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PubMed1984

Fifty years of medical specialty certification--role of the American Board of Medical Specialties.

Those who have had experience with the voluntary system of medical specialty certification will surely prefer it to an imposed bureaucratic type of control. Despite the deficiencies and problems associated with it, as Churchill noted about democracy: "It is the best that exists." Medical science and medical practice are constantly advancing and changing. With those changes it is reasonable to expect change in the specialty credentialing system. However, that change should be thoughtful, cautious, and should be made only in the best interest of the patients for whom we are responsible.

Certification↗
PubMed1990

Manpower needs in academic emergency medicine.

One of the value statements of the American College of Emergency Physicians states that, "Quality Emergency Medicine is best practiced by qualified, credentialed emergency physicians." To address this value ACEP has established the following goal: "The number of board-certified physicians will be sufficient to meet the manpower needs of the public." It is the position of ACEP that there is currently a severe shortage of appropriately trained and certified emergency physicians and, moreover, that the shortage will continue well into the next century. We discuss how ACEP arrived at this position and the role of academic emergency medicine in addressing this shortage. For many years, there has been a public debate as to whether there is a physician shortage or surplus. The Graduate Medical Education National Advisory Commission report of 1980 estimated that there would be 630,000 US physicians by 1990, with a surplus of 70,000. This report also identified emergency medicine as a shortage specialty, indicating there would be a need for 14,000 emergency physicians in 1990, with a supply of only 8,000. Schwartz included such factors as increased provision of administrative and research activity by physicians and concluded that there would be a shortage of 7,000 physicians by the year 2,000.

Certification↗
PubMed1986

A profile of emergency physicians 1984-1985: demographic characteristics, practice patterns, and income.

Emergency physicians (EPs) were profiled using data from a recent national survey of physicians. In addition, we compared EPs to other physicians on demographic and practice characteristics. EPs were younger than physicians in other specialties and were less likely to be foreign medical graduates or board certified. EPs were far more likely to be employed by hospitals and on salary. Their net income averaged $93,000 in 1983, although hospital employees had lower average incomes ($83,000) than did those employed by a corporation or self-employed in a group practice ($101,000). Compared to other specialties, their average income was higher than nonsurgeons, but still far below surgeons. While EPs and other physicians spent about 50 to 51 hours per week in medical activities, EPs saw more patients per hour. EPs saw more uninsured individuals. These results have implications for patient access, "entrepreneurism" in the specialty, and credentialing.

Adult↗
PubMed1997

Ultrasound-guided retrieval of small foreign objects in subcutaneous tissue.

STUDY OBJECTIVE: To identify the physical properties of the materials most easily located in subcutaneous tissue through the use of conventional ultrasound. METHODS: High-resolution real-time sonography was performed by a credentialed sonographer on a chicken breast impregnated with five objects-a metal paper clip, a wooden toothpick, a plastic coffee stirrer, a shard of glass, and an 18-gauge needle. Transducer frequencies ranging from 3.5 to 7.5 MHz with linear, curvilinear, and sector-scanning formats were used. All images were interpreted by a staff attending radiologist with other study authors present. The chicken breast was then subjected to radiography for comparison. RESULTS: Wood yielded the strongest acoustic shadow; plastic had the next-best acoustic shadowing. The 7.5-MHz probe yielded its best resolution at shallow depths, whereas the 5-MHz probe was best at greater depths. CONCLUSION: We conclude that ultrasonography is an excellent technique for the localization and retrieval of nonradiopaque foreign objects in the superficial subcutaneous tissue. It should be given consideration for use in the removal of nonradiopaque superficial foreign objects when conventional radiographic techniques are not effective.

Animals↗
PubMed1998

A study of the workforce in emergency medicine.

STUDY OBJECTIVE: Emergency medicine has progressed significantly since its initial recognition as a medical specialty. Relatively little factual information is known, however, regarding who or how many physicians practice emergency medicine. The purpose of this study is to determine the total number of physicians practicing clinical emergency medicine during a specified period, to describe certain characteristics of those individuals, and to estimate the total number of full-time equivalents (FTEs), as well as the total number of individuals needed to staff those FTEs. METHODS: Data were gathered from a survey of a random sample of 2,062 hospitals drawn from a population of 5,220 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, as well as the total number working during the period June 1, 1997, through June 14, 1997. Demographic data on the individuals were also collected. RESULTS: A total of 942 hospitals responded (a 45.7% return rate). These hospitals reported a total of 5,872 physicians were working during the specified period, or an average of 7.48 persons scheduled per institution. The physicians were scheduled for a total of 297,062 hours. The average standard for FTE was 40 clinical hours per week. This equates to 3,713 FTEs or 4.96 FTEs per institution. The ratio of persons to FTEs was 1.51:1. With regard to demographics, 83% of the physicians were men and 81% were white. Their average age was 42 years. As to professional credentials, 58% were emergency medicine-residency trained and 53% were board certified in emergency medicine; 46% were certified by the American Board of Emergency Medicine. CONCLUSION: Given that there are 4,945 hospitals with EDs and given that the data indicate there are 4.96 FTEs per ED, the total number of FTEs is projected to be 24,548 (standard error = 437). Given further that the data indicate a physician/FTE ratio of 1.51:1, we conclude that there are 36,990 persons (standard error = 683) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 32,026.

