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PubMed2003

The training of geriatricians in the United States: three decades of progress.

During the past 3 decades, significant progress has been made in preparing U.S. physicians to care for the growing elderly population. This paper reviews progress in training and certifying internists and family physicians in geriatric medicine. The establishment of the National Institute on Aging, a series of Institute of Medicine reports, Veterans Health Administration initiatives, and leadership and investment by the public sector and private foundations have supported the development of geriatric medicine training programs. In 1988, the Accreditation Council for Graduate Medical Education initially accredited 62 internal medicine (IM) and 16 family practice (FP) geriatric medicine fellowship programs. By academic year 2001-2002, 120 geriatric medicine fellowships were training 338 fellows. A recent survey of U.S. medical schools found a total of 869 full-time equivalent (FTE) geriatrics faculty members. Their geriatrics programs had a median of 5.0 FTE physician faculty members, with a range of 0 to 42. Recent surveys of IM and FP residency programs found 803 geriatrician faculty members teaching in IM residency programs (53% response rate) and 453 teaching in FP residency programs (75% response rate). From 1988 through 2002, 10,207 Certificates of Added Qualifications in Geriatrics were awarded. The distribution of these practicing geriatricians varied considerably by state, with the national average being 5.5 per 10,000 persons aged 75 and older. Individual state rates ranged from 2.2 to 15.9. Although geriatric medicine training has grown remarkably over the past 3 decades, this growth is still not producing the number of geriatricians needed to care for the growing elderly population. Thus, expanded investment in the training of geriatricians as faculty and practitioners is needed.

Education, Medical, Graduate↗
PubMed1996

Implementing community-based education: essential elements and recommendations.

Two elements are essential for implementing community-based educational programs: a vision of how community experiences fit into the training of the health professionals of the future and a local environment that will support innovation, change, and growth. Change cannot occur unless very basic assumptions regarding medical education are challenged. What is "quality education"? Can programs oriented toward tertiary and specialty care adequately provide the training that should be the core of a 3-year general training program? Do schools and programs select and train physicians to function within the microcosm of the academic center, or do they prepare physicians to manage the country's health care needs? National consensus has had little influence over local environments. Each medical school, training program, and teaching facility must reexamine its values and its culture. Each must have a vision of the physicians of the future and a commitment to train them appropriately. The role of vision and culture in creating successful programs has been clearly described. Several key elements have been found to be consistent with success, the first being vision. Four basic principles will bring the vision to fruition: (1) preserving core values while still stimulating progress; (2) emphasizing the process by which programs are created, implemented, and changed rather than the product; (3) avoiding the "tyranny of the or," learning to be inclusive with a broad vision rather than limited to an "either-or" approach; and (4) aligning the process, management, and values in working toward envisioned progress for the future. Effective leadership is essential for a group or organization to accomplish its mission, as is an organizational structure that aligns responsibility, authority, resources, and accountability.

Community Medicine↗
PubMed1990

Psychotherapy training for the psychiatrist of the future.

There is uncertainty about the future role of psychodynamic psychotherapy in psychiatric practice and education. The Association for Academic Psychiatry and the American Association of Directors of Psychiatry Residency Training formed a joint task force to review the issue. It developed a rationale for continued training in expressive psychotherapy and a model curriculum for such training that is both effective and realistic in terms of the diverse demands and structures of modern residencies. A minimum curriculum was also designed for resource-poor programs.

Adult↗
PubMedDate not supplied

"I get to spend time with my patients": nursing home physicians discuss their role.

OBJECTIVES: The purpose of this study was to learn about the role of the nursing home physician, and to begin to identify and articulate key concepts related to the role. DESIGN: A qualitative exploratory methodology was selected. Two medical students interviewed nursing home physicians in person, using open-ended questions. SETTING: The data reflect the nursing home setting. PARTICIPANTS: Twelve physicians who practice full-time or part-time in a nursing home setting were interviewed. Six physicians were fellowship trained and seven were affiliated with an academic medical center. Eight physicians were from an urban area, and four were from a rural area in a Midwestern state. MEASUREMENT: Qualitative data were grouped and coded to develop conceptual categories. RESULTS: Physicians were categorized as "pursuers, inheritors, or practice builders," based on their path to coming to care for nursing home residents. The medical directors among the physicians reported that their role was heavily dependent upon the desires of the nursing home administrator. Students were encouraged to visit many nursing homes to learn about the different ways in which the medical director role can be played out. Physicians reported positive aspects of their role including relationships with residents, families,staff; interesting and meaningful patient care; and autonomy. Less desirable aspects included: staff turnover, difficult expectations, and administrative issues. Although physicians indicated that social and indeed professional stigma are troublesome to people who work in nursing homes, they assured the medical student interviewer that caring for nursing home residents was gratifying and meaningful work. CONCLUSION: The need for physicians to care for the growing number of nursing home residents will continue for decades. Learning more about how physicians come to care for nursing home residents can be used to develop better ways to recruit, train, and retain physicians. Information about what nursing home physicians value about their role can be used to structure more desirable roles.

