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PubMed2002

End-of-life care education in internal medicine residency programs: an interinstitutional study.

BACKGROUND: Integrating end-of-life care (EOL) education into medical residency programs requires knowledge of what programs currently teach and what residents learn. OBJECTIVE: Evaluate EOL teaching content and practices in internal medicine residency programs and the EOL knowledge of their faculty and residents. DESIGN: An interinstitutional pilot study. We examined patterns of EOL education, discerned from program directors' responses to structured surveys of institutional teaching and evaluation practices, and EOL knowledge, derived from the performance of faculty and residents on a 36-item knowledge examination. SUBJECTS: Program directors, faculty, and residents at 32 accredited U.S. internal medicine residency programs. RESULTS: Although all programs cited inclusion of some EOL education, expected EOL domains were not systematically taught or assessed. Pain assessment and treatment training was required in only 60% of programs. Even fewer programs required instruction on nonpain symptoms (<30%) or hospice and nonhospital care settings (22%). EOL assessment depends primarily on faculty's general ratings of residents' global competency; few programs use knowledge examinations or structured skill assessments. Directors identified barriers and support for improving education. On the knowledge examination, the mean score of residents increased across training levels (F = 21.7, p < .001), and the mean score of faculty was higher than residents' (57.6%: 48.9%, t = 51.6, p < .001). CONCLUSIONS: Existing internal medicine residency education lacks training in critical EOL care domains. Residency programs need additional training for residents and teaching faculty in EOL content and skills, with assessment practices that demonstrate competencies have been acquired. Program directors perceive institutional support for making these changes.

Analysis of Variance↗
PubMed2001

Beyond pharmaceutical manufacturer assistance: broadening the scope of an indigent drug program.

A medication assistance program at a university medical center is described. The program was implemented in July 1999 by the ambulatory care pharmacy at the University of Illinois at Chicago Medical Center (UICMC). A full-time pharmacist and a full-time social worker run the program, along with support from technicians and a student extern. The program functions like a clinic, with both scheduled appointments and drop-ins. Patients are referred by UICMC providers or may self-refer. Sources of assistance include Medicaid, Medicare Part B, several state programs, manufacturers' programs, drug samples, private insurance plans and HMOs, and the patients themselves in the form of small payments. Patients receive medications at UICMC's expense only as a last resort. The medication assistance program helped 231 patients in the six months from July to December 1999. Program costs totaled $110,537, but $237,985 was saved. Only 13% of the savings came from pharmaceutical companies; 63% came from Medicaid. Experience with the program suggests that medication assistance initiatives should be structured to tap the full spectrum of resources for indigent patients, that programs be staffed by personnel with relevant experience, that program staff be prepared to work closely with patients and to follow up, and that the institution's charitable goods and services be restricted to patients for whom there are no other resources. A highly proactive medication assistance program at a university medical center improves the access of indigent patients to medications and is cost-effective.

Academic Medical Centers↗
PubMed2003

MD/MBA programs in the United States: evidence of a change in health care leadership.

PURPOSE: Managerial sciences are playing an increasingly prominent role in the organization and delivery of health care. Despite popular media reports that a rising number of physicians are acquiring a background in this discipline through MD/MBA (medical and master of business administration) programs, no recent study has verified this. This study measured changes in the number and nature of the affiliations between management and medicine in the form of MD/MBA programs in the United States. METHOD: Surveys of admission officers of 125 U.S. allopathic medical schools and of the overseers of each joint MD/MBA degree program were administered in May-October 2001. Main outcome measures included program growth, curriculum and degree requirements, application and admission requirements, and program leadership and organization. RESULTS: The number of MD/MBA programs grew from six to 33 between 1993 and 2001, and 17 more medical schools were considering establishing the joint-degree program. Ten, 15, and 20 programs produced 27, 42, and 61 graduates in 1999, 2000, and 2001, respectively, and over 100 students were expected to graduate per year when all 33 programs matured. Program structures and oversight indicate a spectrum of philosophies regarding the appropriate level of integration of the two degrees. MD/MBA programs apparently attempt to complement medical education with management education rather than the converse. CONCLUSIONS: The growth in the numbers of MD/MBA programs and participants indicates rising cooperation between medical and business schools and increasing interest in management education early in the careers of graduating physicians.