Adult↗
PubMed1998

Pediatric residents in the emergency department: what is their experience?

STUDY OBJECTIVE: We sought to describe the spectrum of illness and number of patients seen by pediatric residents rotating through a pediatric ED. METHODS: Our study was set in the ED of a 200-bed referral children's hospital providing services exclusive of major trauma. We conducted a retrospective review of the database of all visits to the ED between July 1992 and June 1995. Our subjects were 19 pediatric residents who started residency in July 1992 and ended residency in June 1995. Ninety-one other pediatric residents completed individual ED rotations during the same period. RESULTS: The study ED had 70,129 visits between July 1, 1992, and June 30, 1995. The study residents saw a median of 467 patients per resident (range, 290 to 604) during their 3-year residencies. The range of patients seen per resident for the diagnosis of asthma was 35 to 86, that for otitis media was 16 to 110, and that for fever or sepsis was 17 to 62. Similarly large ranges were seen for other diagnoses evaluated and procedures performed by residents. The proportions of the study residents who never saw a case of pyloric stenosis, intussusception, or diabetic ketoacidosis in the ED were 37%, 32%, and 32%, respectively. CONCLUSION: The number and type of patients seen by individual residents in this study showed significant variation. Many illnesses were not seen frequently enough for every resident to develop competence solely on the basis of clinical experience during ED rotations. A computerized, easily accessible ED database can be used to track the experience of individual residents or groups of residents. Such tracking would allow residents and program directors to identify areas that may require alternate educational strategies and would also document the residents' experience for future credentialing.

Child, Preschool↗
PubMed1998

Supporting emergency medicine research: developing the infrastructure.

The long-term goals of developing research within the specialty of emergency medicine include the following: (1) to continue to improve the quality and quantity of emergency patient care; (2) to maximize the research potential of emergency health care professionals to develop new emergency research talent and enthusiasm; and (3) to establish the academic research credentials of the specialty of emergency medicine to become competitive for federal research funding, and further improve emergency patient care. This article addresses the process by which the infrastructure for emergency medicine research can be developed at academic medical centers and provides recommendations. The roles of the academic chair, research director, senior researcher, and departmental faculty are discussed.

Academic Medical Centers↗
PubMed1999

Rapid oral hydration results in hydronephrosis as demonstrated by bedside ultrasound.

STUDY OBJECTIVE: To determine whether vigorous oral hydration (20 mL/kg) causes hydronephrosis as determined by bedside ultrasound. METHODS: We conducted a prospective laboratory trial in 35 healthy volunteers weighing less than 90 kg and between the ages of 18 and 50 years. The right kidney of the volunteers was scanned by emergency physicians at time 0 both before and after voiding, and the volunteers then drank 20 mL/kg of bottled water. The kidney was scanned in the transverse and sagittal planes both before and after voiding at 60 and 90 minutes after completion of the water load. The scans were interpreted by a physician trained and credentialed in emergency ultrasound, blinded to the volunteers' identity, the time of the scan, and the volume of urine voided by the subject. Images were rated as to the degree of hydronephrosis according to literature-established criteria, as follows: grade 0=no hydronephrosis, grade 1=mild, grade 2=moderate, and grade 3=severe hydronephrosis. RESULTS: Hydronephrosis was present in 3 (8.6%) of the 35 subjects at time 0 (prehydration), 24 (68.6%) at 60 minutes, and 20 (57.1%) at 90 minutes. Overall, hydronephrosis occurred at least once in 28 (80%) of the 35 subjects after oral hydration compared with 3 (8.6%) of the 35 subjects before hydration. Hydronephrosis was found to be significantly related to forced hydration for all posthydration times (60 minutes, 90 minutes, and 60+90 minutes combined) versus prehydration time 0 (P <.001). CONCLUSION: Without prior fluid intake, even mild degrees of hydronephrosis were relatively uncommon, and seen in only 8.6% of study patients. In the presence of vigorous oral hydration, however, mild or moderate hydronephrosis is a frequent occurrence seen at least once in 80% of our study of healthy volunteers after hydration. Caution is warranted in this setting when interpreting mild or moderate hydronephrosis found on bedside ultrasound by emergency physicians.