Aged↗
PubMedDate not supplied

Surgical careers and preparedness of graduating residents--an outcomes-based study.

PURPOSE: Outcome-based measures have recently become the focus of residency program evaluations. The ultimate outcome of a surgical training program is the successful development of surgical careers by its graduates. METHODS: We developed a survey that was sent to all residents completing our surgical residency from 1989 to 1999 in order to evaluate practice location, type of practice, practice mixture, additional training obtained after residency, Board certification, and membership in the American College (ACS) or other professional societies. Graduates were asked to report their impression of their residency education program's ability to prepare them for surgical practice as well as to give an overall opinion of their training using a scale of 10 (high) to 1 (low). Solicitations were also made for means to improve the training program. RESULTS: Of 32 graduates sent surveys, 30 responded (94%). A total of 29 of 30 responding graduates (97%) are active in surgery. A total of 26 of 30 graduates are in private or government practice, 3 of 30 are full-time academic, and 1 of 30 is completing fellowship training. A total of 13 of 30 (43%) immediately entered practice, whereas 17 of 30 (57%) received additional fellowship training. Board certification has been achieved by 24 graduates. A total of 17 of 30 (59%) are members of the ACS, and 24 of 30 (83%) are members of at least 1 regional or specialty society. The average score for practice preparedness was 8.35. Overall score for the residency program was 8.7. Specific graduate comments demonstrated a perceived need for additional vascular and oncology operative experience that led to changes in our program. These results demonstrate an overall high satisfaction with our training program by graduates over the past 10 years as well as high success rate as evidenced by successful surgical practices by 97% of our graduates. CONCLUSIONS: We believe this type of outcome information provides valuable feedback to programs with regard to planning and development based on the types of careers graduates choose as well as specific changes in curriculum based on perceived deficiencies.

Journal Article↗
PubMed1993

A comparison of university and community-based family practice physician educators.

BACKGROUND: Differences in satisfaction with training and perceived preparation for practice have been observed among residents trained in community and university family practice residency programs. Our study was undertaken to determine the degree to which faculty training, experience, or practice patterns may contribute to these different resident experiences. METHODS: Questionnaires addressing prior training, experience, current practice content, motivation for entering academic medicine, and satisfaction with current teaching position were sent to full-time physician faculty at 60 family practice residency programs. RESULTS: The 208 faculty responses showed no differences in faculty at various types of residency programs with respect to demographic factors, prior training, or past experience. Only small differences were found in the proportion of time devoted to most professional activities or in the content of clinical practice. CONCLUSIONS: Few differences were found between faculty at university- and community-based family practice residency programs. This implies that differences in residents' perceptions of training may be due to other factors, such as institutional philosophy or self-selection. However, qualitative differences in family practice faculty activities that were not measured in this research cannot be ruled out as factors influencing residents' perceptions of their training experiences.

Attitude of Health Personnel↗
PubMed2001

Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center.