Career Choice↗
PubMed1986

Visiting clinician program in primary care internal medicine.

As part of a primary care internal medicine training program, a visiting clinician program was created to improve house staff education, provide an ongoing critique of the training program, and improve communication between program faculty and other institutions. Thirty-one visitors participated in the program during the two years covered by this report. The visitors were effective teachers, and residents noted that teaching by local faculty improved because the visitors demonstrated effective teaching techniques. Visitors made 337 suggestions to improve the primary care medicine program. A telephone survey after the visit indicated that more than half of the visitors had applied ideas from the host institution to their own programs. The program enhanced resident education, provided a periodic review of the training program, and fostered communication with faculty in other programs. The program's evolution over the two years is reported and suggestions are offered for institutions planning similar programs.

Evaluation Studies as Topic↗
PubMed1987

Design and evaluation of a back injury prevention program within a geriatric hospital.

Two phases of a back injury prevention program were studied using 2035 accident reports filed between 1979 and 1984. Phase 1, Personnel Program, was designed to decrease the duration of wage-loss claims by increasing the effectiveness of the existing procedures used to process these claims. This program significantly lowered the proportion of high-hour claims (P less than .05) and significantly reversed a trend of increasing accident rates (P less than .05). Phase 2, Back Program, was designed to lower the incidence of back injuries through a feedback-oriented educational program. The Back Program itself could not demonstrate a significant reduction in back injuries primarily due to the powerful and confounding effect of the Personnel Program. The combination of the Personnel Program and the Back Program significantly lowered back injuries for nurses when compared with a similar group of injuries that occurred at geriatric hospitals (P less than .001). The large effect of the Personnel Program and the small effect of the Back Program have design implications for any injury prevention program.

Aged↗
PubMedDate not supplied

Attendance and graduation patterns in a group-model health maintenance organization alternative cardiac rehabilitation program.

PURPOSE: Poor rates of participation in cardiac rehabilitation programs are well documented, especially among women and older patients. The Colorado Kaiser Permanente Cardiac Rehabilitation (KPCR) program is a home-based, case-managed, goal-oriented program with an active recruitment process and unlimited program length. This study evaluated the participation rates for the program and the predictors of attendance and graduation. METHODS: Patients hospitalized with acute myocardial infarction, coronary artery bypass graft, and percutaneous coronary intervention from June 1999 to May 2000 (n = 1030) were identified from the administrative database, and the proportion captured by the KPCR staff was determined. Subsequent attendance and graduation patterns were evaluated. RESULTS: Nearly 94% of patients with one of the three aforementioned conditions were identified by the rehabilitation staff, and 41% of all patients attended the KPCR program. More than 75% of the patients who participated went on to graduate from the program. Gender comparisons showed no difference in participation between men (66.8%) and women (59.7%) (P =.07). Participation rates were inversely associated with age, yet age was not associated with graduation from the program. Surgical interventions and two or more events experienced within the first 4 weeks of the index event were the strongest predictors of attendance and graduation from the KPCR program. CONCLUSIONS: Innovative approaches for the capture and retention of patients in cardiac rehabilitation programs are urgently needed. The alternative program evaluated in this study showed little difference in participation between men and women, yet participation among older patients remained poor. Overall, patients who underwent surgical interventions or multiple events were more likely to attend and graduate from the program.

Age Distribution↗
PubMed2006

Abortion training in United States obstetrics and gynecology residency programs.

