Forecasting for the need of dentists and specialists in South Africa until 2030

To manage the increasing burden of dental diseases, a robust health system is essential. In order to ensure the oral health system operates at an optimal level going into the future, a forecast of the national shortfall of dentists and dental specialists in South Africa (SA) was undertaken. There is currently a shortage of dentists and specialists in SA and given the huge burden of dental diseases, there is a dire need to increase the number of these health care workers. The aim was to determine the projected shortfall of dentists and specialists in each of the nine provinces in SA. The projected shortfall was calculated based on the SA Disability-Adjusted Life Years (DALYs) for each province. The estimate for the evaluation of the Global Burden of Disease (GBD) for SA was obtained from the Institute of Health Metrics and Evaluation (IHME) Global Burden of Disease website. For each province, age standardized DALYs were calculated with mid-year population estimates obtained from Statistics SA 2018. In order to reduce the existing human resources for health (HRH) inequity among the provinces of SA, three scenarios were created focussing on attaining horizontal equity. The best-case scenario estimates a shortfall of 430, 1252 and 1885 dentists and specialists in 2018, 2024 and 2030 respectively. In an optimistic scenario, the national shortfall was calculated at 733, 1540 and 2158 dentists and specialists for the years 2018, 2024 and 2030 respectively. In an aspirational scenario, shortfalls of 853 (2018), 1655 (2024) and 2267 (2030) dentists and specialists were forecasted. Access to oral health services should be ensured through the optimum supply of trained dentists and specialists and the delivery of appropriate oral health services. Thus, the roadmap provided for upscaling the oral health services recognizes the influence of both demand and supply factors on the pursuit of equity.

Should Common Bile Duct Exploration for Choledocholithiasis Be a Specialist-Only Procedure?

Background: Common bile duct exploration (CBDE) is performed uncommonly. Issues surrounding its uptake in the laparoscopic era include perceived difficulty and lack of training. We aim to determine the success of CBDE performed by "specialist" and "nonspecialist" common bile duct (CBD) surgeons to determine whether there is a substantial difference in success and safety. Methods: A 10-year retrospective audit was performed of patients undergoing CBD exploration for choledocholithiasis. Northern Health maintains an on-call available "specialist" CBD surgeon roster to aid with CBDE. Results: Five hundred fifty-one patients were identified, of which 489/551 (88.7%) patients had stones successfully cleared. Specialists had a higher success rate (90.8% versus 82.6%, P = .008), associated with a longer surgical time. Method (transcystic or transductal), approach (laparoscopic or open), and indication for operation were similar between groups. There was no significant difference in complications. To be confident of a surgeon having an 80% success rate, 70 procedures over 10 years were required, however, an "in-control" 50% success rate may only require 1 procedure per year. Conclusion: While specialist CBDE surgeons have improved success rates, nonspecialist general surgeons also have a good and comparable success rate with an equivalent complication rate. With realistic annual targets, nonspecialist CBD surgeons should be encouraged to perform CBDE in centers without specialist support.

[Who is in the Hospital Emergency Department? Descriptive study of the variability of specialties in the Emergency Department.]

OBJECTIVE

Giving the absence of specialized training to work as a physician in the Emergency Department in Spain, the aim of the study was to describe the variability of specialties in these departments nationally, by regions and hospital complexity.

METHODS

A descriptive cross-sectional study was carried out through a survey addressed to Emergency Chiefs of Spanish public hospitals, 65 of whom answered between January 2018 and September 2019. Descriptive and correlative analyzes of the variables were performed, assuming those with p<0.05 as statistically significant.

RESULTS

1,706 emergency physicians of 29 different specialties were described, of which 1,336 (78.31%) were Family and Community Medicine specialists. Different number of specialties among regions and hospitals of different complexities were described. 98.46% of surveyed chiefs demanded specialized formation on Emergency Medicine. Direct correlations were found between the complexity of the hospital and the number of specialties in the Emergency Department (r=0.2921, CI: 0.04445-0.5059; p<0.05); the complexity of the hospital and the number of emergency physicians (r=0.69, CI: 0.5310-0.8020; p<0.0001), as well as between the number of emergency physicians and the number of different specialties in the Emergency Department (r=0.3901, CI: 0.1543-0.5838; p<0.005).

CONCLUSIONS

Physicians of 29 different specialties were described working in the Emergency Departments. The variability of specialties changed among regions and hospitals of different complexities. Heads of Emergency Departments agreed on the need for specialized formation on Emergency Medicine.

