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The decision systems group: creating a framework for decision making.

The Decision Systems Group is pursuing a vision in which every available medical resource can be brought together at the point of need. The DSG focuses on the components and tools in specific areas as well as on the models, approaches, and infrastructure that make this type of integration possible. Its academic mission is to train individuals with dual expertise: those who understand and appreciate the issues involved in developing and validating a method or technique, plus the issues of deployment, operation, and interaction in practical environments. Ultimately, the application of this vision can only serve to enhance the current level of healthcare.

Boston↗

[Providing regular relief; considerations for palliative care in the Netherlands].

Over the last few decades the attention devoted to the palliative aspects of medicine, particularly those in hospital care, has declined due to the emphasis on medical technology. In Anglo-Saxon countries a review of this development resulted in structured palliative care that benefited terminally ill patients with a progressive fatal disease, especially cancer patients. Due to increasing national and international criticism of both the practice of euthanasia (assumed to be too liberal) and the lack of attention devoted to structured palliative care in the Netherlands, the Dutch government decided to improve the structure of palliative care. The government's viewpoint is based on the assumption that good palliative care that includes adequate pain control benefits patient care and might eventually lead to fewer requests for euthanasia. The improvements to palliative care should be realised by means of improvements in the structure, training and knowledge. Six academic medical clusters have been designated as Centres for the Development of Palliative Care (Dutch acronym: COPZ) for a 5-year period. Each COPZ must develop the various aspects needed to improve palliative care within the region it serves and ensure that its activities are carefully coordinated with those in the other centres. Research will focus on measuring the efficacy of palliative care as well as ethical and epidemiological aspects. A government committee will assess the appropriateness of the activities undertaken by each of the centres.

Academic Medical Centers↗

[Dutch-Romanian cooperation in the area of family practice].

During the years 1992-2000, there was a cooperative programme between the Romanian general practitioners' association (Societatea Nationala de Medicina Generala) in Romania and the Dutch Foundation for the Advancement of Quality in Healthcare in Romania. A succession of programmes were developed and carried out, which were financed by the Dutch government. The purpose of the cooperative programme was to support the development of Romanian general practice in terms of quality and structure. In the first programme, financed by the Dutch Ministry of Health, Welfare and Sport, about 200 Romanian general practitioners received continuing education. This was followed by a social transformation programme (MATRA) that had two parts: (a) the general practitioners association was supported and advised with respect to improving its organisational efficiency and (b) about 50 carefully selected Romanian general practitioners were trained, in post-academic research, management or teaching. The Romanian authorities accredited these trainees as teachers. The co-operation is being continued in 2001 with the setting up of a sentinel station programme in which 100 Romanian general practitioners collect relevant, representative data on health, illness and practice.

Education, Medical, Graduate↗

Symptom control and palliative care in Chile.

As in other developed and developing countries, the most common chronic disorders affecting the Chilean population are cardiovascular disease, cancer, cirrhosis, diabetes, chronic obstructive pulmo- nary disease and external injuries. Availability of oncology services is not extensive and there are no academic programs to adequately train practitioners in either palliative medicine or comprehensive palliative care for allied health professionals including nurses, psychologists and chaplains. Major efforts have been made to incorporate palliative care as an important health care focus in the last decade and in the development of effective policies for opioid availability. Chile now meets 84% of the 17 criteria outlined by the World Health Organization and the International Narcotics Control Board for opioid availability. Postgraduate medical education in symptom control, clinical use of opioids and end-of-life care remains relatively poor as judged by the results of a questionnaire administered to 158 resident physicians at the Pontificia Universidad Católica de Chile. Improvements in symptom control and the development of palliative care in Chile will depend on the effective assessment of symptom control effectiveness and improved education and training of health professionals in clinical pharmacology, symptom control, clinical ethics, and end-of-life care.

Analgesics, Opioid↗

[From the Natanyahu State Commission to management tasks in the Israeli health system].

