A combined care model using early access to specialists off-hours to reduce cardiac admissions

Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk cardiac patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours would decrease the proportion of these patients admitted to the hospital. We conducted a retrospective study of patients seen in the ED with cardiac diagnoses identified by ICD-9 codes during the time period when the cardiologist was available (6 p.m.-midnight) compared with patients seen at other times of the day in the 12 months before and after the consultation program was implemented. The primary outcome was disposition at the time of discharge from the ED. Logistic regression was used to model the primary outcome. A difference-in-differences approach was used as the primary statistical test .Following the start of the consultation program, the odds of discharge home from the ED with or without observation increased (OR 1.69, 95% CI [1.45-1.96]). There was a significant interaction between pre-/post-intervention status and time of day in the odds of discharge home from the ED (P = 0.04) suggesting an association between the consultation program and disposition patterns that is independent of concurrent programs aimed to reduce utilization. An ED-based cardiology consultation program may reduce the need for inpatient stays by identifying low- to intermediate-risk patients safe for discharge from the ED with or without a period of active management/observation.

The influence of general practitioners on access points to health care in a system without gatekeeping: a cross-sectional study in the context of the QUALICOPC project in Austria

AIM

To assess the rates of specialist visits and visits to hospital emergency departments (ED) among patients in Austria with and without concurrent general practitioner (GP) consultation and among patients with and without chronic disease.

METHODS

The cross-sectional questionnaire study was conducted in the context of the QUALICOPC project in 2012. Fieldworkers recruited 1596 consecutive patients in 184 GP offices across Austria. The 41-question survey addressed patients' experiences with regard to access to, coordination, and continuity of primary care, as well demographics and health status. Descriptive statistics as well as univariate and multivariate regression models were applied.

RESULTS

More than 90% of patients identified a GP as a primary source of care. Among all patients, 85.5% reported having visited a specialist and 26.4% the ED at least once in the previous year. Having a usual GP did not change the rate of specialist visits. Additionally, patients with chronic disease had a higher likelihood of presenting to the ED despite having a GP as a usual source of care.

CONCLUSION

Visiting specialists in Austria is quite common, and the simple presence of a GP as a usual source of care is insufficient to regulate pathways within the health care system. This can be particularly difficult for chronic care patients who often require care at different levels of the system and show higher frequency of ED presentations.

Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs

RATIONALE, AIMS AND OBJECTIVE

Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.

METHOD

The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible.

RESULTS

A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers.

CONCLUSIONS

Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

Inequality in the distribution of ear, nose and throat specialists in 15 Latin American countries: an ecological study

OBJECTIVE

To explore sociogeographical inequalities in the availability and distribution of ear, nose and throat specialists (ENTs) in 15 Latin American (LA) countries.

DESIGN

Ecological.

SETTING

Spanish and Portuguese-speaking countries of LA.The number of registered ENTs in 2017 was obtained from the National ENT Society in each country.

OUTCOME MEASURES

The ENT rate/million population was calculated at the national and subnational (eg, state) level. Three measures were calculated to assess subnational distributive inequality of ENTs: (1) absolute and (2) relative index of dissimilarity; and (3) concentration index (using the Human Development Index as the equity stratifier). Finally, the ratio of ENTs/million population in the capital area compared with the rest of the country was calculated.

RESULTS

There was more than a 30-fold difference in the number of ENTs/million population across the included countries-from 61.0 in Argentina (95% CI 58.7 to 63.4) to 2.8 in Guatemala (95% CI 2.1 to 3.8). In all countries, ENTs were more prevalent in advantaged areas and in capital areas. To attain distributive equality, Paraguay would need to redistribute the greatest proportion of its ENT workforce (67.3%; 95% CI 57.8% to 75.6%) and Brazil the least (18.5%; 95% CI 17.6% to 19.5%).

CONCLUSIONS

There is high inequality in the number and distribution of ENTs between and within the 15 studied countries in LA. This evidence can be used to inform policies that improve access to ear and hearing services in the region, such as scale-up of training of ENTs and incentives to distribute specialists equally. These actions to reduce inequities, alongside addressing the social determinants of ear and hearing health, are essential to realise Universal Health Coverage.