OBJECTIVE: To identify characteristics of programs which provide training in abortion, to calculate the number of procedures done during training, and to compare the availability of abortion training in 2004 with that of prior national surveys. METHODS: An investigator-designed questionnaire about abortion training in obstetrics and gynecology residency programs was mailed to all U.S. residency directors. Collected data included program information, abortion training, and numbers of residents trained. Data were analyzed to estimate differences in abortion training by region, program size, and type of training offered. RESULTS: Of the 252 questionnaires mailed, 185 (73%) were returned. Of the 185, 94 (51%) program directors reported routine instruction in elective abortion, 72 (39%) optional training, and 19 (10%) no training. Large programs and programs located in the Northeast and West Coast were significantly more likely to offer routine training in terminations (P < .01). In the programs offering routine training, more than 50% of residents received instruction in termination practices. Of those practices, the most common were first-trimester surgical abortion (85% of programs), followed by medical abortion (59%), second-trimester induction (51% of programs), and dilation and extraction (36%). As compared with those in programs with optional training, residents in programs with routine training were significantly more likely to receive instruction in all modalities of abortion provision and performed proportionally more first- and second-trimester terminations (P < .01). CONCLUSION: Routine training in elective abortion resulted in greater exposure to abortion practices and greater experience in more complicated abortion techniques during residency.

Abortion, Therapeutic↗
PubMed2005

Resident research and scholarly activity in internal medicine residency training programs.

OBJECTIVES: 1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs. DESIGN: Cross-sectional mailed survey. SETTING: ACGME-accredited internal medicine residency programs. PARTICIPANTS: Internal medicine residency program directors. MEASUREMENTS: Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared. MAIN RESULTS: The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P=.04) and present at local or regional meetings (median, 25% vs 20%; P=.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P=.75) and present nationally (median, 10% vs 5%; P=.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P<.001) and resident interest (55% vs 40%; P=.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%). CONCLUSIONS: Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.

Adult↗
PubMed1999

Perceptions of pediatric emergency medicine fellows and program directors about research education.

UNLABELLED: Pediatric emergency medicine (PEM) fellows who entered training after January 1995 are required to complete three years of fellowship training. Additionally, they are required to receive instruction in related basic sciences and to demonstrate research competence. OBJECTIVES: To determine: 1) whether PEM fellows and program directors perceive their programs as providing adequate training in research principles, 2) the manner in which these principles are taught, and 3) the commitment of fellows and program directors to research and research training. METHODS: Pediatric emergency medicine fellows who participated in the Fourth Annual PEM Fellows Conference (Miami, Florida, March 1997) were surveyed. The survey was then extended via mail to all PEM fellows and program directors in the United States and Canada. RESULTS: A total of 159 of the 220 fellows (72%) in the United States and Canada returned completed questionnaires. Fifty-three of 70 PEM fellows (76%) who attended the conference completed questionnaires, and 106 of 167 fellows (63%) who did not attend the conference responded by mail. Fifty-three of the 63 program directors (84%) returned completed questionnaires. Of 159 responding fellows, 86 (54%), and of 53 responding program directors, 29 (58%) reported that their programs lacked adequate training in one or more of the surveyed research areas. Thirteen program directors (25%) reported no formal research training in their curricula. Programs that included formal research training were perceived to have higher overall quality than programs that failed to offer such formal training. Sixty-six of 158 responding fellows (42%) anticipated an ongoing commitment to research in their careers. One hundred fourteen of 153 responding fellows (75%) indicated that, if given the option, they would have pursued a two-year "clinical track" PEM board certification that did not include a research requirement. CONCLUSIONS: More than half of surveyed PEM fellows and program directors perceived important deficiencies in research education within their training programs. Further research is necessary in order to evaluate the validity of these perceptions.

Attitude of Health Personnel↗
PubMedDate not supplied

A comparison of hospice programs based on Medicare certification status.