Bariatric surgery is being performed in increasing numbers in an era when reimbursements are being reduced. Academic health centers bear the responsibility for training surgeons to perform these operations yet must keep costs to a minimum and retain high quality. The UCLA Bariatric Surgery Program developed a clinical pathway for the pre- and postoperative management for gastric bypass patients to achieve these goals. Medical records for 182 consecutive gastric bypass patients were retrospectively reviewed before implementation of the pathway (Group I) during the fiscal year of 1998/1999. Data on average length of stay, average intensive care unit length of stay, average standard variable cost, percentage readmission rate, and percentage return to the operating room were collected. This information was compared with the data collected prospectively from 182 patients after implementation of the pathway in July of 1999 (Group II) during the fiscal year of 1999/2000. Hospital cost per admission was reduced by 40 per cent in Group II compared with Group I (P < 0.02). The average length of stay was reduced from 4.05 days in Group I to 3.17 days in Group II (P < 0.033). Overall readmission rate was decreased from 4.2 per cent in Group I to 3.2 per cent in Group II (P < 0.05). There were no differences in morbidities between both groups. The pathway reduced costs by reducing the hospital length of stay, intensive care unit utilization, and readmission rates. Quality was maintained as evidenced by a similar pattern of postoperative morbidities yet readmission rates were reduced. Our results indicate that implementation of a clinical pathway for bariatric surgery reduces cost and improves quality of care in an academic institution.

Academic Medical Centers↗
PubMedDate not supplied

Women midshipmen in sports.

This is a study of the physical performance and injury rate for seven classes of women midshipmen at the United States Naval Academy. Women comprise only 6.2% of the brigade of midshipmen, but men and women live in the same dormitory, undergo the same physical training and fitness tests, study the same academic curriculum, and live in an environment where performance and activities can be constantly monitored. The required number of hours of physical education are the same for men and women. The conclusions from this study are: (1) women midshipmen continue to improve their fitness level more rapidly than men; (2) while some disparities in performance are correctly attributed to physiological differences, many of the present disparities should be attributed to societal conditions; (3) should physical performance requirements ever become the same, women will have to work harder than men to achieve the same standards because of the physiological differences; (4) women continue to seek medical attention for stress-related problems (i.e., shin splints, stress fractures) more often than men, but do so less often as they become acclimated to the active life of the Naval Academy; (5) women midshipmen have the same number of serious injuries as men, and in some sports are more susceptible to certain types of injuries.

Athletic Injuries↗
PubMed2000

In defense of a department of geriatrics.

Departmental status for geriatrics offers many advantages, all of which are related to strengthening academic and clinical programs in aging. The training programs and the content of medical school curriculum in geriatrics remain inadequate under the current structures. A department of geriatrics can provide a stronger faculty base and allow effective interaction with other departments (including but not limited to internal medicine) that need geriatric training. A department of geriatrics also focuses on a model of care that involves working closely with other disciplines, such as nursing and social work. This interdisciplinary model helps expert providers work efficiently throughout the spectrum of care, strengthening continuity. The department can include other medical specialists, such as family practitioners, psychiatrists, and physiatrists, who work with caregivers and patients throughout a course of treatment to manage chronic illness and help maintain and enhance function and independence as long as possible. Comprehensive care and proper care management also substantially benefit institutions by expanding the patient population, reducing length of stay, and avoiding unnecessary hospitalization of older patients through effective discharge planning and transitional care. This requires strong relationships with long-term care providers, a characteristic strength of geriatricians. Although not all research in aging needs to be housed in a department of geriatric medicine, the presence of a critical mass of basic and clinical researchers creates an environment that can stimulate new initiatives and attract external funding. Additional research bridging basic translational and clinical phases relevant to the elderly population is best encouraged by maintaining relationships with other basic science and clinical departments.

Academic Medical Centers↗
PubMed2000

Student satisfaction with curriculum modifications in a French dental school.

Since 1994, important modifications have been implemented in the dental curriculum in France, and an additional year has been included in the dental curriculum. The 1st year has remained unchanged; it is common to both medical and dental schools and leads to a selection procedure of 1 in 10 dental students. In the new curriculum, the dental student is engaged in a 5-year programme in dental school (years 2 to 6), as opposed to 4 years in the former programme (years 2 to 5). Basically, this new curriculum emphasises research initiation, links with medical training and offers broader clinical experience. During the academic year 1998-1999, dental schools had 2 different types of students: the 4th year students belonging to the new programme along with the 5th year students in their final year of the old curriculum. Using a specially devised questionnaire, we investigated the students' perception of their respective training, their motivation and professional plans. At the Faculty of Odontology in Lyon, the new curriculum is perceived as an increased strain by the dental students.

Adult↗
PubMed2006

Career choice in academic medicine: systematic review.