BACKGROUND: Ben-Gurion University (BGU) in Beer Sheva inaugurated a special training program for junior academic administrative personnel to improve the quality of service in health care organizations through suitable and high-quality administration. The program, the first of its kind in Israel, has been in operation since 1994 and prepares 50 candidates annually for administrative positions within the health system, or a total of 224 graduates to date. The program was founded on the recommendations of a state commission established in 1990 and headed by retired Supreme Court Justice Shoshana Natanyahu (The Natanyahu Commission, 1990). The commission was appointed to examine the performance of the health system in Israel and recommend reforms and changes that would improve the quality and efficiency of health services and the overall performance of the system. AIM: This study examined the integration of graduates of the undergraduate program in Health Systems Management (HSM) within the private and public health system in Israel, including employment trends and a retrospective evaluation of the program. METHODS: Within the framework of the study, questionnaires were sent to all graduates of the program. Participants were requested to answer questions regarding their present place of employment, their satisfaction with their academic degree, how they found employment, and so forth. RESULTS: The research results show that 59% of the graduates of the HSM department at BGU who responded to the questionnaire, worked in the health system upon completion of their studies, and in 2002--at the time of the survey--42% of all graduates were currently employed within the health system. Most of the graduates who entered the system and remained within the system, were women: out of 46 graduates working in the health system today, 38 (83%) are women. It should be noted that while there is some migration of graduates to work in other systems and sectors of the economy, 78% of the respondents believe that the degree program in HSM is justified. Apparently, according to the study, although the health system needs graduates, it does not always know how, or does not always want to or finds difficulty in absorbing the graduates and effectively utilizing their skills to meet the needs of the system. CONCLUSIONS: The data reveals that graduates of the undergraduate program in HSM have integrated well into the health system, but not as well as may have been expected. The graduates encountered difficulties in their absorption into management roles in the public health system and felt that the extent of their abilities has yet to be fully recognized and utilized by the system.

Delivery of Health Care↗

Transplantation activities in Iran.

Iran is a tropical country with a land area of 1,648,000 square kilometers and a population of 68,100,000. Iran has a recorded history that dates back 2553 years. Its earliest medical school was Pasargad. Jondi Chapour University was founded 1753 years ago during the Sassanid dynasty as a center for higher education in medicine, philosophy, and pharmacology. Indeed, the idea of xenotransplantation dates back to days of Achaemenidae (Achaemenian dynasty), as evidenced by engravings of many mythologic chimeras still present in Persepolis. Avicenna (980-1037 AD), the great Iranian physician, performed the first nerve repair. Transplantation progress in Iran follows roughly the same pattern as that of the rest of the world, with some 10-20 years' delay. Modern organ transplantation dates back to 1935, when the first cornea transplant was performed at Farabi Hospital in Tehran, Iran. The first living-related kidney transplantation performed at Shiraz University Hospital dates back to 1968. The first bone marrow transplant was performed at Dr. Shariaati's Hospital in Tehran. The first heart transplant was performed 1993 in Tabriz, Iran. The first liver transplant was performed in 1993 in Shiraz. The first lung transplant was performed in 2001, and the first heart and lung transplants were performed in 2002, both at Tehran. In late 1985, the renal transplantation program was officially started in a major university hospital in Tehran and was poised to carry out 2 to 4 transplantations each week. Soon, another large center initiated a similar program. Both of these centers accepted surgical, medical, and nursing teams from other academic medical centers for training in kidney transplantation. Since 2002, Iran has grown to include 23 active renal, 68 cornea, 2 liver, 4 heart, 2 lung, and 2 bone marrow transplantation centers in different cities. In June 2000, the Organ Transplantation Brain Death Act was approved by the Parliament, followed by the establishment of the Iranian Network for Transplantation Organ Procurement. This act helped to expand heart, lung, and liver transplantation programs. By 2003, Iran had performed 131 liver, 77 heart, 7 lung, 211 bone marrow, 20,581 cornea, and 16,859 liver tranplantations. Sources of these donations were living-unrelated donor, 82%; cadaver, 10%; and living-related donor, 8%. The 3-year renal transplant patient survival rate was 92.9%, and the 40-month graft survival rate was 85.9%. Another large step in expanding the transplantation program is the construction of the Avi- Cenna (Abou Ali Sina) Transplant Hospital in Shiraz. This hospital hopefully will begin operation in 2 years. It will offer the opportunity for the exchange and sharing of organs and increased cooperation between transplant teams in the Middle East. The hospital offers great promise for transplant medicine in Iran and other Persian Gulf countries.

History, 20th Century↗

["Two professions for a single task". The introduction of chemical engineering in Spain during the first Francoism].

Through the first half of the 20th century, chemical engineering was established as an academic option in the training of specialists for the North-American and European chemical industry, whereas it was not a special field of study in Spain until the 1990s. The reason for this delay was a battle of interests between chemist and industrial engineers to control this career during the first Francoism. This article will try to show the development and professionalization of specialists for the Spanish chemical industry.

Chemical Engineering↗

The impact of the NINCDS on the neurosciences: an essay written for the centennial of the NIH.

