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PubMed1996

Do surgeons have a role as infectious disease consultants?

BACKGROUND: Antibiotic drug restriction policies have become widespread in North America hospitals mandating medical infectious disease consultation for use of routine antimicrobial agents. OBJECTIVE: To determine physician and institutional attitudes regarding the credibility of surgeons in the area of infectious disease. DESIGN: A survey of the Surgical Infectious Disease Society (SIS) membership. PARTICIPANTS: Members of the SIS practicing in the United States and Canada (n = 464) were sent a simple opinion poll regarding surgical infectious disease specialists. After receiving the survey, the SIS members were given approximately 4 weeks to anonymously complete the questionnaire and return it to our office. RESULTS: Responses were received from 198 SIS members (43%). Most were from large (> 400 bed) institutions (63%), and the majority of them were from university centers (76%). Predictably, 86% of the respondents were in full-time academic practice. Some SIS respondents (21%) had undergone special training in infectious disease, and of these, 63% actually had completed a formal surgical infectious disease fellowship. Antibiotic restriction policies were nearly universal and required in 87% of institutions. Only 44% of surgeons in these hospitals, however, were privileged to release antibiotic drugs. Medical infectious disease physicians recognized surgical expertise in infectious disease in few instances (32%). The great majority of responding SIS members (81%) believed that an examination or certification in infectious disease for surgeons was not warranted. CONCLUSIONS: Antibiotic drug restriction is prevalent in North America, and medical infectious disease specialists do not generally recognize surgical expertise in the area of infectious disease. Despite this environment, responding SIS members believe that special credentialing of surgeons in the area of infectious disease is unnecessary.

Communicable Diseases↗
PubMedDate not supplied

Group psychotherapy for recently diagnosed breast cancer patients: a multicenter feasibility study.

As many as 80% of breast cancer patients report significant distress during initial treatment, yet there is little in the way of systematic psychotherapeutic interventions for women coping with the stress of a recent diagnosis of breast cancer. The literature on psychotherapeutic treatment of cancer patients provides uniform evidence for an improvement in mood, coping and adjustment as a result of group therapy. The present study examined the feasibility of implementing a manualized treatment, supportive-expressive group psychotherapy, in busy oncology practices across the US. This intervention was applied to women with primary breast cancer in a manner which tests not only the efficacy of the approach but also its accessibility to group therapists not previously experienced in its use. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from ten geographically diverse sites of the National Cancer Institute's Community Clinical Oncology Program (CCOP) and two academic medical centers. Two therapists from each site were trained in supportive-expressive group psychotherapy. Training consisted of participation in a workshop, reading a treatment manual, and viewing explanatory videotapes. Each patient participated in a supportive-expressive group that met for 12 weekly sessions lasting 90 min. Assessment of mood disturbance was made at entry, 3, 6, and 12 months. Results indicated a significant 40% decrease in the Total Mood Disturbance (TMD) scores of the Profile of Mood States (POMS) (ANOVA F [2,174]=3.98, p<0.05). The total symptom score of the Hospital Anxiety and Depression Scale (HADS) was likewise significantly reduced over the 6-month period (F [2, 174]=5.2, p<0.01). Similarly, the total score of the Impact of Event Scale (IES) was significantly reduced (F [2,174]=4.0, p<0.05). There was substantial uniformity of treatment effect across sites. Outcome was independent of stage of disease (I vs. II). We conclude that this treatment program can be effectively implemented in a community setting and results in reduced distress among breast cancer patients.

Adaptation, Psychological↗
PubMed2006

Maryland's Special Populations Network. A model for cancer disparities research, education, and training.