Additional qualifications of trainees in specialist training programs in Australia

BACKGROUND

In Australia, the number of medical graduates per year has increased at a greater rate than the increase in the number of specialist training places. Consequently, competition for training positions is intensifying. There is anecdotal evidence to suggest that medical graduates are acquiring additional qualifications to compete with their peers Stevenson 2017 ( https://insightplus.mja.com.au/2017/36/specialty-training-places-the-other-looming-crisis/ ). Our study investigates this phenomenon of additional credentialing and demonstrates the number and type of postgraduate and research qualifications obtained by specialists in training in Australia. This is the first study to assess the number and type of credentials acquired by registrars in each specialty and to provide insight into differences between specialities.

METHODS

Information on specialists in training was obtained through the Medicine in Australia: Balancing Employment and Life (MABEL) survey conducted between 2008 and 2014. The number of any additional qualifications and specific PhD, Master's degree, postgraduate diploma/certificate and research degrees from medical school were assessed for each specialist training scheme in the database.

RESULTS

Overall, 995 registrars representing 13 specialties were included. Just under a third (30.4%) completed a research-based degree during their medical degree and almost half (46.7%) of specialist registrars obtained further qualifications after completing medicine. A significantly higher proportion of ophthalmology (78.6%) and paediatric (67.5%) registrars, and a lower percentage of emergency medicine (36.7%) registrars, held postgraduate qualifications. Overall, 2.4% of registrars held a PhD and 10.1% held a Master's degree. A higher percentage of either PhD or Master's was held by ophthalmology (64.3%) and surgical (30.6%) trainees and a lower percentage by anaesthetics (6.3%) and physician trainees (7.9%). Postgraduate diplomas or certificates were most common among paediatric (41.2%) and obstetrics and gynaecology (25.6%) registrars.

CONCLUSION

This is the first study to investigate the additional qualifications of specialists in training in Australia. Almost half of specialists in training surveyed (46.7%) have completed some form of additional study, whether it is a PhD, Master's, postgraduate diploma/certificate or research degree from medical school. Trainees of specialist training schemes are more qualified than specialists who trained in the past Aust Fam Physician 32:92-4, 2003.

PharmD graduates' perceptions of the impact of a teaching specialization

INTRODUCTION

The purpose of this study was to evaluate graduates' perceptions of the impact of a teaching (education) specialization and identify aspects of the specialization that could be enhanced.

METHODS

A 20-item online survey was emailed to graduates of the education specialization at Southern Illinois University Edwardsville School of Pharmacy. Data was analyzed using descriptive statistics. Regression analysis was used to examine (1) association between overall self-rated competence on abilities and skills as a teacher and the number of types of teaching experiences and (2) association between overall self-rated competence on abilities and skills as a teacher and history of holding a faculty position. Chi square was used to determine differences between the two cohorts in confidence areas.

RESULTS

Fifty-six out of 69 alumni (81.2%) responded to the survey. Graduates reported high levels of confidence in most teaching abilities. There was a high level of agreement that the specialization enhanced motivation to teach. Regression analysis indicated statistically significant associations between self-rated competence on abilities and skills across a variety of teaching experiences (e.g., classroom lecturing, precepting, continuing education, staff training, lab instruction, facilitating small groups) and history of faculty employment. Enhanced skills in experiential education and teaching outside of academia were identified as further areas for development.

CONCLUSION

The education specialization offered at Southern Illinois University Edwardsville School of Pharmacy may be an alternative entry level PharmD pathway for stimulating interest in academia. The majority of graduates agreed that they have applied the knowledge and skills to their careers.

How does 'banter' influence trainee doctors' choice of career? A qualitative study

BACKGROUND

Negative comments from senior colleagues about specialties, such as general practice and psychiatry, are known to influence trainees' career choice, but little is known about the extent of this influence or the mechanism by which it works. There have been calls to ban these disparaging comments, also known as 'banter'. This study explored how recently qualified doctors make sense of banter in the context of other experiences and information.

METHODS

Semi-structured telephone interviews were conducted with 24 trainee doctors in their second postgraduate year in South West England. Thematic Analysis was used to code the data and organise them into themes.