This essay, written as a contribution to the June 1987 participation by the NINCDS in the celebration of the centennial of the NIH (dated from the founding of the Hygienic Laboratory at Staten Island in 1887), discusses the impact of the NINDB/NINCDS on the neurosciences. Contrasts are drawn with the status of basic and clinical neurosciences in the late 19th century and prior to 1950, when the NINDB was established. This impact has involved its role as advocate and focal point for the support of research and research training in the neurosciences; the training of research and academic personnel and the funding of research projects, both significant factors in the postwar proliferation of methods and technologies; and the catalyzing of the steady progress in scientific knowledge, as reflected in examples from various facets of the programs of the neurological institute, in a continuum from the very basic and fundamental to the very clinical and pathological neurosciences.

Cerebrovascular Disorders↗

Changes in plasma volume following intense intermittent exercise in neutral and hot environmental conditions.

BACKGROUND: The purpose of the present investigation was to examine the effect of supramaximal short duration intermittent exercise in neutral and hot environmental conditions on changes in plasma volume. The return of plasma volume (PV) to pre-exercise values following different recovery conditions was also examined. METHODS: Experimental design. Within subject design in which one way analysis of variance was conducted. SETTING: Research, sports science academic institute. PARTICIPANTS: Ten trained men, 25.5 +/- 3/1 (yrs), volunteers. INTERVENTIONS: Subjects performed six 1-min bouts of exercise at 100% VO2peak on a cycle ergometer, with 4-min rest intervals between the bouts. Each subject exercised twice in thermoneutral (22 degrees C, 40% RH) and twice in hot (35 degrees C, 30% RH) conditions. Exercise was followed by either 40 min of passive recovery (sitting) or by 20 min active recovery (cycling at 35% VO2peak) and 20 min passive recovery, named thereafter "active recovery". MEASURES: Hematocrit (Hct) and hemoglobin (Hb) were determined upon entry into the climatic chamber following 20 min rest in the chamber (pre-exercise), immediately postexercise, and 40 min postexercise. From the changes in Hct and Hb, PV changes were calculated. RESULTS: There was a significant decrease in PV immediately postexercise. However, there was no significant difference between the two types of environmental conditions and no difference between the two types of recovery. PV increased significantly following recovery and returned to pre-exercise values following 40 min of recovery. CONCLUSIONS: Changes in PV caused by maximal short duration cycling bouts is not affected by environmental conditions, PV returns to its pre-exercise values within 40 min of recovery regardless of the recovery mode.

Adult↗

The re-emergence of space medicine as a distinct discipline.

Space Medicine is a discipline whose scope will encompass primary and advanced medical care amidst the environmental constraints of space. At one time, there was a Department of Space Medicine associated with the U.S. Air Force School of Aviation Medicine. Until 1993, an academic, university-based training program dedicated to space medicine did not exist. This paper reviews the history of space medicine in the United States. It presents the current conceptions of space medicine, and postulates the need for space medicine to mature as a distinct discipline.

Aerospace Medicine↗

Career development of residents in university and independent training programs: the influence of special training fellowships, type of practice, specialization, and research.

General surgical chief residents in all approved training programs were surveyed to evaluate the influence of fellowships, specialization, and research. Respondents represented 76% of programs and 60% of residents. Most chief residents plan to take post-residency fellowships. This is most common among those from university training programs and residents planning an academic career. Vascular surgery and cardiothoracic surgery represent half of all fellowships. Sixty-two percent of residents plan to enter private practice compared with 28% who plan to join a medical school faculty. More than one third of university trainees plan an academic career. More than 90% plan fellowships. The practice of general surgery alone or combined with a specialty was more common among trainees from independent training programs. Practice of a subspecialty was more common among university trainees. More than 80% of residents did research during training. Research leading to publication was more common among university trainees planning academic careers and least common among future general surgeons. This survey suggests that general surgery is predominant among residents in independent training programs who then enter private practice. University programs produce subspecialists who are predominant among future academic surgeons. This trend has vital implications for the future of academic general surgery.

Adult↗

The impact of a respiratory therapy consult service on house officers' knowledge of respiratory care ordering.

