Hospital acquisitions of medical practices. The physician's perspective.
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Attitude of Health Personnel↗
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Professionalism and team care in the clinical setting.
The introduction of an 80-hr work week mandates frequent sign-out or transfer of patient information sessions among training physicians. At the same time, patients are increasingly more complex and cared for by teams employing technologically driven interventions. In order for team care to work, residents and medical students must master the elements of professionalism, upon which solid leadership and clear communication rests. Early instruction should include topics, such as clarity of language, cultural sensitivity, a subordination of self-interest to the needs of the patient, and a dedication to lifelong learning of cognitive and motor skills. This exposure to professionalism may begin in the dissection room and continue seamlessly through residency and into practice.
Attitude of Health Personnel↗
Waiting to see the doctor. The impact of organizational structure on medical practice.
In this article it is assessed whether or not the scheduling and office visit queues a patient faces depend upon the organizational structure of the physician's practice (i.e., does the physician practice in the fee-for-service system or in a health maintenance organization [HMO], and if in an HMO, in what type of an HMO). Data pooled from two national studies (N = 2448) reveal two major findings. First, although scheduling queues may be predicted from the organizational structure of physicians' practices and other factors, office queues appear to be more of a random phenomenon. Second, a distinct pattern emerges among the effects of the organizational structure of physicians' practices on patient queues, including 1) physicians in solo practice offer their patients the shortest queues, 2) physicians in group model HMOs maximize scheduling queues but minimize waiting room queues, 3) patient queues for physicians practicing in IPAs are no different from those of their counterparts in group-practice fee-for-service settings, and 4) patient queues for salaried physicians practicing in a predominantly salaried environment are among the longest. The implications of these findings are discussed with special reference to extent and future studies of the effects of organizational structure on medical practice.
Appointments and Schedules↗
King's theory of goal attainment as a framework for managed care implementation in a hospital setting.
Implementation of nursing conceptual frameworks and theories in practice settings is essential to foster the growth and advancement of the discipline of nursing. Over the past several decades nurse educators, administrators, and clinicians have often seemed to function in isolation. Educators developed conceptual models and theories, but these frameworks were infrequently applied in practice settings. In addition, administrators used management theories as a framework for nursing practice in institutional settings, while clinicians were left to utilize the medical model and theories from other disciplines as a base to guide practice. This article focuses on how King's theory of goal attainment can serve as a nursing framework for managed care.
Goals↗
Styles of practice of female physicians.
This study reports findings on a study of styles of practice of female physicians from the revised program in medical education at Case Western Reserve. It contrasts some of the results with practice sytles of male physicians from the same period.
Female↗
A retrospective analysis of institutional review board and informed consent practices in EMS research.
STUDY OBJECTIVE: To assess the frequency of institutional review board (IRB) review and informed consent in emergency medical services (EMS) research. DESIGN: Two-year, retrospective review of published EMS research. MEASUREMENTS AND MAIN RESULTS: One hundred two studies were analyzed. Seventy-one (70%) were exempt from IRB review; 31 (30%) were not exempt. Seventeen nonexempt studies (55%) did not obtain IRB review. Eight of these did not specify a consent method; one used implied consent and eight used volunteers. Volunteers gave informed consent in one study. Of the 14 nonexempt studies with IRB approval, seven did not specify a consent method. Two used informed consent, one received an informed consent waiver, one used verbal consent, and three involved volunteers. Written parent permission was used once when volunteers were minors. CONCLUSION: IRB review is often omitted by EMS investigators. This raises ethical concerns about EMS research. Investigators should document their consent method or approval to use an informed consent waiver in their manuscripts. A consent method should be specified for volunteers.
Emergency Medicine↗
Response to "Institutionalizing practice: historical and future perspectives".
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Chicago↗
Similarities of a general medicine clinic in a teaching hospital to internal medicine practice. Clinic compared with private practice.