Specialty career preferences among final year medical students at Makerere University College of health sciences, Uganda: a mixed methods study

BACKGROUND

Uganda has an imbalanced distribution of the health workforce, which may be influenced by the specialty career preferences of medical students. In spite of this, there is inadequate literature concerning the factors influencing specialty career preferences. We aimed to determine the specialty career preferences and the factors influencing the preferences among fifth year medical students in the School of Medicine, Makerere University College of Health Sciences (MakCHS).

METHODS

A sequential explanatory mixed methods study design with a descriptive cross-sectional study followed by a qualitative study was used. A total of 135 final year medical students in MakCHS were recruited using consecutive sampling. Self-administered questionnaires and three focus group discussions were conducted. Quantitative data was analysed in STATA version 13 (StataCorp, College Station, Tx, USA) using descriptive statistics, chi-square tests and logistic regression. Qualitative data was analysed in NVIVO version 12 (QRS International, Cambridge, MA) using content analysis.

RESULTS

Of 135 students 91 (67.4%) were male and their median age was 24 years (IQR: 24, 26). As a first choice, the most preferred specialty career was obstetrics and gynecology (34/135, 25.2%), followed by surgery (27/135, 20.0%), pediatrics (18/135, 13.3%) and internal medicine (17/135, 12.6%). Non-established specialties such as anesthesia and Ear Nose and Throat (ENT) were not selected as a first choice by any student. Female students had 63% less odds of selecting surgical related specialties compared to males (aOR = 0.37, 95%CI: 0.17-0.84). The focus group discussions highlighted controlled lifestyle, assurance of a good life through better financial remuneration and inspirational specialists as facilitators for specialty preference. Bad experience during the clinical rotations, lack of career guidance plus perceived poor and miserable specialists were highlighted as barriers to specialty preference.

CONCLUSION

Obstetrics and Gynecology, Surgery, Pediatrics and Internal Medicine are well-established disciplines, which were dominantly preferred. Females were less likely to select surgical disciplines as a career choice. Therefore, there is a need to implement or establish career guidance and mentorship programs to attract students to the neglected disciplines.

Specialist to non-specialist teleconsultations in chronic respiratory disease management: A systematic review

BACKGROUND

Chronic respiratory diseases (CRD), are common public health problems with high prevalence, disability and mortality rates worldwide. Further uneven distribution of the health workforce is a major barrier to the effective diagnosis and treatment of CRDs. Teleconsultation between a specialist and non-specialist could possibly bridge the gap in access to health care and decrease CRD burden in remote areas. This review investigates the evidence for the effective use of specialist to non-specialist teleconsultation in the management of CRDs in remote areas and identifies instances of good practice and knowledge gaps.

METHODS

We searched for articles till November 2020, which focused on specialist to non-specialist teleconsultations for CRD diagnosis or management. Two independent reviewers conducted the title and abstract screening and extracted data from the selected papers and the quality was assessed by Joanna Briggs Institute's (JBI) tool. A descriptive and narrative approach was used due to the heterogeneous nature of the selected studies.

RESULTS

We found 1715, articles that met the initial search criteria, but after excluding duplicates and non-eligible articles, we included 10 research articles of moderate quality. These articles were from nine different studies, all of which, except one, were conducted in high-income countries. The studies reported results in terms of impact on the patients, and the health care providers including primary care physicians (PCP) and specialists. The teleconsulting systems used in all the selected papers primarily used audio modes in addition to other modes like the audio-video medium. The included studies reported primarily non-clinical outcomes including effectiveness, feasibility, acceptability and usability of the teleconsultation systems and only three described the clinical outcomes. The teleconsultation was predominantly conducted in the PCP's office with the specialist located remotely.

CONCLUSIONS

We found relatively few, papers which explored specialist to non-specialist teleconsultation in management of CRDs, and no controlled trials. Two of the included papers described systems, which were used for other diseases in addition to the CRD. The available literature although not generalisable, encourages the use of specialist to non-specialist teleconsultation for diagnosis and management of CRDs.

Addressing Kentucky's Physician Shortage While Securing a Network for a Research-Intensive, Referral Academic Medical Center: Where Public Policy Meets Effective Clinical Strategic Planning