Adolescent↗
PubMed2004

[Analysis of the relationship between primary care doctors and the pharmaceutical industry].

OBJECTIVES: To describe the type of relationship between primary care family doctors (PCDs) and the pharmaceutical industry (PI) and its representatives in Aragon, to describe doctors' attitudes to this relationship and to find out how doctors behave towards offers from the industry. DESIGN: Descriptive cross-sectional study, through a self-filled questionnaire with closed replies, of a representative sample of the population under study. SETTING AND PARTICIPANTS: Family doctors working in primary care teams throughout Aragon. RESULTS: The reply rate of 28.17% maintained the study's representativity. Differences in the kind of relationship between PCDs and PI were found in gender (greater relationship of male doctors) and setting (it was greater in urban areas). Doctors working in centres with teaching credentials and woman doctors had a more critical attitude. The tendency to collaborate with the industry's offers was greater in the rural areas and among men. The group of doctors that interacted most with the industry tended to collaborate more with the proposals of the PI. No relationship was found between attitude and conduct of PCDs. CONCLUSIONS: Results confirm both the starting hypotheses: a) the nature of relationships between PCDs and the PI and its representatives affects prescribing behaviour, and b) there are differences between what doctors think they should do and what they really do in their dealings with the PI.

Attitude of Health Personnel↗
PubMed2003

Management and leadership: a dual role in nursing education.

The purpose of this paper is to review the dual concepts of leadership and management in nursing education. It provides a consideration of caring as the end purpose of nursing education and argues that empowered caring makes use of professional academic credentials to form collaborative alliances that influence health care delivery. Inspiring and empowering leadership also transform educational services. In particular the key issues of investing in technology, supporting life long learning and creating a community workplace are addressed. It concludes with the suggestion that the nurse education ought to be led and managed differently.

Curriculum↗
PubMed2004

Social class and self-reported health status among men and women: what is the role of work organisation, household material standards and household labour?

Social class understood as social relations of ownership and control over productive assets taps into parts of the social variation in health that are not captured by conventional measures of social stratification. The objectives of this study are to analyse the association between self-reported health status and social class and to examine the role of work organisation, material standards and household labour as potential mediating factors in explaining this association. We used the Barcelona Health Interview Survey, a cross-sectional survey of 10,000 residents of the city's non-institutionalised population in 2000. This was a stratified sample, strata being the 10 districts of the city. The present study was conducted on the working population, aged 16-64 years (2345 men and 1874 women). Social class position was measured with Erik Olin Wright's indicators according to ownership and control over productive assets. The dependent variable was self-reported health status. The independent variables were social class, age, psychosocial and physical working conditions, job insecurity, type of labour contract, number of hours worked per week, possession of appliances at home, as well as household labour (number of hours per week, doing the housework alone and having children, elderly or disabled at home). Several hierarchical logistic regression models were performed by adding different blocks of independent variables. Among men the prevalence of poor reported health was higher among small employers and petit bourgeois, supervisors, semi-skilled (adjusted odds ratio-aOR: 4.92; 95% CI: 1.88-12.88) and unskilled workers (aOR: 7.69; 95%CI: 3.01-19.64). Work organisation and household material standards were associated with poor health status with the exception of number of hours worked per week. Work organisation variables were the main explanatory variables of social class inequalities in health, although material standards also contributed. Among women, only unskilled workers had poorer health status than the referent category of manager and skilled supervisors (aOR: 3.25; 95%CI: 1.37-7.74). All indicators of work organisation and household material standards reached statistical significance, excepting the number of hours worked per week. In contrast to men, among women the number of hours per week of household labour was associated with poor health status (aOR: 1.02; 95% CI: 1.01-1.03). Showing a different pattern from men in the full model, household material deprivation and hours of household labour per week were associated with poor health status among women. Our findings suggest that among men, part of the association between social class positions and poor health can be accounted for psychosocial and physical working conditions and job insecurity. Among women, the association between the worker (non-owner, non-managerial, and un-credentiated) class positions and health is substantially explained by working conditions, material well being at home and amount of household labour.