BACKGROUND: Although available studies show that implementation of respiratory care protocols by respiratory therapists can enhance the allocation of respiratory care services, concern has been expressed that respiratory therapists' involvement in assessing patients and in determining treatment plans may detract from medical trainees' education and experience in ordering respiratory care services. OBJECTIVE: Compare the rates of correct responses to case-based questions about respiratory care ordering in two groups of internal medicine house officers at academic medical centers: one group training at an institution using respiratory care protocols (The Cleveland Clinic Foundation) and the other group training in an institution at which respiratory care protocols have not been used (University of Nebraska). DESIGN: Prospective cohort study. SETTING: Two academic medical centers, one using respiratory protocols and the other not using respiratory care protocols. MEASUREMENTS: Percent of correct responses to questions regarding respiratory care management posed in 5 case studies administered to both groups. RESULTS: Responses were available from 41 and 17 internal medicine house officers at The Cleveland Clinic Foundation and University of Nebraska, respectively. Respondents represented postgraduate years one, two, and three, and constituted a similar percentage of all internal medicine house officers at each institution (33%). The rate of correct responses to the 20 questions posed in the 5 case studies was high overall (76.8%) and similar in the two house staff groups (77.2 +/- 11.6% at The Cleveland Clinic Foundation and 75.8 +/- 12.0% at University of Nebraska, p = 0.69). The 95% confidence interval for the difference straddled zero (-5.4%, 8.1%), making it very unlikely that any important difference exists between the two groups in rate of correct responses. Analysis of covariance also showed no difference between groups, suggesting that postgraduate training level did not affect this conclusion. In one of the 5 case studies, the percent of correct responses was higher among trainees where respiratory care protocols were in use (86.8 +/- 18% at The Cleveland Clinic Foundation vs 69.1 +/- 14% at University of Nebraska, p = 0.0001). CONCLUSIONS: In this comparison of internal medicine house officers' knowledge regarding respiratory care ordering at institutions using versus not using respiratory care protocols, the rates of correct responses by both groups were similar and unlikely to differ significantly. For one of the 5 case studies, respondents from the institution using respiratory care protocols scored significantly higher. Taken together, these results suggest that use of respiratory care protocols implemented by respiratory therapists does not detract from internal medicine trainees' expertise in respiratory care management. Whether these results generalize to other institutions or reflect expertise in actual practice remains uncertain.

Academic Medical Centers↗

Psychiatric residency training, managed care, and contemporary clinical practice.

Managed care has transformed the health care environment that residents encounter on completion of their training. Unfortunately, residency education has not kept pace with changes in the field, leaving graduates inadequately prepared. The authors identify necessary changes in the residency training tasks of instilling values, imparting required knowledge, building core skills, selecting appropriate training sites, and offering a diversity of instructors and supervisors. They also discuss the obstacles that have impeded the evolution of academic clinical services and clinical training. They suggest strategies of change that may lead to more relevant educational programs that provide residents with a balanced perspective on the strengths and weaknesses of both traditional and contemporary approaches to delivering care.

Humans↗

[Tutorial training in cardiology and cardiothoracic surgery. Preliminary report].

INTRODUCTION AND OBJECTIVES: Personal contact has been lost in medical training due to the increase in numbers of medical students but not of teachers. This fact has impaired training in medical specialties. This is the reason that the Hospital for Cardiology has developed a program of tutelary training. In this paper we present our initial evaluation of this program. METHODS: The inclusive criteria for tutors and students have been defined as have the procedures to develop the program. After three months, 20 residents involved in the tutelary training program were randomly analyzed. Academic activities, clinical practice, research activities and extra-academic activities were evaluated. RESULTS: Currently there are 14 tutors. 50% of residents have developed research projects, 60% has increased academic activities, 50% has improved clinical practice and 65% has defined their postgraduate research projects. CONCLUSIONS: It was concluded that tutelary training in Cardiology and Cardiothoracic Surgery is a useful alternative to improve quality of graduates in these specialties.

Cardiac Surgical Procedures↗

Emergency medicine as an academic discipline.

Because of an explosive increase in the use of emergency rooms in hospitals across the country, many hospitals have found it expedient to employ full-time emergency physicians. The demand for emergency physicians has prompted the development of training programs in emergency medicine in academic medical centers. The first such training program was instituted at The Medical College of Pennsylvania in 1970. The 32 current programs in the nation are filling a real need in providing manpower for hospital emergency rooms. With the increasing identification and distribution of emergency physicians, there has been an attempt to develop emergency medicine as a distinct discipline and to establish its legitimacy in the structure of academic medical centers. A variety of problems must be addressed to clarify the role of emergency medicine in the academic setting.

Curriculum↗

Structure of medical psychotherapy: program for academic formation.

Starting from a general definition of psychoanalysis and with the aim of deepening our knowledge of the relationship between theory and practice, a scientific structure of psychotherapy is developed. The necessity of a training for doctors specialized in the field of psychotherapy has led us to design a training program consisting of three academic courses. This program, established by the Academy of Analytical Psychotherapy in a University Department of Psychiatry and Medical Psychology, introduces a new speciality in our country. In these three academic courses the theoretical aspects are covered (in a series of courses, seminars and lectures) as well as practical aspects (dealt with in sessions of individual and group psychoanalyses) and methods of evaluation at both individual and group levels. The model stated above can be considered the basis of a training program for doctors specializing in analytical psychotherapy.

Curriculum↗