A critical shortage of physicians is looming in the United States. The situation in Kentucky is especially dire, especially in rural areas. Class size constraints have resulted in the University of Kentucky College of Medicine (UK COM) unable to admit over 100 qualified Kentuckians each year. This article describes how leadership at University of Kentucky committed to addressing the state physician shortage while simultaneously strengthening relationships with critical partners through the establishment of two 4-year UK COM regional medical campuses. Based on criteria (such as a commitment to educating physicians, ample patients, sufficient willing physician preceptors, etc.), partners selected were Med Center Health, the leading health care system in southwestern Kentucky, and St. Elizabeth Healthcare, the predominant health care system in northern Kentucky. These regional campuses allow UK COM to expand its class size to 201 and total enrollment to 804, increasing from historically 70 to currently 120 graduates per year expected to practice in Kentucky. Critical to the success of this expansion is the buy-in of leadership and the Admissions Committee to consider students with a wider range of Medical College Admission Test scores. The regional clinical partners have substantially increased their teaching opportunities, with a greater ability to attract physicians. Both partners have made substantial financial contributions in support of the regional campuses. These relationships have energized UK COM engagement with its area alumni and have resulted in fewer Kentuckians referred out of state for advanced specialty care. Partnerships are also occurring with UK COM to increase graduate medical education offerings at the regional sites, fulfilling the vision of "training Kentuckians in Kentucky to practice in Kentucky."

Difficulty in distinguishing malignant gastric lymphoma from advanced gastric cancer: Focusing on endoscopic findings of the Borrmann type

Malignant gastric lymphoma (MGL) accounts for a small proportion (upto 5%) of gastric malignancies. However, unlike for advanced gastric cancer (AGC) that requires surgical treatment, the standard treatments for MGL are chemotherapy and radiotherapy. Hence, the initial impression of the endoscopist is critical for the differential diagnosis and for planning future treatment. The purpose of this study was to assess the endoscopic diagnostic accuracy and the possibility of distinguishing between AGC and MGL depending on the endoscopist's experience.A total of 48 patients who had MGL, and 48 age and sex-matched patients who had AGC were assessed by endoscopic review at a tertiary referral hospital between June 2008 and February 2017. Two endoscopic specialists reviewed the endoscopic findings and divided these diagnoses into 5 groups: Borrmann type (1, 2, 3, and 4) and early gastric cancer-like type. After this, 7 experts and 8 trainees were asked to complete a quiz that was comprised of 6 images for each of the 96 cases and to provide an endoscopic diagnosis for each case. The test results were analyzed to assess the diagnostic accuracy according to the pathologic results, endoscopic subgroups, and endoscopists' experience. For inter-observer agreement was calculated with Fleiss kappa values.The overall diagnostic accuracy of endoscopic findings by the experts was 0.604 and that by the trainees was 0.493 (P = .050). There was no significant difference in the diagnosis according to the final pathology (lymphoma cases, 0.518 vs 0.440, P = .378; AGC cases, 0.690 vs 0.547, P = .089, respectively). In the subgroup analysis, the experts showed significantly higher diagnostic accuracy for the endoscopic Borrmann type 4 subgroup, including lymphoma or AGC cases, than the trainees (P = .001). Inter-observer agreement of final diagnosis (Fleiss kappa, 0.174) and endoscopic classification groups (Fleiss kappa, 0.123-0.271) was slightly and fair agreement.The experts tended to have a higher endoscopic diagnostic accuracy. Distinguishing MGL from AGC based on endoscopic findings is difficult, especially for the beginners. Even if the endoscopic impression is AGC, it is important to consider MGL in the differential diagnosis.

Is Specialisation Needed in Laparoscopic Cholecystectomy? A Retrospective Cohort Study of 5122 Patients

Background: Gallstone disease is a common problem and laparoscopic cholecystectomy (LC) is a common elective procedure. This operation was performed by a general surgeon, colorectal surgeons, breast and vascular surgeons according to the largest UK's audit (CholeS study). Objectives: To compare the outcomes of laparoscopic cholecystectomy performed by a specialist upper gastrointestinal (UGI) surgeon to that of CholeS and large international studies. Our hypothesis is: UGI specialist is producing better outcomes for LC patients. Methods: All patient who underwent LC between 1999 and 2019 at one hospital by an UGI consultant and 2014-2019 at another hospital by another UGI consultant surgeon were included. The inclusion criteria were LC performed by UGI surgeon. Lost to follow up, procedures done by trainees and gallbladder cancer patients were excluded. The outcome measures of bile leak, bile duct injuries, bleeding, infectious complications, bowel injuries, vascular injuries and pseudoaneurysms, neuralgia, port site hernia, mesenteric haematoma, 30-day mortality and conversion to open were reported. Statistical tests were used to assess the significant differences, the confidence interval was 95% and the p-value was taken as 0.05. Results: Two UGI specialists performed 5122 LC, 4396 (86%) were female and 715 (14%) male. The age was 13-93 year (median of 48 years). 3681 (72 %) was done as a day surgery case. 1431(28%) as an inpatient and 287 (5.6%) emergency LC. There was no death in the 30 days periods of surgery, 8 (0.15%) biliary leak from the duct of Luschka, 4 (0.19%) common bile duct (CBD) injuries, 9(0.02%) conversions and 17(0.33%) procedures were abandoned. There were significant differences in the above complications between our study and the CholeS report. Conclusions: Laparoscopic cholecystectomy is associated with acceptable outcomes, low risk of bile duct injury and no mortality when performed by a specialist upper GI surgeon.