OBJECTIVES: To review systematically the evidence about what factors influence the decision to choose or not choose a career in academic medicine. DESIGN: A systematic review of relevant literature from 1990 to May 2005. DATA SOURCES: Searches of The Cochrane Library, Medline (using Ovid and PubMed) from 1990 to May 2005, and EMBASE from 1990 to May 2005 were completed to identify relevant studies that explored the influential factors. Additional articles were identified from searching the bibliographies of retrieved articles. SELECTION OF STUDIES: We attempted to identify studies that included residents, fellows, or staff physicians. No restrictions were placed on the study methodologies identified and all articles presenting empirical evidence were retrieved. For cohort, case-control, and cross-sectional studies, minimum inclusion criteria were the presence of defined groups, and the ability to extract relevant data. For surveys that involved case series, minimum inclusion criteria were a description of the population, and the availability of extractable data. Minimum inclusion criteria for qualitative studies were descriptions of the sampling strategy and methods. RESULTS: The search identified 251 abstracts; 25 articles were included in this review. Completion of an MD with a graduate degree or fellowship program is associated with a career in academic medicine. Of the articles identified in this review, this finding is supported by the highest quality of evidence. Similarly, the completion of research and publication of this research in medical school and residency are associated with a career in academic medicine. The desire to teach, conduct research, and the intellectual stimulation and challenge provided in academia may also persuade people to choose this career path. The influence of a role model or a mentor was reported by physicians to impact their decision making. Trainees' interest in academic medicine wanes as they progress through their residency. CONCLUSIONS: In order to revitalize academic medicine, we must engage trainees and retain their interest throughout their training. Research opportunities for medical students, and fellowships or graduate training can meet this challenge and influence career choice. Initiatives to stimulate and maintain interest in academic medicine should be evaluated in prospective studies across multiple sites.

Academic Medical Centers↗
PubMed2005

Changing clinical practice, helping people quit: the Wisconsin Cessation Outreach model.

Six University of Wisconsin-Center for Tobacco Research and Intervention (UW-CTRI) Regional Outreach Specialists, based in 5 regions across the state, provide training and technical assistance on evidence-based tobacco cessation interventions to clinics, hospitals, health systems, insurers, community organizations and worksites through academic detailing methods. The core of this approach involves individualized training on the U.S. Public Health Service Clinical Practice Guideline, "Treating Tobacco Use and Dependence" as well as follow-up technical assistance to achieve sustainable system changes and a reduction in barriers to tobacco cessation services. The program's scope includes health systems, managed care organizations, hospitals, worksites, and community organizations. The program also links organizations and the communities they serve to the Wisconsin Tobacco Quit Line and related cessation services. Since 2001, over 10,000 health care providers in over 500 clinics and 26 health systems and managed care organizations have received Guideline-based cessation training through the Outreach program. This paper examines research supporting this Cessation Outreach Model, describes its operation, discusses key outcomes, and reviews future directions and applications.

Community Health Services↗
PubMed1997

Are there sex biases in standardized tests of radiation oncology knowledge?

PURPOSE/OBJECTIVE: Recent studies have identified biases directed against women in standardized tests. We tested for the existence of such biases in the American College of Radiology (ACR) In-Training Examination in Radiation Oncology and the American Board of Radiology (ABR) Written Radiation Oncology Board Examination. MATERIALS AND METHODS: Our request to the ABR to permit us to study performance on their examinations, as a function of sex, was refused. We obtained scores, through the cooperation of six academic radiation oncology departments, for residents-in-training taking the in-service examination and candidates taking the written board examination for the first time. Test results for 1984 to 1995 were blinded as to name, but not sex or institution of training. For the in-service examination, scores are reported as percentiles normalized to the year of training. The effect of multiple scores for the same resident was assessed using a repeated-measures analysis of variance. Residents were nested within each sex/institution combination and crossed with training year and calendar year. The effects of three factors (sex, institution, and year the examination was taken) on the results of the biology, physics, and clinical sections were evaluated with an analysis of variance. The interactions of sex with institution and year were included to determine the scope of the sex effect. For the board examination, scores are reported as percentiles, as well as an overall pass/ fail outcome. An analyses of variance was performed similar to that used for the in-service examination. In addition, Fisher's exact test and logistic regression were used to analyze overall outcome (pass/fail). RESULTS: We obtained data for 79 residents (48 men and 31 women, 1.54:1) who took the in-service examinations 165 times. Sixty-two residents (41 men and 21 women, 1.95:1) had an initial sitting for the ABR written examination. On the in-service examination, for the biology, physics, and clinical subsections, calendar year, training year, and sex did not have a significant effect on examinees scores. Institution of training had a significant effect (P < .02) on the scores in biology and physics. The total in-service examination scores were not significantly influenced by calendar year, training year, or sex. Institution of training has a strong influence on overall score (P = .03) and the interaction of sex with training year is near significance level (P = .06). The power for our statistical tests ranged from 0.88 to 0.99. On the board examination, sex, institution of training, year the examination was taken, and interaction of sex with year or sex with institution of training did not have a significant effect on test scores. Pass rates were 90% for men versus 81% for women (P = .43). CONCLUSION: Sex did not significantly influence the results of the in-service examination or the written board examination. Institution of training is the strongest influence on the results of the in-service examination.