The unequal burden of cancer in minority and underserved communities nationally and in Maryland is a compelling crisis. The Maryland Special Populations Cancer Research Network (MSPN) developed an infrastructure covering Maryland's 23 jurisdictions and Baltimore City through formal partnerships between the University of Maryland School of Medicine, University of Maryland Statewide Health Network, University of Maryland Eastern Shore, and community partners in Baltimore City, rural Eastern Shore, rural Western Maryland, rural Southern Maryland, and Piscataway Conoy Tribe and statewide American Indians. Guided by the community-based participatory framework, the MSPN undertook a comprehensive assessment (of needs, strengths, and resources available) that laid the foundation for programmatic efforts in community-initiated cancer awareness and education, research, and training. The MSPN infrastructure was used to implement successful and innovative community-based cancer education interventions and technological solutions; conduct education and promotion of clinical trials, cancer health disparities research, and minority faculty cancer research career development; and leverage additional resources for sustainability. MSPN engaged in informed advocacy among decision- and policymakers at state and national levels, and its community-based clinical trials program was recognized by the U.S. Department of Health and Human Services as a Best Practice Award. The solutions to reduce and eliminate cancer health disparities are complex and require comprehensive and focused multidisciplinary cancer health disparities research, training, and education strategies implemented through robust community-academic partnerships. Cancer 2006. (c) American Cancer Society.

Biomedical Research↗
PubMed1991

Epidemiology and the new public health; implications for training.

It is currently believed that epidemiology should play a much greater part in the research and practice of public health medicine. Although epidemiology has much to offer in this field, the nature of the scientific method is often in conflict with the pragmatic and incremental responses of public health medicine, particularly at the district level. This should not prevent the development of collaborative work in public health practice, but it does require some re-orientation of attitudes, and there are implications for training. It is suggested that the training of public health epidemiologists should be based in academic departments and have two major components, (a) an ongoing programme of scientific study in the academic environment, and (b) involvement in a range of collaborative service projects which will also provide general experience of public health medicine. This arrangement should help to maintain the scientific skills and judgement of the public health epidemiologist when faced with the need to modify traditional methods of investigation.

England↗
PubMed2004

Intravenous immunoglobulin for severe infections: a survey of Canadian specialists.

PURPOSE: To survey the opinions of Canadian critical care medicine and infectious disease specialists about the use of intravenous immunoglobulin (IVIG) for the treatment of severe infections. MATERIALS AND METHODS: A scenario-based, cross-sectional survey of Canadian critical care medicine and infectious disease specialists was conducted from March to June 2003. RESULTS: The response rate was 291/487 (60%). Respondents were primarily medically trained and most (241/291; 83%) were practicing in large academic referral centers. Physicians reported that they would use IVIG in patients with streptococcal toxic shock syndrome (STSS; 218/288; 76%), streptococcal necrotizing fasciitis without STSS (143/286; 50%), staphylococcal toxic shock syndrome (75/288; 26%), streptococcal soft tissue infection without NF or STSS (31/286; 11%), and septic shock due to intra-abdominal focus (9/283; 3%). The majority (> or =67%) of respondents believed that it would be ethical to randomize patients to IVIG or placebo in a clinical trial in each of the five scenarios. One third (192/286) reported that it would not be ethical to randomize patients with STSS. Canadian specialists commonly report favoring the use of IVIG to treat STSS and necrotizing fasciitis but less commonly endorse this treatment for other infections. CONCLUSION: Specialist's beliefs surrounding the efficacy of IVIG would challenge but not preclude the conduct of future placebo controlled trials of severe streptococcal infections in Canada.

Attitude of Health Personnel↗
PubMed2002

Educating a new generation of clinical laboratory scientists.

In many countries the new generation of laboratory scientists comes from the graduates of the biological sciences. Their training in the sciences is usually of high quality, but is almost totally lacking in the clinical application of their scientific knowledge. They obtain this clinical knowledge most often by on-the-job training and experience. This paper describes a new undergraduate academic program in Laboratory Medicine developed at the Faculty of Medicine of the Technion, the Israel Institute of Technology. The program is carried out with the collaboration of the Faculty of Biology and the Faculty of Medicine, and upon completion of the classroom studies there is a period of internship for practical experience. The first students of the program are now in their internship period and will graduate this year.