Physician Density by Specialty Type in Urban and Rural Counties in the US, 2010 to 2017

This cross-sectional study uses data from the American Medical Association Physician Masterfile to examine physician density by specialty type across metropolitan and rural US counties from 2010 to 2017.

Dementia Care in Diverse Older Adults in the U.S. Deep South and the Rest of the United States

BACKGROUND

Use of specialists and recommended drugs has beneficial effects for older adults living with Alzheimer's disease and related dementia (ADRD). Gaps in care may exist for minorities, e.g., Blacks, and especially in the United States (U.S.) Deep South (DS), a poor U.S. region with rising ADRD cases and minority overrepresentation. Currently, we have little understanding of ADRD care utilization in diverse populations in this region and elsewhere in the U.S. (non-DS), and the factors that adversely impact it.

OBJECTIVE

To examine utilization of specialists and ADRD drugs (outcomes) in racial/ethnic groups of older adults with ADRD and the personal or context-level factors affecting these outcomes in DS and non-DS.

METHODS

We obtained outcomes and personal-level covariates from claims for 127,512 Medicare beneficiaries with ADRD in 2013-2015, and combined county-level data in exploratory factor analysis to define context-level covariates. Adjusted analyses tested significant association of outcomes with Black/White race and other factors in DS and non-DS.

RESULTS

Across racial/ethnic groups, 33%-43% in DS and 43%-50% in non-DS used specialists; 47%-55% in DS and 41%-48% in non-DS used ADRD drugs. In adjusted analyses, differences between Blacks and Whites were not significant. Vascular dementia, comorbidities, poverty, and context-level factor "Availability of Medical Resources" were associated with specialist use; Alzheimer's disease and senile dementia, comorbidities, and specialist use were associated with drug use. In non-DS only, other individual, context-level covariates were associated with the outcomes.

CONCLUSION

We did not observe significant gaps in ADRD care in DS and non-DS; however, research should further examine determinants of low specialist and drug use in these regions.

Active management of severe hyponatraemia is associated with improved mortality

OBJECTIVE

Severe hyponatraemia (plasma sodium concentration, pNa <120 mmol/L) is reported to be associated with mortality rates as high as 50%. Although there are several international guidelines for the management of severe hyponatraemia, there are few data on the impact of treatment.

DESIGN AND METHODS

We have longitudinally reviewed rates of specialist input, active management of hyponatraemia, treatment outcomes and mortality rates in patients with severe hyponatraemia (pNa <120 mmol/L) in 2005, 2010 and 2015, and compared the recent mortality rate with that of patients with pNa 120-125 mmol/L.

RESULTS

Between 2005 and 2010 there was a doubling in the rate of specialist referral (32 to 68%, P = 0.003) and an increase in the use of active management of hyponatraemia in patients with pNa <120 mmol/L (63 to 88%, P = 0.02), associated with a reduction in mortality from 51 to 15% (P < 0.001). The improved rates of intervention were maintained between 2010 and 2015, but there was no further reduction in mortality. When data from all three reviews were pooled, specialist consultation in patients with pNa <120 mmol/L was associated with a 91% reduction in mortality risk, RR 0.09 (95% CI: 0.03-0.26), P < 0.001. Log-rank testing on in-hospital survival in 2015 found no significant difference between patients with pNa <120 mmol/L and pNa 120-125 mmol/L (P = 0.56).

CONCLUSION

Dedicated specialist input and active management of severe hyponatraemia are associated with a reduction in mortality, to rates comparable with moderate hyponatraemia.

Similarities and Differences Between Rural and Urban Telemedicine Utilization

Telemedicine has traditionally been used in rural areas, but the recent development of mHealth solutions has led to a growth in urban telemedicine services. The aim of this study was to determine whether urban and rural patients in a large academic medical center use telemedicine to access different healthcare specialties at different rates. This retrospective cohort study examined all telemedicine visits dated 2008-2017 at a large academic medical center. Visits were classified by clinical specialty. Teledermatology, child telepsychiatry, and adult telepsychiatry made up 97 percent of telemedicine visits. Rural patients were more likely to have multiple telehealth visits. A significant difference was observed between rural and urban use of telemedicine, both in terms of specialties and demographics. This suggests that health systems should consider adjusting resources and training to meet the different needs of these two populations. In particular, telemedicine may offer help for the nationwide maldistribution of adolescent psychiatry providers.