Adult↗
PubMedDate not supplied

Training and education for public health: the role of the U.S. Public Health Service.

In 1993 Assistant Secretary for Health Philip R. Lee commissioned an evaluation of U.S. Public Health Service (USPHS) activities in training and education for public health (TEPH). Findings revealed significant shortages of professionals and academic faculty in the public health fields of epidemiology, biostatistics, environmental and occupational health, public health nutrition, public health nursing, and preventive medicine. An inventory of PHS activities showed that about $217 million was spent on 151 public health and prevention training programs serving over 141,000 persons in fiscal year 1993. The $217 million amounted to about 18% of the total reported PHS training expenditures of $1.2 billion and about 1% of the total spending of $19.4 billion in fiscal year 1993. The National Institutes of Health (NIH) and Health Resources and Services Administration (HRSA) had the largest training expenditures of $655 and $445 million respectively, but spent only about 7% and 17% on public health and prevention training. Other PHS agencies had larger proportional investments in prevention, but the amounts were smaller. Priority recommendations were provided to Dr. Lee in seven key areas: advanced technology, core public health functions, policy and financing, academic-practice links, educational research, research training, and coordination. Together, these could dramatically increase the PHS proportional investment in TEPH. The PHS has a rich variety of resources for TEPH, but a lack of prioritization, coordination, and planning is causing opportunities to be missed. Medical Subject Headings (MeSH): public health, training, education.

Curriculum↗
PubMed1993

Evaluation of pediatric training by the alumni of a residency program.

An evaluation of a large pediatric residency program by its alumni was undertaken to determine whether the program is providing quality education and relevant training for pediatricians. A questionnaire was mailed to physicians who began their training at Children's Hospital Medical Center in July 1974 or later and finished prior to July 1990. Of the 372 questionnaires sent, 274 were returned (74% response rate). Current positions included primary care physicians (41%), academic pediatricians (33%), and other (26%). Fifty-seven percent pursued fellowship training. Overall, 94% of the responders believed that their pediatric training was adequate in preparing them for their current position. The variety of patients seen, the inpatient experience, resident camaraderie, and neonatology training were rated the highest quality, means 4.38 to 4.75 (1 = poor, 3 = average, 5 = excellent quality). Behavioral/developmental pediatrics, adolescent medicine, well-child care/continuity clinic, the outpatient experience, and pediatric surgery were rated the poorest quality, means 2.66 to 3.08, and judged to have too little quantity of training relative to the other aspects of training, means 1.93 to 2.42 (1 = too little, 3 = just enough, 5 = too much quantity). The quantity of neonatology training, the volume of patients, on-call experience, subspecialty inpatient services, such as bone marrow transplantation, and overall inpatient experience were considered too high relative to other components, means 3.51 to 4.08. There were no significant differences in responses by whether the alumni were in academic or primary care positions nor by year of training, and few differences by whether or not the training was considered adequate preparation for their current position.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Factors influencing the pursuit of careers in academic medicine: a survey of MD-PhD residents in dermatology programs in the United States.

A survey of all MD-PhD residents in dermatology in the United States was conducted to evaluate the factors important to them in making career pathway decisions. Twenty-six MD-PhDs responded to the survey representing a 90% response rate. Although essentially all entered dermatology with the intention of pursuing a career in academic medicine, 77% percent thought they would be in academic medicine 5 years post-residency. Factors explored for a negative influence on entrance into academic medicine post-residency were 1) financial concerns, 2) length of training, 3) research hiatus due to clinical training, and 4) eligibility for existing funding mechanisms.

Academic Medical Centers↗