Chemistry, Clinical↗
PubMed1996

Orientation to higher education: the challenges and rewards.

A new 'starter' course for qualified nurses entering higher education is discussed in this article. The background and aims of this course, which enables traditionally trained nurses to enter a pathway of professional and academic development, are presented. Learning outcomes of the course, identified through a formal evaluation procedure, were categorized into product and process components. Course teachers anticipated that the product outcomes would be evaluated most highly but the participants reported that the process outcomes were more important to them. They believed these process outcomes would empower them not only to undertake further academic studies but also to take a greater part in clinical decision-making. The results of this evaluation demonstrate that for many nurses, who seek to launch themselves into higher education, a 'bridging' programme is necessary to support this transition.

Career Mobility↗
PubMed1999

Internal medicine in the next millennium: whither vascular medicine?

Cardiovascular diseases cause a staggering amount of morbidity and mortality. The knowledge derived from advances in vascular biology and vascular medicine has provided the practicing clinician with an already impressive number of effective treatments, but these treatments need to be applied more consistently and more effectively. The field of vascular medicine is growing at a high rate. In order to better apply existing knowledge and to be prepared for new developments, education in vascular medicine should be enhanced both in the training programme for Dutch internists and in postgraduate education. Academic and large community hospitals should consider the founding of multidisciplinary centres for vascular medicine. General internists should play a coordinating role in such centres.

Cardiology↗
PubMed2003

Efficacy of the RECAP intervention program for children with concurrent internalizing and externalizing problems.

The authors evaluated the efficacy of RECAP, a psychosocial intervention developed to treat concurrent internalizing and externalizing problems in children. Participants included 93 4th-grade children assigned to the treatment group or a no-treatment control group. The school-based program, which lasts the 9-month academic year, provides individual, group, classroom, teacher, and parent training in the RECAP skills-development curriculum, which was derived from empirically supported treatment programs for nonconcurrent internalizing and externalizing problems. Outcome assessments included parent-, teacher-, self-, and peer reports. A mixed hierarchical linear models analysis indicated that, overall, treatment children's rate of improvement in both internalizing and externalizing problems was significantly greater than that for control participants.

Child↗
PubMed2005

The ERA-EDTA cohort study--comparison of methods to predict survival on renal replacement therapy.

BACKGROUND: Accurate prediction of patient survival from the time of starting renal replacement therapy (RRT) is desirable, but previously published predictive models have low accuracy. We have attempted to overcome limitations of previous studies by conducting an ambidirectional inception cohort study in patients on RRT from centres throughout Europe. A conventional multivariate regression (MVR) model, a self-learning rule-based model (RBM) and a simple co-morbidity score [the Charlson score modified for renal disease (MCS)] were compared. METHODS: In 1996, all 3640 dialysis centres registered with the ERA-EDTA were invited to identify all patients on RRT for end-stage renal failure (ESRF) who died during the 28 days of February 1997 (training cohort) and all patients who started RRT in the same period (validation cohort). Fifty-four clinical and laboratory variables from the time of starting RRT were collected in both cohorts using a two-page questionnaire. The data from the training cohort were given to statisticians at the Amsterdam Academic Medical Centre to create the MVR model and to engineers in Strathclyde University to create the RBM. They were then given the baseline data from patients in the validation cohort to predict how long each patient would survive. Follow-up questionnaires were sent to the centre of each patient in the validation cohort to determine actual survival. RESULTS: A total of 2310 patients from 793 centres in 37 countries in the ERA-EDTA area were used to construct and validate the models. For predicting 1-year survival, the RBM had the highest positive predictive value (PPV) (84.2%), the MVR model had the highest negative predictive value (NPV) (47%) and the RBM had the highest likelihood ratio (1.59). For predicting 5-year survival, the MCS had the highest PPV (79.4%), the RBM had the highest NPV (74.3%) and the MCS had the highest likelihood ratio (7.0). The proportion of explained variance in survival for MCS, MVR and RBM was 14.6, 12.9 and 3.95%, respectively. CONCLUSION: Using the ambidirectional inception cohort design of this ERA-EDTA Registry survey, we have been able to create and validate two novel instruments to predict survival in patients starting RRT and compare them with a simple scoring model. The models tended to predict 5-year survival with more accuracy than 1-year survival. Examples of potential applications include informing clinical decision making about the likely benefit of starting RRT and listing for transplantation, adjusting for baseline risk in comparative studies and identifying specific risk groups to participate in clinical trials.