Reschovsky J, Jones DJ, Kimmey L, Furukawa MF, Rich EC. Health system integration with physician specialties varies across markets and system types

OBJECTIVE

To examine system integration with physician specialties across markets and the association between local system characteristics and their patterns of physician integration.

DATA SOURCES

Data come from the AHRQ Compendium of US Health Systems and IQVIA OneKey database.

STUDY DESIGN

We examined the change from 2016 to 2018 in the percentage of physicians in systems, focusing on primary care and the 10 most numerous nonhospital-based specialties across the 382 metropolitan statistical areas (MSAs) in the US. We also categorized systems by ownership, mission, and payment program participation and examined how those characteristics were related to their patterns of physician integration in 2018.

DATA COLLECTION/EXTRACTION METHODS

We examined local healthcare markets (MSAs) and the hospitals and physicians that are part of integrated systems that operate in these markets. We characterized markets by hospital and insurer concentration and systems by type of ownership and by whether they have an academic medical center (AMC), a 340B hospital, or accountable care organization.

PRINCIPAL FINDINGS

Between 2016 and 2018, system participation increased for primary care and the 10 other physician specialties we examined. In 2018, physicians in specialties associated with lucrative hospital services were the most commonly integrated with systems including hematology-oncology (57%), cardiology (55%), and general surgery (44%); however, rates varied substantially across markets. For most specialties, high market concentration by insurers and hospital-systems was associated with lower rates of physician integration. In addition, systems with AMCs and publicly owned systems more commonly affiliated with specialties unrelated to the physicians' potential contribution to hospital revenue, and investor-owned systems demonstrated more limited physician integration.

CONCLUSIONS

Variation in physician integration across markets and system characteristics reflects physician and systems' motivations. These integration strategies are associated with the financial interests of systems and other strategic goals (eg, medical education, and serving low-income populations).

Impact of the COVID-19 pandemic on specialty community practices: an oncology perspective

OBJECTIVES

Typically, a community-based specialty practice is prepared for a limited public health crisis that is driven by a natural disaster or a localized environment event. This article describes the unexpected impact that the coronavirus disease 2019 (COVID-19) pandemic has had on community-based specialty practices across the United States, especially oncology practices.

STUDY DESIGN AND METHODS

We conducted an electronic national survey of community-based specialty practice administrators to determine the impact of COVID-19 on their practices and their ability to manage through a global pandemic. The 22-question survey focused on an initial observation period of March 15, 2020, to May 15, 2020, compared with a second period of May 16, 2020, to August 15, 2020.

RESULTS

Oncology practices accounted for 46% of the 155 specialty practices that participated in the survey. Overall, 57% of respondents saw at least a 30% decline in total patient volume and/or financial impact during the initial observation period, compared with a 38% decline for the oncology practices. More than 70% of all practices experienced improvement after May 15, 2020, with at least 60% improving regardless of specialty. The initial decline was primarily driven by declines in new patient volume and procedures. Approximately 62% of practices anticipate a moderate-to-significant impact on patient outcomes over the next 12 months. The impact expected was slightly higher in retina and ophthalmology practices than oncology.

CONCLUSIONS

Although unexpectedly impacted in delivering care for their patients, specialty practices generally and oncology practices especially have been resilient by leveraging federal funds and adopting operational enhancements.

A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career

There is a lack of theory about what drives choice to be a generalist or specialist doctor, an important issue in many countries for increasing primary/preventative care. We did a realist evaluation to develop a theory to inform what works for whom, when and in what contexts, to yield doctors’ choice to be a generalist or specialist. We interviewed 32 Australian doctors (graduates of a large university medical school) who had decided on a generalist (GP/public health) or specialist (all other specialties) career. They reflected on their personal responses to experiences at different times to stimulate their choice. Theory was refined and confirmed by testing it with 17 additional doctors of various specialties/career stages and by referring to wider literature. Our final theory showed the decision involved multi-level contextual factors intersecting with eight triggers to produce either a specialist or generalist choice. Both clinical and place-based exposures, as well as attributes, skills, norms and status of different fields affected choice. This occurred relative to the interests and expectations of different doctors, including their values for professional, socio-economic and lifestyle rewards, often intersecting with issues like gender and life stage. Applying this theory, it is possible to tailor selection and ongoing exposures to yield more generalists.