The authors undertook this study to determine whether a general medicine clinic in a teaching hospital provided an experience similar in content to that in the office of a general internist. Data on all patient visits to the university clinic during 1979 were collected. Analyses of 4856 visits revealed significant differences (p less than 0.001) in duration of visit, admission rate, and referral rates between the clinic and internists studied by the National Ambulatory Medical Care Survey (NAMCS). However, the 12 most common problems seen in the clinic were among the 15 most common problems seen by NAMCS physicians despite some differences in the prevalence of certain diagnoses. Knowing the relative prevalence of specific diagnoses in this setting helps teach cost--benefit principles of ordering diagnostic studies designed to detect uncommon problems. This study supports the value of a teaching hospital ambulatory care experience as preparation for the practice of general internal medicine.
Adolescent↗
A pill in the sandwich: covert medication in food and drink.
The covert administration of medicines in food and drink has been condemned by some and condoned by others. We used questionnaires to ascertain the views of people caring for patients with dementia in institutions and in the community. In 24 (71%) of 34 residential, nursing and inpatient units in south-east England, the respondent said that medicines were sometimes given in this way. It was often done secretly and without discussion, probably for fear of professional retribution. Few institutions had a formal policy on the matter. Of 50 people caring for demented patients in the community, 48 (96%) thought the practice sometimes justifiable, but 47 believed that doctors should consult with carers before deciding. Even if, as most carers and some authorities believe, covert medication can be justified, the poor recording and secrecy surrounding the practice in institutions are cause for concern.
Attitude to Health↗
Public-private partnership organizations in health care: cooperative strategies and models.
Value-adding partnerships have emerged as a preferred strategy of private health care providers to achieve high-quality, low-cost provider status. This same strategy can be applied by public sector providers through the creation of public-private partnership organizations (3POs). Strategies to build 3POs between local governments and their medical communities currently under development are outlined. The conceptual and practical aspects of implementing 3POs are presented.
Attitude of Health Personnel↗
Commentary: Medical errors, sentinel events, and malpractice.
Medical errors do not necessarily represent negligence. Even when a mental health professional deviates from the standard of care, minor injury to a patient is unlikely to result in a lawsuit. The standard of care is not the same as the quality of care. Quality of care refers to the total care a patient receives, the patient's health care decisions, and the available mental health services. As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "sentinel events," such as a patient's suicide, do not necessarily imply that a deviation in the standard of care occurred. Psychiatrists and hospital staff are held to an "ordinarily employed" standard of practice. The Institute of Medicine (IOM) guidelines recommend evidence-based care related to patient needs and values. Both JCAHO and IOM promote best practices. Experts err when they testify to a best practice standard in malpractice cases.
Humans↗
Multivariate analysis of risk factors for deep and superficial sternal infection after coronary artery bypass grafting at a tertiary care medical center.
Identification of modifiable risk factors for sternal infection is essential for the development and institution of practices that decrease the incidence of these infections. This study analyzed 4004 consecutive patients undergoing coronary artery bypass grafting performed at a single institution between January 1996 and May 2003. Specific risk factors for both superficial and deep sternal wound infection were identified by univariate and multivariate analysis. The incidence of superficial sternal wound infections was 2.2% (N = 87) while the incidence of deep sternal wound infections was 1.8% (N = 73). Risk factors for superficial sternal infection identified by multivariate analysis include increasing body mass index (BMI) (OR 1.089, 95% CI 1.057-1.122, P < 0.001), female gender (OR 1.412, 1.108-1.717, P = 0.036), active smoking (OR 1.856, 1.079-3.193, P = 0.025), utilization of bilateral internal mammary arteries (OR 7.546, 3.175-17.935, P < 0.001), and transfusion of > or =4 units of packed red blood cells postoperatively (OR 2.009, 1.158-3.485, P = 0.013). Risk factors for deep sternal infection include increasing BMI (OR 1.077, 1.042-1.114, P < 0.001), diabetes mellitus (OR 2.412, 1.376-4.231, P = 0.002), and transfusion with > or =2 units of platelets postoperatively (OR 2.787, 1.279-6.071, P = 0.010). These data suggest that cessation of smoking, improved blood glucose management, preoperative weight loss, limitation of transfusions, and discriminate use of bilateral internal mammary arteries are all practices that may decrease the incidence of postoperative wound complications following coronary revascularization.
Aged↗
The physician exodus from hospitals.