Comorbidity↗
PubMed2002

Primary care at a crossroads.

The author explains why primary care is especially beleaguered today (e.g., growth in specialization and widening income gaps between specialists and generalists, growth of managed care, cutbacks in Medicare and Medicaid payments to academic medical centers, and pro-technology biases in fee-for-service payment). Medical students sense primary care's troubles; primary care residency matches continue to decline. Attempts to encourage generalist practice cannot compete with such forces as pro-specialist reimbursement policies, the way research is funded, the dominance of specialist role models, and the daunting knowledge demands of the generalist mandate. Can generalists find a niche in the current health care marketplace? How will the under-65 population influence the future of primary care practice? (The author predicts a scenario based on patients' degrees of affluence.) Will consumers be willing to pay for the services that primary care is uniquely well positioned to offer? The author explains why increasingly important issues of cost, quality, and convenience could help create a niche for primary care. He also maintains that academic medicine must rededicate itself to producing well-trained generalists, despite all the pressures not to, and discusses the challenges that family practice, internal medicine, and pediatrics must face if they are to flourish. He concludes that if generalism fails the market test, something very precious will be lost-and that generalist physicians would be so badly missed that they might have to be reinvented.

Humans↗
PubMed2002

Current practice in the intramedullary nailing of tibial shaft fractures: an international survey.

BACKGROUND: Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The variability in outcomes with tibial shaft fractures may reflect technical aspects of the surgical procedure and perioperative care regimens among surgeons. Identifying the distribution of surgeons' preferences in nailing technique, and the rationale for their choices, will aid in focusing educational activities for the orthopedic community and planning future clinical trials. Our objectives were to clarify surgeons' opinions regarding technical aspects of surgery and perioperative care after intramedullary nailing of closed and open tibial shaft fractures, and to identify predictors of surgeons' preferences in technique and perioperative care. METHODS: This study was a cross-sectional survey using focus groups, key informants, and sampling to redundancy strategies to develop a survey to examine surgeons' preferences in the treatment of tibial shaft fractures. The survey was pilot tested for clarity and content validity. We mailed this survey in July 2000 to 577 orthopedic surgeons who have an interest in trauma care. These were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, or European AO International affiliated trauma centers. We used several strategies to improve response rates including personalized cover letters, stamped return envelopes, follow-up telephone calls, and repeat mailing of questionnaires. Main outcome measures included technical issues such as reduction, exposure, intramedullary reaming, and interlocking screws; and factors associated with surgeons' preferences such as age, fellowship, academic practice, and geographic location. RESULTS: Four hundred forty-four surgeons (77%) responded. Sixty percent of respondents had an academic practice, 84% supervised residents, and 65.1% had fellowship training in trauma. Approximately half (51.5%) of surgeons used a tourniquet. The odds that a surgeon in Asia or Africa used tourniquets was 10 times that of a North American surgeon (p = 0.004 and p = 0.002, respectively). Patellar tendon retraction and an inferior-based entry portal was the popular choice among surgeons (70.1% and 70.8%, respectively). Surgeons from Australia (odds ratio [OR] = 50, p < 0.001), South America (OR = 9.0, p < 0.001), Europe (OR = 3.7, p = 0.001), and Asia (OR = 3.8, p = 0.006) were significantly more likely to use a patellar splitting approach compared with North American surgeons. In the perioperative care of open tibial shaft fractures, there was consensus in the use of intravenous antibiotics and wound irrigation (96.5% and 95.6%, respectively). However, we found considerable variability in surgeons' preference in wound irrigation pressures (high, 38.7%; low, 45.4%). Surgeons in South America were 10 times more likely to use low-pressure irrigation than North American surgeons (p = 0.0005). In grade IIIB open tibial shaft fractures, 94% of surgeons believed wound closure should be obtained within the first 7 days after the injury. A surgeon's geographic location was a significant predictor of the timing of soft tissue coverage (p = 0.001). CONCLUSION: Consensus in the use of irrigation and intravenous antibiotics in open fractures was achieved among surgeons. However, there remains considerable variability in the surgical technique of intramedullary nailing, the duration of antibiotic use, and the timing of wound closure in open tibial fracture care. Continued education and large multicenter trials are needed to establish best practice in the operative treatment of tibial shaft fracture.