Task specialization across research careers

Research careers are typically envisioned as a single path in which a scientist starts as a member of a team working under the guidance of one or more experienced scientists and, if they are successful, ends with the individual leading their own research group and training future generations of scientists. Here we study the author contribution statements of published research papers in order to explore possible biases and disparities in career trajectories in science. We used Bayesian networks to train a prediction model based on a dataset of 70,694 publications from PLoS journals, which included 347,136 distinct authors and their associated contribution statements. This model was used to predict the contributions of 222,925 authors in 6,236,239 publications, and to apply a robust archetypal analysis to profile scientists across four career stages: junior, early-career, mid-career and late-career. All three of the archetypes we found - leader, specialized, and supporting - were encountered for early-career and mid-career researchers. Junior researchers displayed only two archetypes (specialized, and supporting), as did late-career researchers (leader and supporting). Scientists assigned to the leader and specialized archetypes tended to have longer careers than those assigned to the supporting archetype. We also observed consistent gender bias at all stages: the majority of male scientists belonged to the leader archetype, while the larger proportion of women belonged to the specialized archetype, especially for early-career and mid-career researchers.

[Comparative study of the assaults to professionals in Primary Care against Specialized Care, in the Aragón Health Service during the year 2018.]

OBJECTIVE

The risk that health personnel have of being assaulted in the workplace is not homogeneous. Factors such as professional category, level of care or service, modulate their probability. The objective of this work was to analyze the aggressions registered by the Servicio Aragonés de Salud professionals, comparing the characteristics of those that occurred in primary care with those that took place in specialized care during 2018.

METHODS

A cross-sectional descriptive study was made, carried out using the information available in the Aragon aggression registry database, during the year 2018. The study variables included sociodemographic characteristics of the people attacked, type of aggression, level of assistance and sick leave. Frequencies and percentages were calculated for the qualitative variables and mean and standard deviation for the quantitative ones; the relationship between the variables was made using the Mann-Whitney and Chi-Square tests.

RESULTS

236 assaults were registered, of which 75.4% took place in AE. The average age was 45 years. Doctors were more attacked in primary care, while nursing staff was more attacked in specialized care. In primary there were more verbal attacks, while in specialized there were more physical attacks.

CONCLUSIONS

Occupational violence suffered by health professionals change depending on the level of care, where a higher incidence of assaults is observed in specialized care. It is necessary to establish improvements in the registry of aggressions in Aragón, to improve the prevention and safety of workers.

Hydroxychloroquine and Chloroquine Prescribing Patterns by Provider Specialty Following Initial Reports of Potential Benefit for COVID-19 Treatment - United States, January-June 2020

Hydroxychloroquine and chloroquine, primarily used to treat autoimmune diseases and to prevent and treat malaria, received national attention in early March 2020, as potential treatment and prophylaxis for coronavirus disease 2019 (COVID-19) (1). On March 20, the Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for chloroquine phosphate and hydroxychloroquine sulfate in the Strategic National Stockpile to be used by licensed health care providers to treat patients hospitalized with COVID-19 when the providers determine the potential benefit outweighs the potential risk to the patient.* Following reports of cardiac and other adverse events in patients receiving hydroxychloroquine for COVID-19 (2), on April 24, 2020, FDA issued a caution against its use^† and on June 15, rescinded its EUA for hydroxychloroquine from the Strategic National Stockpile.^§ Following the FDA's issuance of caution and EUA rescindment, on May 12 and June 16, the federal COVID-19 Treatment Guidelines Panel issued recommendations against the use of hydroxychloroquine or chloroquine to treat COVID-19; the panel also noted that at that time no medication could be recommended for COVID-19 pre- or postexposure prophylaxis outside the setting of a clinical trial (3). However, public discussion concerning the effectiveness of these drugs on outcomes of COVID-19 (4,5), and clinical trials of hydroxychloroquine for prophylaxis of COVID-19 continue.^¶ In response to recent reports of notable increases in prescriptions for hydroxychloroquine or chloroquine (6), CDC analyzed outpatient retail pharmacy transaction data to identify potential differences in prescriptions dispensed by provider type during January-June 2020 compared with the same period in 2019. Before 2020, primary care providers and specialists who routinely prescribed hydroxychloroquine, such as rheumatologists and dermatologists, accounted for approximately 97% of new prescriptions. New prescriptions by specialists who did not typically prescribe these medications (defined as specialties accounting for ≤2% of new prescriptions before 2020) increased from 1,143 prescriptions in February 2020 to 75,569 in March 2020, an 80-fold increase from March 2019. Although dispensing trends are returning to prepandemic levels, continued adherence to current clinical guidelines for the indicated use of these medications will ensure their availability and benefit to patients for whom their use is indicated (3,4), because current data on treatment and pre- or postexposure prophylaxis for COVID-19 indicate that the potential benefits of these drugs do not appear to outweigh their risks.