RESULTS

Trainees are commonly exposed to banter about the merits of different specialties and those who work in them, but these messages are not received uncritically and are not perceived to be decisive in determining career choice. The views of senior doctors are assimilated with other experiences and information, as trainees strive to assess their 'fit' with a specialty. While banter is seen as positioning specialties in a status hierarchy, other factors such as work-life balance and feeling 'at home' in a specialty are often believed to be more significant factors in career choice. We posited two theories of banter; the 'propaganda model' and the 'person-specialty fit model,' and found the latter to provide a better understanding of how banter informs career choice.

CONCLUSIONS

Banter often comprises stereotypes and caricatures, but despite its biases and distortions, it may still aid career choice. The challenge is not to ban banter, but to provide more accurate and reliable knowledge and experiences of what working life is like in different specialties.

Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study

OBJECTIVES

Many countries are driving forward policies to widen the socioeconomic profile of medical students and to train more medical students for certain specialties. However, little is known about how socioeconomic origin relates to specialty choice. Nor is there a good understanding of the relationship between academic performance and specialty choice. To address these gaps, our aim was to identify the relationship between socioeconomic background, academic performance and accepted offers into specialty training.

DESIGN

Longitudinal, cohort study using data from the UK Medical Education Database (https://www.ukmed.ac.uk/).

PARTICIPANTS

6065 (60% females) UK doctors who accepted offers to a specialty training (residency) post after completing the 2-year generic foundation programme (UK Foundation Programme) between 2012 and 2014.

MAIN OUTCOME MEASURES

Χ² tests were used to examine the relationships between sociodemographic characteristics, academic ability and the dependent variable, specialty choice. Multiple data imputation was used to address the issue of missing data. Multinomial regression was employed to test the independent variables in predicting the likelihood of choosing a given specialty.

RESULTS

Participants pursuing careers in more competitive specialties had significantly higher academic scores than colleagues pursuing less competitive ones. After controlling for the presence of multiple factors, trainees who came from families where no parent was educated to a degree level had statistically significant lower odds of choosing careers in medical specialties relative to general practice (OR=0.78, 95% CI, 0.67 to 0.92). Students who entered medical school as school leavers, compared with mature students, had odds 1.2 times higher (95% CI, 1.04 to 1.56) of choosing surgical specialties than general practice.

CONCLUSIONS

The data indicate a direct association between trainees' sociodemographic characteristics, academic ability and career choices. The findings can be used by medical school, training boards and workforce planners to inform recruitment and retention strategies.

Attitudes towards psychiatry amongst medical and nursing students in Singapore

BACKGROUND

A shortage of specialists in psychiatry, both in terms of psychiatrists and psychiatric nurses is evident worldwide. While there are multiple factors leading to an individual's decision to specialize in psychiatry, the individual's perceptions and attitudes towards psychiatry tend to play an essential role. This study thus aimed to explore attitudes towards psychiatry amongst medical and nursing students in Singapore and examine factors associated with these attitudes.

METHODS

The present cross-sectional study used an online web survey tool to assess attitudes towards psychiatry amongst 502 medical and 500 nursing students in Singapore using the Attitudes towards Psychiatry (ATP-18) scale. Descriptive statistics and multiple linear regressions were used to examine associated factors (sociodemographic and education).

RESULTS

The majority of students in this population endorsed favourable attitudes towards the following aspects of psychiatry: challenges within psychiatry, importance of psychiatry and psychiatric skills, treatment efficacy and view towards psychiatrists, but had generally unfavourable attitudes towards psychiatric patients. Male participants (compared to female; β = - 1.190, p < 0.05), participants in the middle income group (compared to higher income group; β = - 0.945, p < 0.05), participants who rated average for psychiatry lecture course and psychiatry clinical placement course (compared to above average; β = - 1.654, p < 0.05; β = - 1.181, p < 0.05) had a less favourable attitude to psychiatry. Not surprisingly, participants who were more likely to specialize in psychiatry (β = 2.053, p < 0.001) had a more favourable attitude towards psychiatry compared to those who were less likely to specialize in psychiatry.