Adult↗
PubMed1984

A future pattern of psychiatric services and its educational implications: some suggestions.

Psychiatry has expanded rapidly as a medical discipline in the last two decades but has not always been able to recruit sufficient young doctors of ability to its ranks. In view of recent governmental and professional reports on future medical practice we set up a study group comprising members from academic, NHS, sub-specialty, community and in-training psychiatry to examine the present tasks, attractions and constraints within a career in psychiatry and propose possible improvements for further consideration. In marrying these views to foreseeable developments we are sensitive to the requirement to take into account both the needs of the community and the job satisfaction of the future psychiatrist. To this end we indicate briefly our views concerning the attractions that a career in psychiatry currently has for the good graduate and ways in which the provision of interest and stimulation, educationally and professionally, can be increased so as to attract psychiatrists of high calibre both to general adult psychiatry and to areas of the specialist services which are at present unpopular. Finally, we propose a pattern of psychiatric services which we believe will embody both a useful and an attractive specialized job and interesting educational goal for future medical practitioners.

Career Choice↗
PubMed1989

The medical school as a social organization: the sources of resistance to change.

Medical schools vary by nation and by culture but, for students, the experience appears to be very similar. Also, despite a half-century of radical changes in medical practice, education as a process of socialization for the profession is relatively unchanged. At the same time, medical educators have frequently instituted curricular reforms. To analyse this history of reform without change, this paper first establishes what the content and structure of medical education is, and how it came to be that way; second it traces a process whereby the scientific mission of academic medicine has crowded out its social responsibility to train for society's most basic health-care delivery needs. The main argument is that medical education's manifest humanistic mission is little more than a screen for the research mission that is the major thrust of the institution's social structure.

Education, Medical↗
PubMed2004

Curricular framework: core competencies in multicultural geriatric care.

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.

Aged↗
PubMed2000

Emergency medicine resident documentation: results of the 1999 american board of emergency medicine in-training examination survey.

OBJECTIVES: To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of patient care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instruction and formal didactic experience with this component of their curriculum. METHODS: A survey was conducted consisting of closed-ended questions investigating medical record documentation in the ED. The survey was distributed to all EM residents, EM-internal medicine, and EM-pediatrics residents taking the 1999 American Board of Emergency Medicine (ABEM) In-Training examination. Five EM residents and the Society for Academic Emergency Medicine (SAEM) board of directors prevalidated the survey. Summary statistics were calculated and resident levels were compared for each question using either chi-square or Fisher's exact test. Alpha was 0.05 for all comparisons. RESULTS: Completed surveys were returned from 88.5% of the respondents. A small minority of the residents code their own charts (6%). Patient encounters are most frequently documented on free-form handwritten charts (38%), and a total of 76% of the respondents reported using handwritten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record information for a patient evaluated in their ED within the previous 72 hours. Twenty-five percent "never" record their supervising faculty's involvement in patient care, and another 25% record that information "1-25%" of the time. Seventy-nine percent are "never" or "rarely" requested by their faculty to clarify or add to medical records for billing purposes. Only 4% of the EM residents were "extremely confident" in their ability to perform billing and coding, and more than 80% reported not knowing the physician charges for services or procedures performed in the ED. CONCLUSIONS: The handwritten chart is the most widely used method of patient care documentation, either entirely or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to overestimation of faculty noncompliance with HCFA billing guidelines. Emergency medicine residents are not confident in their knowledge of medical record documentation and coding procedures, nor of charges for services rendered in the ED.