This article presents results from a study of 119 hospice programs in the United States. Personal interviews and questionnaires were utilized to collect data about hospice programs, their directors, nurses, social workers, and chaplains. Specifically, this article describes reasons programs sought Medicare certification, and the perceived advantages and disadvantages to being a Medicare certified program. Characteristics of both certified and non-certified programs are presented, and examined for differences. Potential access barriers such as restrictive admission criteria are examined in this article. Finally, perceptions of staff about hospice services in certified and non-certified programs are compared. Results from this study indicate that Medicare certified programs have longer lengths of stays, were more likely to include a nurse on the first visit, and billed patients more frequently than noncertified programs. Volunteer use was lower in the Medicare certified programs. Staff in Medicare certified programs were much more likely to view patients' medical needs as the primary focus of their programs. Results from this study suggest that Medicare certified programs may reflect a more medical model of palliative care.

Certification↗
PubMed1993

Development of level of institutionalization scales for health promotion programs.

This study was conducted to test an instrument for measuring the level of institutionalization (LoIn) of health promotion programs. Institutionalization occurs when a program becomes an integral part of an organization, and the LoIn instrument is a beginning effort to measure the extent of program integration into organizations. The instrument is based on theory that holds that organizations are composed of production, maintenance, supportive, and managerial subsystems. Institutionalization occurs when a program becomes imbedded into these subsystems. A questionnaire designed to test this construct was mailed to 453 administrators in 141 organizations that operate health promotion programs. Based on 322 usable responses (71%), a confirmatory factor analysis was conducted. The results support the hypothesis of an eight-factor model: four factors concern how routinized the program was in each subsystem and four factors concern the degree of program saturation within each subsystem. Correlations of the eight factors with the number of years the programs had been in operation, and managers' perceptions of program permanency, indicated that the four routinization factors were more highly correlated with program longevity than the four niche saturation factors, and the niche saturation factors were more highly correlated with managers' perceptions of program permanence than the routinization factors. The instrument, which is available from the authors, may be used as both a research instrument and a diagnostic tool in assessing the institutionalization of health promotion programs.

Community Health Services↗
PubMed1986

Comparisons of perceptions of the environments of adolescent drug treatment residential and outpatient programs by staff versus clients and by sex of staff and clients.

The Moos Community Oriented Program Environment Scale (COPES) was administered to 482 adolescent clients and 291 drug counselors in 30 outpatient and 27 residential drug treatment programs. Both clients and staff of residential programs were found to rate their programs more positively than did clients and staff of outpatient programs in the following specific ways: "encourage and provide more support"; "provide more practical help", such as training; "more concern with clients' personal problems"; and "encourage clients to argue, express anger, and display aggressive behavior". The only COPES factor on which the outpatient programs were perceived as superior to residential programs was "spontaneity" ("The program encourages clients to act openly and to express their feelings openly"). Across both types of programs, staff perceived the programs significantly more positively than did clients. The male staff ratings were the most positive of the ratings of the four subgroups. Female clients rated the program environments more positively than did male clients, but female staff did not rate the program environments more positively relative to male staff. Since the female staff ratings tend to be somewhat more similar to the ratings of the clients, both male and female, than did the male staff ratings, it might seem reasonable to hypothesize that the female staff ratings are more valid than the male staff ratings.

Adolescent↗
PubMed2005

Efficacy of Ovsynch program on reproductive performance in dairy cattle: a meta-analysis.