CONCLUSIONS

The majority of students in this study endorsed unfavourable attitudes towards patients in the psychiatric setting. The present psychiatry curriculum could be improved to nurture the development of empathetic attitudes towards people with mental illness. De-stigmatization strategies could also be integrated into other curricula besides psychiatry.

Prevalence of care fragmentation among outpatients attending specialist clinics in a regional hospital in Singapore: a cross-sectional study

OBJECTIVE

To measure the extent of multispecialty care fragmentation among outpatients receiving specialist care and identify associated risk factors for fragmented care.

DESIGN

A retrospective cross-sectional study.

SETTING

Specialist outpatient clinics (SOCs) in a Singapore regional hospital.

PARTICIPANTS

A total of 40 333 patients aged 21 and above with at least two SOC visits in the year 2016. Data for 146 792 physician consultation visits were used in the analysis and visits for allied health services and medical procedures were excluded.

OUTCOME MEASURES

The Fragmentation of Care Index (FCI) was used to measure care fragmentation for specialist outpatients. Log-linear regression with stepwise selection was used to investigate the association between FCI and patient age, gender, race and Most Frequently Visited Specialty (MFVS), controlling for number of different specialities seen.

RESULTS

About 36% experienced fragmented care (FCI >0) and their mean FCI was 0.70 (SD=0.20). FCI was found to be positively associated with age (p<0.001). Patients who most frequently visited Haematology, Endocrinology and Anaesthesiology specialities were associated with more fragmented care while those who most frequently visited Medical Oncology, Ophthalmology and Orthopaedics Surgery specialities were associated with less fragmented care.

CONCLUSION

Multispecialty care fragmentation was found to be moderately high in the outpatient specialist clinics and was found to be associated with patients' age and certain medical specialties. With an ageing population and a rising prevalence of multimorbidity, healthcare providers should seek to eliminate unnecessary referrals to reduce the extent of care fragmentation.

Factors influencing primary care providers' decisions to accept new Medicaid patients under Michigan's Medicaid expansion

OBJECTIVES

Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)' decision to accept new Medicaid patients under Medicaid expansion.

STUDY DESIGN

Statewide survey of PCPs informed by semistructured interviews.

METHODS

After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs' current acceptance of new Medicaid patients.

RESULTS

Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes.

CONCLUSIONS

In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients' medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.

Specialty care access for Medicaid enrollees in expansion states

OBJECTIVES

Community health centers (CHCs) historically have reported challenges obtaining specialty care for their patients, but recent policy changes, including Medicaid eligibility expansions under the Affordable Care Act, may have improved access to specialty care. The objective of this study was to assess current levels of difficulty accessing specialty care for CHC patients, by insurance type, and to identify specific barriers and strategies that CHCs are using to overcome these barriers.

STUDY DESIGN

Cross-sectional survey, administered during summer 2017, of medical directors at CHCs in 9 states and the District of Columbia, all of which expanded Medicaid.

METHODS

Surveys were administered to medical directors at 361 CHCs (response rate, 55%) to assess the difficulty of accessing specialty care by insurance type and to identify the specialties for which it was most difficult to obtain new patient visits. The survey also elicited ratings of commonly reported barriers to obtaining specialty care and identified strategies used by CHCs to access specialty care for patients. Descriptive results are presented.

RESULTS

Nearly 60% of CHCs reported difficulty obtaining new patient specialty visits for their Medicaid patients, most often for orthopedists. Barriers to specialty care reported by CHCs included that few specialists in Medicaid managed care organization (MCO) networks were accepting new patients (69.4%) and MCO administrative requirements for obtaining specialist consults (49.0%). To enhance access to specialists, CHCs reported that they entered into referral agreements, developed appointment reminder systems, and participated in data exchange and other community-based initiatives.

CONCLUSIONS

Medicaid patients at CHCs face many barriers to accessing specialty care. Payment policies and network adequacy rules may need to be reexamined to address these challenges.

[Prescribing of Non-Steroidal Anti-Inflammatory Drugs to Patients with Diabetes Mellitus in Portugal]

INTRODUCTION

Portugal presents the highest incidence of stage 5 chronic kidney disease in Europe. It is speculated that a high consumption of non-steroidal anti-inflammatory drugs (NSAIDS) may contribute to this high incidence. Our aim was to characterize the prescription of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus in Portugal.

