intensive care in England and Wales. A survey of current practice, training and attitudes.

A questionnaire circulated to members of the Intensive Care Society in England and Wales brought 101 replies, representing 74 hospitals, including 16 teaching hospitals. Anaesthesia is the dominant specialty in this field and the majority of general units included in this survey are staffed and directed by consultants from this specialty, though their involvement in such work varies widely. Only about half the units are largely supervised by consultants with a heavy commitment to it. The junior staff too are predominantly anaesthetists. Whilst the FFARCS examination strongly emphasises the importance of intensive care to the specialty, only about half the members believe present training in this field, including academic activity, is satisfactory. The dearth of full-time training posts, their brevity and their domination by the teaching hospitals are major problems. There is considerable support for the idea of National Training Standards, and for a full-time training period of not less than 2 years, including special experience in certain fields, for those with a special interest in and aptitude for this type of work. But there is much less support for a Diploma. Despite this agreement on special training, only a small minority of members believe intensive care work should largely be restricted to separate career specialists, "intensivists'. However most recognise the need for each unit to have a largely full-time manager and coordinator, whose personal qualities are more important than his original specialty. Most units have one kind of problem or another, the most common being a shortage of money and nurses.

Anesthesiology↗
PubMed1974

Training and career appointments in the pathological sciences in the United Kingdom.

Pathologists usually receive initial training in clinical work, or in general pathology, or in academic work, followed by speciality training as a senior registrar or lecturer. Consultant status is generally achieved by the age of 34, now almost always in a single discipline. The distribution of pathologists between disciplines, in National Health Service and university posts, is tabulated: there are many unfilled appointments.

Allergy and Immunology↗