The efficacy of the Ovsynch program in improving conception and pregnancy rates was compared with untreated controls and other synchrony programs in lactating dairy cows. This meta-analysis examined 71 treatment and control comparisons extracted from 53 research papers. Programs evaluated included Ovsynch, natural breeding, single, double, or triple prostaglandin injections, Select Synch, Heat Synch, and modified Ovsynch. Pregnancy rates for Ovsynch programs did not differ significantly from those with natural breeding programs [predicted Bayesian relative risk (RR) = 1.04, 95% Bayesian credible interval = 0.36 to 3.23]. Results of Ovsynch vs. PGF(2alpha) programs showed that the risk of conception (predicted Bayesian RR = 0.89, 95% Bayesian credible interval = 0.31 to 2.64), and pregnancy rates predicted Bayesian RR = 1.11, 95% Bayesian credible interval = 0.61 to 2.13) did not differ significantly between the Ovsynch group and cows in the PGF(2alpha) group. Comparisons between Ovsynch and Select Synch demonstrated that the risk of conception (predicted Bayesian RR = 0.94, 95% Bayesian credible interval = 0.52 to 1.59), and pregnancy rates (predicted Bayesian RR = 1.08, 95% Bayesian credible interval = 0.38 to 3.09) did not differ significantly between the 2 groups. Examination of Ovsynch vs. modified Ovsynch programs showed that the risk of pregnancy in cows synchronized with modified Ovsynch was similar to those treated with Ovsynch (predicted Bayesian RR = 0.89, 95% Bayesian credible interval = 0.71 to 1.12).Meta-analyses identified that the conception and pregnancy rates obtained with the prostaglandin, Select Synch, and modified Ovsynch (including presynch and CoSynch) programs were comparable with the Ovsynch program. Modifications to the Ovsynch program such as presynchronization and timed artificial insemination at the time of second GnRH injection (CoSynch) may be an alternative for reproductive management of dairy herds where detection of estrus is less than optimal. The findings of this study demonstrate that the Ovsynch program could benefit dairy operations because it allows for timed artificial insemination of lactating cows without detection of estrus. There was, however, little or no significant improvement in pregnancy rates using Ovsynch over other programs and the costs of labor and hormone administration should be considered when selecting this form of reproductive technology for routine use.

Animals↗
PubMed2006

Benefits of cooperation between breeding programs in the presence of genotype by environment interaction.

Dairy cattle breeding programs and dairy farmers are selecting sires and dams across environments. Genotype x environment interaction (G x E) limits the possibilities for cooperation between breeding programs operating in different environments. The objectives of this study were 2-fold: 1) to investigate the effects of heritability, selection intensity, number of progeny per bull, and size of breeding programs on possibilities for cooperation between dairy cattle breeding programs in the short and long term in the presence of G x E, and 2) to quantify the effect of such cooperation on genetic gain. A dairy cattle situation with 2 breeding programs operating in 2 environments was simulated using a deterministic pseudo-BLUP selection index model. Long-term cooperation between the 2 breeding programs was possible in the presence of G x E, when the genetic correlation was higher than 0.80 to 0.90, resulting in up to 15% extra genetic gain. In addition, in the initial generations of selection, the breeding programs could benefit from mutually selecting sires and dams from each other when the genetic correlation was as low as 0.40 to 0.60. With more intense selection, breeding programs were less likely to benefit from cooperation with breeding programs in other environments. Heritability and number of progeny per bull had little effect on possibilities for cooperation, unless the heritabilities and the number of progeny per bull were extremely different in the 2 environments. Small breeding programs benefited more from cooperation than did large breeding programs, and benefits were possible even at lower values (i.e., <0.80) of the genetic correlation. Possibilities for cooperation across environments would affect the optimal design of dairy cattle breeding programs considering genetic gain, inbreeding, and costs.

Animals↗
PubMed2004

[A meta-analysis of the effects of smoking prevention programs in Korea].

PURPOSE: The purpose of this paper was to describe the characteristics of smoking prevention programs in Korea, to estimate overall effect size of Korean smoking prevention programs, and to investigate effect size variations by program modality and instruction method. METHOD: Meta-analysis was performed on 21 programs in 20 studies. RESULT: The estimation of overall effect size for knowledge and attitude was not possible because effect sizes were not homogeneous in this meta-analysis. However, effect sizes of studies that were socially influential programs or active/interactive methods were larger than information-oriented programs or passive/non-interactive methods in the pictures. The effects for behavioral outcomes were generally not as positive and not statistically significant. Q statistics showed that variations among effect sizes within program modality and instruction method classifications were heterogeneous. CONCLUSION: The results from this meta-analysis support the continued use of socially influential programs and active/interactive methods for smoking prevention programs. Because behavioral effect might be the fundamental objective of smoking prevention programs, the present results indicate that smoking prevention programs should consider adopting more effective programs.