MATERIAL AND METHODS

We analyzed the national prescription database in triennium 2015 - 2017. In patients with diabetes mellitus, we evaluated the prescription of non-steroidal anti-inflammatory drugs according to age, gender and region of the patient and specialty of the prescribing physician. We evaluated the prescription of non-steroidal anti-inflammatory drugs in all patients with diabetes mellitus, in patients with presumed renal impairment, and in those with concomitant prescription of angiotensin converting enzyme inhibitors or angiotensin receptor antagonists.

RESULTS

We analyzed 23 320 620 prescriptions, corresponding to 610 157 adults, including 104 306 patients with diabetes mellitus. The most prescribed non-steroidal anti-inflammatory drugs were ibuprofen (20.1%), metamizole (14.7%), and diclofenac (11.4%). The prescription of non-steroidal anti-inflammatory drugs was higher in females, in patients aged 51 - 70 years and in the Alentejo region. Non-steroidal anti-inflammatory drugs were prescribed to 70.6% of patients with diabetes mellitus, from which 10.6% were prescribed ≥ 10 packages during the three years. Among patients with diabetes mellitus on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and with presumed reduction in kidney function, 69.3% were prescribed non-steroidal anti-inflammatory drugs and 11.5% were prescribed ≥ 10 packages during the three years.

DISCUSSION

The level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus is high. The concern of reducing non-steroidal anti-inflammatory drugs prescription to patients already on angiotensin converting enzyme inhibitors/angiotensin receptor antagonists and/or decreased renal function does not seem to exist.

CONCLUSION

In Portugal, the level of prescribing of non-steroidal anti-inflammatory drugs to patients with diabetes mellitus should be reduced, particularly in the subgroups identified with higher prescription and with higher risk of progression to stage 5 chronic kidney disease.

Swedish doctors' experiences and personality regarding medical specialty choice: a qualitative study

OBJECTIVES

To explore an understanding of medical doctors' entire process of specialty choice with a focus on the influence of personal experiences and personality traits on choices made.

METHODS

A qualitative study was performed. Semi-structured individual interviews were conducted with medical doctors undergoing their specialty training in Sweden about their experiences and personalities. The transcribed interviews were analyzed with an inductive content analysis approach.

RESULTS

A total of 15 medical doctors participated. Three themes were identified using content analysis: To be invited or not, to fit in or not and to contribute or not. Furthermore, the results refute that specialty choice is a long-term, complex process.

CONCLUSIONS

First, the importance of being invited to the specialty choice was stressed by the doctors, especially in their early years when they needed to feel valued and trusted. Secondly, the need to fit in was essential to make a sustainable career choice. Finally, the doctors' expressed a will to contribute to the medical field of their chosen specialty. The interviews showed that specialty choice is a long-term, complex process; therefore, one implication for the healthcare sector would be to target the entire chain of medical education to improve recruitment strategies for those specialties with recruitment difficulties. More studies are needed to understand better how positive and negative encounters within the healthcare sector can influence young doctors' specialty choice.

Disciplinary boundaries and integrating care: using Q-methodology to understand trainee views on being a good doctor

BACKGROUND

Rising numbers of patients with multiple-conditions and complex care needs mean that it is increasingly important for doctors from different specialty areas to work together, alongside other members of the multi-disciplinary team, to provide patient centred care. However, intra-professional boundaries and silos within the medical profession may challenge holistic approaches to patient care.

METHODS

We used Q methodology to examine how postgraduate trainees (n = 38) on a range of different specialty programmes in England and Wales could be grouped based on their rankings of 40 statements about 'being a good doctor'. Themes covered in the Q-set include: generalism (breadth) and specialism (depth), interdisciplinarity and multidisciplinary team working, patient-centredness, and managing complex care needs.

RESULTS

A by-person factor analysis enabled us to map distinct perspectives within our participant group (P-set). Despite high levels of overall commonality, three groups of trainees emerged, each with a clear perspective on being a good doctor. We describe the first group as 'generalists': team-players with a collegial and patient-centred approach to their role. The second group of 'general specialists' aspired to be specialists but with a generalist and patient-centred approach to care within their specialty area. Both these two groups can be contrasted to those in the third 'specialist' group, who had a more singular focus on how their specialty can help the patient.