Forensic peer specialists: Training, employment, and lived experience

OBJECTIVE

Despite calls for increased peer support services for individuals involved with the criminal justice system, little is known about the training, employment, and characteristics of forensic peer specialists (FPSs). Pennsylvania developed the nation's first FPS program and remains at the forefront of the field. This paper responds to three research questions regarding forensic peer support in Pennsylvania, assessing: (a) employment patterns and demographic characteristics; (b) work tasks and sites; and (c) challenges and benefits of working as an FPS.

METHOD

Data are drawn from a larger mixed-methods study of forensic peer support in Pennsylvania, including a detailed online survey of 117 FPS-trained workers, followed by 16 qualitative interviews with a subset of survey respondents.

RESULTS

While all survey respondents completed forensic peer support training, only 36% (n = 44) have been employed as FPSs. 96% of survey respondents report having used mental health services, compared to 55% reporting past incarceration. FPSs spend the majority of their work time providing individual support to peer clients and work in multiple settings. Additionally, FPSs report both benefits and challenges related to their work.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Study results suggest that FPS characteristics, practices, and work settings simultaneously align with and differ from nonspecialized peer support services. Program developers and advocates should focus attention on expanding employment opportunities, and FPSs with lived experience should be prioritized for these positions. Despite significant implementation barriers, FPSs are passionate about this work and promote the expansion of the field. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Sport specialization and sport participation opportunities and their association with injury history in female high school volleyball athletes

OBJECTIVE

Determine the association of sport specialization in female volleyball athletes with previous injury history and determine the association of sport specialization with volleyball participation opportunities.

DESIGN

Cross-sectional.

SETTING

Recruitment occurred from 83 Wisconsin high schools during the 2018 volleyball season.

PARTICIPANTS

Female volleyball athletes (N = 1,588, grades 9-12, age = 15.6 ± 1.1 years).

MAIN OUTCOMES

Participants completed a pre-season questionnaire soliciting information regarding 1) demographics, 2) sport specialization, 3) sport participation, and 4) sport-related injuries in the previous 12 months. Univariable logistic regression models were used to identify associations with previous injury. Chi-square analyses were used to investigate associations between sport specialization classification and other sport participation opportunities.

RESULTS

Both moderately and highly specialized athletes were more likely to report a previous injury compared to low specialized athletes (moderate OR: 1.84 [1.29-2.62]; p < 0.001 and high OR: 2.30 [1.64-3.24]; p < 0.001). Highly specialized athletes were more likely to report participating in club volleyball, summer tournaments, and training camps in the past 12 months. Participants who reported participating in club volleyball, summer competitions, and training camps last year were more likely to report an injury.

CONCLUSIONS

Specialization was associated with injury history and year-round volleyball opportunities among female adolescent volleyball athletes.

Preferences of physicians for public and private sector work

BACKGROUND

The public-private mix of healthcare remains controversial. This paper examines physicians' preferences for public sector work in the context of dual practice, whilst accounting for other differences in the characteristics of jobs.

METHODS

A discrete choice experiment is conducted with data from 3422 non-GP specialists from the Medicine in Australia: Balancing Employment and Life (MABEL) panel survey of physicians.

RESULTS

Physicians prefer to work in the public sector, though the value of working in the public sector is very small at 0.14% of their annual earnings to work an additional hour per week. These preferences are heterogeneous. Contrary to other studies that show risk averse individuals prefer public sector work, for physicians, we find that those averse to taking career or clinical risks prefer to work in the private sector. Those with relatively low earnings prefer public sector work and those with high earnings prefer private sector work, though these effects are small.

CONCLUSIONS

Other job characteristics are more important than the sector of work, suggesting that these should be the focus of policy to influence specialist's allocation of time between sectors.

Characteristics of ACGME Residency Programs That Select Osteopathic Medical Graduates

BACKGROUND

The transition from American Osteopathic Association (AOA) and Accreditation Council for Graduate Medical Education (ACGME) residency matches to a single graduate medical education accreditation system culminated in a single match in 2020. Without AOA-accredited residency programs, which were open only to osteopathic medical (DO) graduates, it is not clear how desirable DO candidates will be in the unified match. To avoid increased costs and inefficiencies from overapplying to programs, DO applicants could benefit from knowing which specialties and ACGME-accredited programs have historically trained DO graduates.

OBJECTIVE

This study explores the characteristics of residency programs that report accepting DO students.

METHODS

Data from the American Medical Association's Fellowship and Residency Electronic Interactive Database Access were analyzed for percentage of DO residents in each program. Descriptive statistics and a logit link generalized linear model for a gamma distribution were performed.