Health Promotion↗
PubMed2000

Recruitment behavior and program directors: how ethical are their perspectives about the match process?

OBJECTIVE: This study examined family practice residency directors' perspectives on the 1999 National Resident Matching Program (NRMP) process and identified directors' expectations for students' recruitment behavior. METHODS: Subjects were the family practice residency program directors. A 22-item written questionnaire was mailed to each director. The questions related to the directors' perceptions of the following issues: applicants interviewing in more than one specialty, communication initiated by programs or applicants, commitments made to applicants and by applicants, ethical dilemmas faced by the program director, and the NRMP process itself. Descriptive statistics were reported. RESULTS: Only a few of the residency program directors (9.1%) felt that it was ethically wrong for an applicant to interview in more than one specialty. However, most program directors (83%) indicated that the knowledge of an applicant interviewing in more than one specialty had a "significant" negative or "some" negative effect on the applicant's rank order. Ninety-five percent of program directors indicated that they engage in follow-up communication with applicants following the formal interview. Almost all program directors (98%) reported that at least some applicants contact them following the formal interview to inform them that the program was a "high" or No. 1 rank-order choice. The majority of program directors (94%) felt that the NRMP process placed their program in the position of having to be dishonest with applicants to match their top choices. CONCLUSIONS: The results of the study indicate that the actions of many program directors and applicants may not be consistent with the written policies of the NRMP.

Administrative Personnel↗
PubMed2000

[Current nutrition supporting programs of the population in the USA].

In this work main programs of nutrition-supporting in the USA were presented as a part of national and local social and health policy. Following programs were reviewed namely: FSP (The Food Stamp Program), NSLP (The National School Lunch Program), SBP (School Breakfast Program), SMP (The Special Milk Program), WIC Program (The Special Supplemental Food For Women, Infants and Children), SFSP (The Summer Food Service Program). The level of monthly income per person (no more than 130% of poverty line) is the condition for participation in every program. Some programs (e.g. FSP) are addressed to all citizens, who are fulfilling income criteria, whereas other (e.g. WIC, SBP) are available to selected population groups only. Assistance within these programs may occur in various forms (e.g. food stamps for family, possibilities in using of low cost meals, free of cost milk for school children). Authors suggest to utilize some of US experience in nutrition-supporting programs also in Poland.

Health Promotion↗
PubMed2001

A national survey of procedural skill requirements in family practice residency programs.

BACKGROUND AND OBJECTIVES: Procedural skill training is a controversial but important component of family practice residency programs. This study examines the use and composition of required procedure lists in US family practice residency programs. METHODS: The study used a cross-sectional nine-item questionnaire. This survey was sent to 467 residency program directors listed in the 1999 American Academy of Family Physicians Directory of Family Practice Residency Programs. RESULTS: A total of 326 programs (70%) responded to the survey. Of these, 242 programs (74% of respondents) reported use of a required procedure list. Sixty-six programs provided a list. Of these, 63 lists were interpretable. The number of required procedures on the lists ranged from a minimum of 3 procedures to a maximum of 117, with an average of 42. A total of 265 distinct procedures were identified, with 25 procedures named on more than half of the lists. Thirteen programs (21%) mandated competency in required procedures, but only five programs (8%) gave clear definitions of what constituted competency. There were no significant differences in lists among training program type, university affiliation, number of hospitals used for rotation, size of affiliated hospital, or number of residents. CONCLUSIONS: The expectations of individual programs vary greatly in terms of required procedures. Few programs define how to evaluate the technical competency of their residents.

Clinical Competence↗