CONCLUSIONS

Whilst distinct, the priorities and values of trainees in this study share some important aspects. The results of our Q-sort analysis suggest that it may be helpful to understand the relationship between generalism and specialism as less of a dichotomy and more of a continuum that transcends primary and secondary care settings. A nuanced understanding of trainee views on being a good doctor, across different specialties, may help us to bridge gaps and foster interdisciplinary working.

Empathy and big five personality model in medical students and its relationship to gender and specialty preference: a cross-sectional study

BACKGROUND

Given the influence that personality can have on empathy, this study explores the relationship between empathy and personality, using three different measures of empathy, and taking into account gender and specialty preference.

METHODS

Cross-sectional study. One hundred and ten medical students completed the Jefferson Scale of Physician Empathy, the Interpersonal Reactivity Index, the Empathy Quotient, and the NEO-FFI Big Five personality model. Multivariable linear regression was performed to assess the association between personality traits and empathy.

RESULTS

Empathy scales showed weak and moderate correlation with personality. The strongest correlations were observed between IRI-Fantasy and Openness, and between IRI-Personal Distress and Neuroticism. Gender and specialty preference can modify this relationship. The extreme groups of Empathy Quotient had significant differences in most personality traits.

CONCLUSIONS

This study confirmed that empathy is related to personality. Using three empathy scales allows personalizing the evaluation of different empathy models and its relation with personality. These results can help to design programs to study if some personalized intervention strategies could improve the empathy in medical students.

Factors influencing the career preferences of medical students and interns: a cross-sectional, questionnaire-based survey from India

PURPOSE

The study aimed to identify the motivational factors and demographic variables influencing the career preferences of medical students in India.

METHODS

We conducted a questionnaire-based survey at Christian Medical College, Vellore, India. The participants were 368 of the 460 medical students and interns enrolled at the institution from October 2015 to August 2016. We designed the questionnaire to collect demographic data, students' preferences for career specialties, and the motivational factors influencing them. Then, we analyzed the influence of these factors and demographic variables on career preferences using regression analysis.

RESULTS

Of the 368 respondents, 356 (96.7%) expressed their intention to pursue a residency program after the MBBS program, and about two-thirds indicated their preference to do so in India. The specialties most preferred by students were general surgery, general medicine (internal medicine), and pediatrics, while the least preferred were anatomy, obstetrics and gynecology, and community medicine. Factor analysis yielded three motivational factors, which we named 'personal growth,' 'professional growth,' and 'personal satisfaction' based on the items loaded in each. The motivational factors were predicted by demographic variables (gender, geographical background, current stage in the MBBS program, and the presence of relatives in the health professions). Demographic variables and the motivational factors also had significant influences on career preferences.

CONCLUSIONS

This study provides insights into the motivational factors that influence the career preferences of Indian medical students and interns. A robust longitudinal study would be required to study intra-individual variations in preferences and the persistence of choices.

Early Subspecialization in Orthopedic Surgery Training

Recent studies have shown that applicants to the American Board of Orthopaedic Surgery Part II examination are performing fewer procedures outside of their chosen subspecialty. In this study, the authors assessed whether trainees are beginning their subspecialization during residency. The authors reviewed the chosen fellowships and case logs of 231 residents graduating from 5 academic orthopedic residency training programs from 2002 to 2017. The number of cases logged by residents who chose a specialty was then compared with the number of cases logged by residents who chose other specialties. Residents who chose spine surgery (108.4±50.7 vs 74.4±60.2, P<.01), hand surgery (242.2±92.9 vs 194.3±78.2, P<.01), and sports medicine (278.5±105.8 vs 229.0±93.9, P<.01) performed significantly more procedures in their chosen fields than their colleagues. In contrast, for total joint arthroplasty (P=.18) and foot and ankle surgery (P=.46), there was no significant difference in the number of cases between residents who chose the sub-specialty and those who did not. Residents pursuing careers in spine surgery, hand surgery, and sports medicine obtained additional operative exposure to their chosen field during residency. Formalizing this early experience with specialization tracks during the chief year may be considered. [Orthopedics. 2019; 42(1):e39-e43.].