Adult↗
PubMed2002

Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients.

OBJECTIVE: To describe the testing requirements and practices of emergency physicians (EPs) when conducting a medical screening examination of psychiatric patients. METHODS: An anonymous survey was developed and mailed to 500 EPs randomly selected through American College of Emergency Physicians membership rolls. RESULTS: Two hundred ninety surveys were returned (58%). Eighty-five percent of the respondents were male, 70% practiced in a community setting and 28% in an academic setting, 58% were emergency medicine (EM) residency-trained, and 88% were EM board-certified or board-eligible. Ninety-eight percent stated they were actively involved with the psychiatric medical screening exam (PMSE). Routine testing was required by 35% of the respondents, with 16% being required by ED protocol, and 84% by the psychiatrist/psychiatric institute. Of those with required testing, tests required were: complete blood cell count (56%), electrolytes (56%), serum alcohol (85%), serum toxicology screen (31%), urine toxicology screen (86%), electrocardiogram (18%), liver function test (16%), blood urea nitrogen (45%), and creatinine (40%). Many clinicians believed that certain tests were unnecessary as part of a PMSE. There was no statistical difference between the opinions of the physicians required to test and those not required to test in terms of which tests they thought were a necessary part of a PMSE regardless of the patient's clinical presentation. The EM-trained physicians were also found to be significantly less likely to think certain tests were necessary for the PMSE when compared with the non-EM-trained physicians. CONCLUSIONS: Routine testing was required as part of the medical screening examination of psychiatric patients for only one-third of the respondents. Few respondents believed that any of these tests were necessary. Emergency medicine-trained physicians were less likely to feel that routine testing was necessary.

Adult↗
PubMed2006

The Society for Academic Emergency Medicine's 2004-2005 emergency medicine faculty salary and benefit survey.

OBJECTIVES: To report on the sixth survey of the Society for Academic Emergency Medicine (SAEM) of emergency medicine faculty salaries, benefits, work hours, and department demographics for all programs accredited by the Residency Review Committee for Emergency Medicine (RRC-EM). METHODS: Data represent compensation paid for the 2004-2005 academic year. Responses were collected by SAEM, and blinded program and individual faculty data were entered into a customized version of a relational database program with a built-in statistical package. Salary data were sorted by criteria such as program region, faculty title, American Board of Emergency Medicine certification, academic rank, years since completing residency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria including department staffing levels, emergency department (ED) volumes, ED length of stay, department income sources, salary incentive components, research funding, and specific type and value of fringe benefits offered. Data were compared with previous SAEM studies. RESULTS: Sixty-one of 132 (46%) accredited programs responded, yielding data on 1,213 full-time faculty from all four AAMC regions. Mean salaries were reported as follows: all faculty, 189,848 dollars; first-year faculty, 153,855 dollars; programs reporting data to AAMC, 183,605 dollars; programs not reporting data to AAMC, 204,383 dollars; core faculty, 197,259 dollars; and noncore faculty, 164,215 dollars. Mean salaries as reported by AAMC region were as follows: Northeast, 192,864 dollars; South, 182,768 dollars; Midwest, 192,224 dollars; and West, 195,732 dollars. Full-time emergency medicine residency program faculty are reported to be working an average of 1,032 total clinical hours per year. Workweeks average 22 clinical hours per week and 22 nonclinical hours per week, with 5.1 weeks of time off per year. CONCLUSIONS: Reported salaries for full-time emergency medicine residency faculty continue to rise overall but fell for the first time in one region (the Midwest). Academic rank continues to correlate directly with salary. Fellowship training continues to show a negative correlation with salary. Significant regional differences in salaries have been present in all six SAEM surveys.

Emergency Medicine↗