RESULTS

Characteristics associated with graduate medical education programs that reported a lower percentage of DO graduates as residents were surgical subspecialties, longer training, and higher US Medical Licensing Examination Step 1 scores of their residents compared with specialty average. Characteristics associated with a higher percentage of DO graduates included interviewing more candidates for first-year positions and reporting a higher percentage of female residents.

CONCLUSIONS

Wide variation exists in the percentage of DO graduates accepted as residents among specialties and programs. This study provides valuable information about the single Match for DO graduates and their advisers and outlines education opportunities for the osteopathic profession among the specialties with low percentages of DO students as residents.

Claims data analysis of medical specialist utilization among nursing home residents and community-dwelling older people

BACKGROUND

Most older people, and especially those in need of long-term care, suffer from one or more chronic diseases. Consequently, older people have an increased need of medical care, including specialist care. There is little evidence as yet whether older people with greater medical care needs obtain adequate medical care because existing studies do not sufficiently control for differences in morbidity. In this study we investigate whether differences in medical specialist utilization exist between older people with and without assessed long-term care need in line with Book XI of the German Social Code, while at the same time controlling for individual differences in morbidity.

METHODS

We used data from the 11 German AOK Statutory Health and Long-term Care Insurance funds of 100,000 members aged 60 years or over. Zero-inflated Poisson regression analyses were applied to investigate whether the need for long-term care and the long-term care setting are associated with the probability and number of specialist visits. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner (GP) utilization.

RESULTS

Older people in need of long-term care are more likely to have no specialist visit than people without the need for long-term care. This applies to nearly all medical specialties and for both care settings. Yet, despite these differences in utilization probability the number of specialist medical care visits between older people with and without the need for long-term care is similar.

CONCLUSION

Older people in need of long-term care might face access barriers to specialist care. Once a contact is established, however, utilization does not differ considerably between those who need long-term care and those who don't; this indicates the importance of securing an initial contact.

Women's Representation Among Members and Leaders of National Medical Specialty Societies

PURPOSE

National medical specialty societies speak for their respective fields in policy debates, influence research, affect trainees' specialization decisions, provide career development opportunities, and confer awards and recognitions. This study provides a comprehensive overview of the gender demographics of society members and leaders.

METHOD

In 2016, the Group on Women in Medicine and Science (of the Association of American Medical Colleges) sought to characterize the gender of members and leaders of specialty societies from 2000 to 2015. This report provides descriptive data, including how many of the responding societies (representing each of 30 major medical specialties) had substantial (> 10%) increases in women's representation among leadership between the first and second halves of the study period.

RESULTS

The average proportion of full members who were female in responding societies was 25.4% in 2005 and 29.3% in 2015. The proportion of women among those serving as the highest-ranking elected leader between 2000 and 2015 in each specialty ranged from 0% to 37.5% (mean, 15.8%). The mean proportion of women on governing boards ranged from 0% to 37.3% (mean of means, 18.8%) in 2000-2007 and from 0% to 47.6% (mean of means, 25.2%) in 2008-2015. In 9 specialties, the mean percentage of women serving on governing boards increased by over 10% from the first to the second half of the study period.

CONCLUSIONS

Although many women are full members of specialty societies, women still constitute a minority of leaders. This report establishes a baseline from which to evaluate the effect of societies' efforts to improve diversity, equity, and inclusion.

Gender differences in specialty preference among medical Students at Aleppo University: a cross-sectional study

BACKGROUND

This study aims to identify gender differences in specialty preference and career choice among Syrian medical students.

METHOD

A cross-sectional study comprising currently enrolled second, fourth and sixth year medical students at Aleppo University was conducted. Demographics, specialty preferences and factors influencing this decision were collected and analyzed.

RESULTS

A total of 561 students (44% males, 56% females) responded to our survey (87% response rate). Surgical specialties (40%) and internal medicine (16%) comprised the two most common specialties chosen by males. In contrast, the majority of females preferred other specialties (17%), internal medicine (16%) and surgical specialties (15%). The most common factor affecting the choice of a specialty by both genders (74% females and 71% males) was 'A specialty that I like and find interesting'. Work/life balance and anticipated income were the second most common influencing factors by females (62%), males (67%), respectively. The majority of both genders supported the idea that medical students should be able to pursue any medical specialty they want, regardless of their gender. However, females more often believed that they had decreased opportunities for professional advancement based on their gender compared to males (33% vs. 4% respectively, p < 0.001).

CONCLUSIONS

We illustrated significant gender differences in specialty preferences and factors influencing this decision. While the majority of participants agreed that medical students should be able to pursue any medical specialty they desire regardless of gender, more women believed they had decreased opportunities for professional advancement based on gender. Policy makers should advocate for a culture of gender equity and develop educational programs to insure gender balance of physicians into different specialties.