Predictors of medical student interest in Indigenous health learning and clinical practice: a Canadian case study

BACKGROUND

Including content on Indigenous health in medical school curricula has become a widely-acknowledged prerequisite to reducing the health disparities experienced by Indigenous peoples in Canada. However, little is known about what levels of awareness and interest medical students have about Indigenous peoples when they enter medical school. Additionally, it is unclear whether current Indigenous health curricula ultimately improve students' beliefs and behaviours.

METHODS

A total of 129 students completed a 43-item questionnaire that was sent to three cohorts of first-year medical students (in 2013, 2014, 2015) at one undergraduate medical school in Canada. This survey included items to evaluate students' sociopolitical attitudes towards Indigenous people, knowledge of colonization and its links to Indigenous health inequities, knowledge of Indigenous health inequities, and self-rated educational preparedness to work with Indigenous patients. The survey also assessed students' perceived importance of learning about Indigenous peoples in medical school, and their interest in working in an Indigenous community, which were examined as outcomes. Using principal component analysis, survey items were grouped into five independent factors and outcomes were modelled using staged multivariate regression analyses.

RESULTS

Generally, students reported strong interest in Indigenous health but did not believe themselves adequately educated or prepared to work in an Indigenous community. When controlling for age and gender, the strongest predictors of perceived importance of learning about Indigenous health were positive sociopolitical attitudes about Indigenous peoples and knowledge about colonization and its links to Indigenous health inequities. Significant predictors for interest in working in an Indigenous community were positive sociopolitical attitudes about Indigenous peoples. Knowledge about Indigenous health inequities was negatively associated with interest in working in an Indigenous community.

CONCLUSIONS

Students' positive sociopolitical attitudes about Indigenous peoples is the strongest predictor of both perceived importance of learning about Indigenous health and interest in working in Indigenous communities. In addition to teaching students about the links between colonization, health inequities and other knowledge-based concepts, medical educators must consider the importance of attitude change in designing Indigenous health curricula and include opportunities for experiential learning to shape students' future behaviours and ultimately improve physician relationships with Indigenous patients.

Golf habits among physicians and surgeons: observational cohort study

OBJECTIVES

To examine patterns of golfing among physicians: the proportion who regularly play golf, differences in golf practices across specialties, the specialties with the best golfers, and differences in golf practices between male and female physicians.

DESIGN

Observational study.

SETTING

Comprehensive database of US physicians linked to the US Golfing Association amateur golfer database.

PARTICIPANTS

41 692 US physicians who actively logged their golf rounds in the US Golfing Association database as of 1 August 2018.

MAIN OUTCOME MEASURES

Proportion of physicians who play golf, golf performance (measured using golf handicap index), and golf frequency (number of games played in previous six months).

RESULTS

Among 1 029 088 physicians, 41 692 (4.1%) actively logged golf scores in the US Golfing Association amateur golfer database. Men accounted for 89.5% of physician golfers, and among male physicians overall, 5.5% (37 309/683 297) played golf compared with 1.3% (4383/345 489) among female physicians. Rates of golfing varied substantially across physician specialties. The highest proportions of physician golfers were in orthopedic surgery (8.8%), urology (8.1%), plastic surgery (7.5%), and otolaryngology (7.1%), whereas the lowest proportions were in internal medicine and infectious disease (<3.0%). Physicians in thoracic surgery, vascular surgery, and orthopedic surgery were the best golfers, with about 15% better golf performance than specialists in endocrinology, dermatology, and oncology.

CONCLUSIONS

Golfing is common among US male physicians, particularly those in the surgical subspecialties. The association between golfing and patient outcomes, costs of care, and physician wellbeing remain unknown.

Is There a Surplus of Non-Specialist Physicians in Portugal or Just Poor Human Resources Planning?

N/A.

Impact of accelerated, graduate-entry medicine courses: a comparison of profile, success, and specialty destination between graduate entrants to accelerated or standard medicine courses in UK

BACKGROUND

Little research has compared the profile, success, or specialty destinations of graduates entering UK medical schools via accelerated, 4-yr, standard 5-yr and 6-yr programmes. Four research questions directed this investigation:- What are the success rates for graduates entering graduate-entry vs. undergraduate medicine courses? How does the sociodemographic and educational profile differ between these two groups? Is success - in medical school and foundation training - dependent on prior degree, demographic factors, or aptitude test performance at selection? What specialty do graduate entry medicine students subsequently enter?