Adolescent↗
PubMed2000

[Continuous practice and advanced training in interventional cardiology. Recommendations for the assessment and maintenance of proficiency in interventional cardiology. A statement for physicians and advanced training units from the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology].

This report reflects the interest of the Section of Hemodynamics and Interventional Cardiology of the Spanish Society of Cardiology in increasing quality, safety and applicability of percutaneous procedures, by giving scientific keys aimed at improving related functions of teaching or planning in this field and enhancing competence and prestige of Spanish interventional cardiologists. The purpose of the document is to describe the importance of current interventional cardiology, to identify quality references and to establish minimum acceptable requirements for assessing and maintaining the competence of practicing or providing advanced training in this discipline. To achieve this goal, a search for a gold standard of the different techniques of general interventional practice was carried out, and predictors of postprocedural outcome were analyzed, as well as their relation with different kinds of circumstances. This analysis identified coronary angioplasty as the standard on which recommendations regarding competence in overall interventional cardiology standards of quality and assessment and maintenance of proficiency must be based. On the other hand, the strong influence of experience and knowledge of results has been documented, especially in high-risk or high-complexity settings. On this basis, the report establishes specific recommendations about proficiency for practice and advanced training. It also suggests that interventional cardiology should be considered as a subspecialty, of cardiology requiring specific credentials.

Cardiology↗
PubMed2000

An anatomical and photographic technique for forensic facial identification.

The increase in the use of photographs on individual identification credentials such as driving licences, credit cards, security passes and passports has led, for the purpose of criminal activities, to the falsification of genuine documents bearing photographs of the perpetrating criminal. These photographs may be used as valuable physical evidence when compared with known photographs of a suspect as they form somewhat of a signature of the suspect that is left behind on the evidence. The comparison of ID photographs requires the cooperation of two predominantly visual disciplines; forensic photography and morphological anatomy. This paper describes a photographic technique which allows accurate anatomical measurement and tracing of facial features, which allows direct physical comparison of ID document images.

Anthropometry↗
PubMed1999

Expert witness testimony: An update.

This update provides an overview of the current state of expert witness testimony regarding malpractice cases. Many trials are reduced to a battle of the experts and many physicians advertise their credentials and expertise in hopes of attracting lucrative cases. This article focuses on what constitutes an expert witness, medical organizations oversight, the peer review process, and physician immunity.

Expert Testimony↗
PubMed2000

Treating substance abuse in the context of severe and persistent mental illness: clinicians' perspectives.

Patients with comorbid substance use and major mental disorders are treated frequently in the mental health system. Treatment models relevant for this subset of patients have emerged in recent years, however, few have been validated empirically and so relatively few sites benefit from this treatment development activity. Important additional sources of information about good treatment practices are the clinicians who have adopted the treatment of patients with dual disorders as a specialty. We conducted four focus groups (N = 12) with clinicians who were nominated by their peers as experienced and/or expert in treating persons with comorbid substance use and psychiatric disorders. Discussions followed a four-part outline that included (a) general questions about training and experience with the population, (b) preferred treatment methods, (c) motivational issues, and (d) recommendations to the field. Participants were trained in a variety of mental health disciplines and pursued substance abuse treatment credentials or other educational experiences outside of their primary training programs. Their treatment approaches emphasized psychoeducation, a good therapeutic relationship, and the need to be flexible regarding methods and goals. Abstinence was the preferred goal among most clinicians; even so, they expressed a pragmatic flexibility and other views consistent with the principles of harm reduction. Clinicians tended to respond to patients' ambivalent motivational states by addressing the consequences of behaviors in a nonconfrontive style; they also made use of positive incentives and external support. A number of recommendations were made to improve treatment, including greater institutional and programmatic support for the unique needs of this population.

Adult↗
PubMed2002

Characteristics, beliefs, and practices of community clinicians trained to provide manual-guided therapy for substance abusers.

The successful dissemination of empirically supported addiction therapies to community providers requires an appreciation of the characteristics of those practitioners who might be willing participants in this process of technology transfer. Clinicians (N = 66) from 11 community treatment programs associated with six research-clinic partnerships of the National Drug Abuse Clinical Trials Network volunteered to be trained in Motivational Interviewing or Motivational Enhancement Therapy (MET/MI) and were assessed prior to training. The sample of clinicians was heterogeneous in education and credentials, had a high level of counseling experience, reported using a wide range of counseling techniques and orientations, but had limited prior exposure to MET/MI or to the use of treatment manuals of empirically supported therapies. In general, many of the clinicians reported beliefs and techniques that were consistent with their stated theoretical orientation and recovery status. Relatively few participants reported relying on one dominant orientation or set of techniques.