Physicians are spending increasingly less of their work week in the hospital. This is true of surgeons because they are performing more ambulatory surgery, often off the hospital premises, and for primary care physicians because they are delegating hospital care of their patients to others. What are the effects of this physician exodus on hospitals, patients, physicians, and medical education? Some of these consequences are explored, from disruptions in the continuity of care, to increase in practice productivity, to preparing undergraduates for the realities of medical practice.
Ambulatory Surgical Procedures↗
The prognosis for the hospital-based pathologist--Part 2.
Last month the authors diagnosed the condition of the hospital-based pathologist and prescribed a large dose of competitive activities to improve security and financial well-being. In this concluding article the complications of this treatment are examined, highlighting the issues that pathologists must resolve as they venture forth into a new practice environment.
Hospital Departments↗
[Results of 2 years of contact lens-application in hospital practice].
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Adolescent↗
Information exchange between general practitioner and nursing home physician in The Netherlands.
BACKGROUND: In response to the specific characteristics of nursing home residents, the Netherlands has become the only country to develop the specialty of nursing home medicine. The "nursing home physician" has attained independent status. This development has, however, created a division between medical care in the community and medical care in nursing homes, which challenges the quality of the transitional processes taking place when a patient is admitted to or discharged from nursing home care. OBJECTIVES: To give insight into the type of medical information exchanged between general practitioners (GPs) and nursing home physicians (NHPs) at the time of admission, while a patient is under care of the NHP, and at the time of discharge. METHODS: Questionnaires were sent to a sample of 780 GPs, who were selected using a 2-phase sample strategy. Three hypothetical patient vignettes, involving the admission of a patient to a nursing home, to day care, and to an outreaching nursing home care project, were constructed and presented in the questionnaire. GPs were asked to answer questions about the information exchanged during the care of a patient illustrated in each vignette only if they were really familiar with a patient such as presented. The advantage of hypothetical patient vignettes is that each physician reacts to a standardized situation. RESULTS: In the case of admitting a patient to or discharging a patient from the nursing home, results indicate that the continuity of care at those moments will be better ensured if GPs have more frequent personal contacts with NHPs. In the case of day care patients, the study also reveals that GPs who have frequent personal contact with NHPs will share relevant patient information significantly more often at the start of the day care program, both during day care and also when intercurrent medical problems occur. Similar findings can be expected in patients receiving outreaching nursing home care. CONCLUSIONS: The findings indicate the advantages of personal contacts between different medical professionals in exchanging specific patient information. It can be expected that this will lead to more tailor-made medical care for the patient. Adequate exchange of relevant information is an important aspect of mutual collaboration between professionals. Recommendations as to how to achieve more personal contact and a better collaboration among medical professionals are proposed.
Aged↗
The practice of hospital psychiatry: a formulation.
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Attitude of Health Personnel↗
New Oslerians and real Flexnerians: the response to threatened professional autonomy.
As federal governmental involvement in U.S. health care had become a fact in the mid-1960s, a significant number of contributors to The Journal of the American Medical Association (JAMA) had recommended educational reforms to save an autonomous profession. In the late 1970s, demands for additional professional reforms began to appear in JAMA and The Journal of Medical Education (JME), particularly from contributors who perceived threats to professional autonomy from corporate medicine. The New Oslerian reform agenda is an application of the "humanizing" movement to the clinical phase of medical education. In its most restricted formulation (the inherent ethic argument), proponents simply urged clinicians to permit every student's inborn sense of moral duty to blossom on the wards. Others argued that Sir William Osler's legacy was more complex and involved systematic instruction, especially in ethics, at the bedside (the service ethic argument). Real Flexnerian reforms were based on an assumption that unintended distortions in Abraham Flexner's reform measures had eventuated in stultifying and counterproductive teaching of the biomedical model. Consequently, medical education should be altered to train future physicians in what Flexner had really intended--the capacity to think and problem-solve in a scientific manner. In time, many reformers emphasized the complementarity of Real Flexnerian and New Oslerian curricular proposals. The most comprehensive proposal to date, GPEP (General Professional Education of the Physician), makes a strong case that implementation of these old, turn-of-the-century reform proposals would make physicians in the 21st century well-rounded and competent. But GPEP's proposed changes in medical education are inadequate because the recommendations do little to prepare future physicians to contend with the corporate context in which most of them will be practicing.
Decision Making↗