METHODS

The data from two cohorts of graduates entering medical school in 2007 and 2008 (n = 2761) in the UKMED (UK Medical Education Database) database were studied: 1445 taking 4-yr and 1150 taking 5-yr medicine courses, with smaller numbers following other programmes.

RESULTS

Completion rates for degree programmes were high at 95%, with no significant difference between programme types. 4-yr entrants were older, less likely to be from Asian communities, had lower HESA (Higher Education Statistics Agency) tariff scores, but higher UKCAT (UK Clinical Aptitude Test) and GAMSAT (Graduate Medical School Admissions Test) scores, than 5-yr entrants. Higher GAMSAT scores, black or minority ethnicity (BME), and younger age were independent predictors of successful completion of medical school. Foundation Programme (FPAS) selection measures (EPM - educational performance measure; SJT - situational judgment test) were positively associated with female sex, but negatively with black or minority ethnicity. Higher aptitude test scores were associated with EPM and SJT, GAMSAT with EPM, UKCAT with SJT. Prior degree subject, class of degree, HESA tariff, and type of medicine programme were not related to success.

CONCLUSIONS

The type of medicine programme has little effect on graduate entrant completion, or EPM or SJT scores, despite differences in student profile. Aptitude test score has some predictive validity, as do sex, age and BME, but not prior degree subject or class. Further research is needed to disentangle the influences of BME.

Views of UK doctors in training on the timing of choosing a clinical specialty: quantitative and qualitative analysis of surveys 3 years after graduation

BACKGROUND

Workforce studies show a declining proportion of UK junior doctors proceeding directly to specialist training, with many taking career breaks. Doctors may be choosing to delay this important career decision.

AIM

To assess doctors' views on the timing of choosing a clinical specialty.

METHODS

Surveys of two cohorts of UK-trained doctors 3 years after qualification, in 2011 and 2015.

RESULTS

Presented with the statement 'I had to choose my career specialty too soon after qualification', 61% agreed (27% strongly) and 22% disagreed (3% strongly disagreed). Doctors least certain about their choice of specialty were most likely to agree (81%), compared with those who were more confident (72%) or were definite regarding their choice of long-term specialty (54%). Doctors not in higher specialist training were more likely to agree with this statement than those who were (72% vs 59%). Graduate medical school entrants (ie, those who had completed prior degrees) were less likely to agree than non-graduates (56% vs 62%). Qualitative analysis of free text comments identified three themes as reasons why doctors felt rushed into choosing their future career: insufficient exposure to a wide range of specialties; a desire for a greater breadth of experience of medicine in general; and inadequate career advice.

CONCLUSIONS

Most UK-trained doctors feel rushed into choosing their long-term career specialty. Doctors find this difficult because they lack sufficient medical experience and adequate career advice to make sound choices. Workforce trainers and planners should enable greater flexibility in training pathways and should further improve existing career guidance.

The impact of the 2008/2009 financial crisis on specialist physician activity in Canada

Fee-for-service physicians are responsible for planning for their retirements, and there is no mandated retirement age. Changes in financial markets may influence how long they remain in practice and how much they choose to work. The 2008 crisis provides a natural experiment to analyze elasticity in physician service supply in response to dramatic financial market changes. We examined quarterly fee-for-service data for specialist physicians over the period from 1999/2000 to 2013/2014 in Canada. We used segmented regression to estimate changes in the number of physicians receiving payments, per-physician service counts, and per-physician payments following the 2008 financial crisis and explored whether patterns differed by physician age. The number of specialist physicians increased more rapidly in the period since 2008 than in earlier years, but increases were largest within the youngest age group, and we observed no evidence of delayed retirement among older physicians. Where changes in service volume and payments were observed, they occurred across all ages and not immediately following the 2008 financial crisis. We conclude that any response to the financial crisis was small compared with demographic shifts in the physician population and changes in payments per service over the same time period.