Adult↗
PubMed2004

Cumulative sum failure analysis of the learning curve with endovascular abdominal aortic aneurysm repair.

PURPOSE: The purpose of this study was to evaluate the importance of experience and the learning curve with endovascular abdominal aortic aneurysm (AAA) repair. METHODS: A retrospective analysis was performed of all elective endovascular AAA repairs attempted by an individual surgeon and radiologist over a 4-year period. The primary outcome variable was achievement and 30-day maintenance of initial clinical success as defined by the Society for Vascular Surgery/American Association of Vascular Surgery reporting standards. Following standard statistical analysis, the cumulative sum (CUSUM) method was used to analyze the learning curve, with a predetermined acceptable failure rate of 10% and calculated 80% alert and 95% alarm lines. RESULTS: Ninety-six elective endovascular AAA repairs were attempted by this team between 1998 and 2002 (mean age 74 +/- 0.8 years; mean aneurysm diameter 5.98 +/- 0.8 cm). Initial clinical success was achieved and maintained in 85 of 96 patients (88.5%). Although results were acceptable throughout the study period, improved results with respect to the target failure rate (10%) were not achieved until 60 patients were treated. The learning or CUSUM curves did not differ for different device manufacturers, with improved results being achieved following 20 implantations of each device. The results did differ when comparing aortouniiliac grafts (n = 27) and bifurcated grafts (n = 64). Results with bifurcated grafts remained consistent throughout the study period, whereas with aortouniiliac grafts, results improved after only a few procedures in comparison with the target failure rate. CONCLUSION: Success rates with endovascular aneurysm repair will improve with an individual's experience. The CUSUM method is a valuable tool in the evaluation of this learning curve, which has credentialing and training implications. Although acceptable results were obtained throughout the study period, this analysis indicates that 60 endovascular aneurysm repairs, or 20 with an individual device, are necessary before optimal rates of initial clinical success can be achieved. These results can be achieved more readily with aortouniiliac grafts than with bifurcated grafts.

Aged↗
PubMed1996

A program of operative angioplasty: endovascular intervention and the vascular surgeon.

PURPOSE: Vascular surgeons are ideally suited to select and perform endovascular interventions either as primary therapy or as an adjunct to bypass surgery. Attaining proficiency in endovascular techniques is an important goal in the training of vascular surgeons. We report our initial experience with a program of endovascular intervention performed in the operating room by vascular surgeons. METHODS: During the previous three years, we performed 109 angioplasty procedures, 60 aortoiliac (55%), 32 femoropopliteal (29%), and 17 popliteal/tibial (16%), using guidewires and angioplasty balloons directed by intraoperative digital subtraction C-arm arteriography with road-mapping capabilities. Indications for angioplasty included disabling claudication in 59 patients (54%), rest pain in 18 (17%), and tissue loss in 32 (29%). Angioplasty was accompanied by stent placement in 39 of 60 aortoiliac procedures (65%) and in two of 32 femoral procedures (6%). In 16 cases (15%), the endovascular procedure was performed in conjunction with a bypass procedure. In selected cases (15, 14%), duplex scanning was the sole diagnostic method used before surgery to identify the lesion, eliminating the need for preoperative arteriographic scans. Segmental pressure measurements, duplex ultrasound scans, and treadmill exercise testing as indicated were performed before and after surgery. The efficacy of the endovascular intervention was assessed at 3-month intervals during the first year and at 6-month intervals thereafter. RESULTS: A successful results was defined using criteria recommended by the Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures from the Society for Vascular Surgery/International Society for Cardiovascular Surgery. This included the combination of symptomatic improvement, obtaining an anatomically successful result with < 30% residual lumen stenosis, and elimination of the translesion gradient with an improvement in high thigh-brachial index or ankle-brachial index greater than 0.15. Initial success was achieved in 55 of 60 aortoiliac (92%), 28 of 32 femoropopliteal (88%), and 16 of 17 popliteal/tibial (94%) angioplasty procedures. Clinical follow-up has been achieved in all cases, with continued clinical success rates of 80%, 75%, and 82% for aortoiliac, femoropopliteal, and popliteal/tibial angioplasty procedures, respectively, with a mean follow-up of 15.7 months. CONCLUSION: These results confirm the value of a program in which C-arm technology was used by vascular surgeons in the performance of angioplasty and stenting procedures in the operating room. This experience in therapeutic endovascular intervention will facilitate the credentialing process for future vascular surgeons.

Aged↗