Dentists in Nepal: A Situation Analysis

BACKGROUND

Human resource data is essential for planning and implementation of health care delivery system. However, very few information is available on dental health human resource in the country. The aim of study was to assess the number of dentists in the country and to explore their distribution according to demographic and professional characteristics.

METHODS

A census was performed during July 2015 to July 2016 about the Nepali dentists. The study assessed demographic and professional characteristics of dentists including age, gender, ethnicity, education attainment, university, country/year of graduation, and work place using data collection sheet by trained data collectors. For those not accessible for direct contact, the information was obtained through secondary data. Data entry was done in CSPro software application and was analyzed in SPSS 20.

RESULTS

The total number of registered Nepali dentists was 1803 with 419 specialists until June 2015. The male to female ratio was 1:1.46. Among all; 1318 (73%) were present in the country, 1047 (58%) were professionally active, and 1366 (76%) were below the age of 35 years. Among the professionals; 831 (79%) were employed in private sector and 601 (57%) worked in Kathmandu valley.

CONCLUSIONS

The dentist-population ratio is decreasing exponentially in capital and major cities of Nepal however it remains very high in rural areas. Compared to other provinces,Province 6 and Province 7 lack service of dentists.

Getting the right balance? A mixed logit analysis of the relationship between UK training doctors' characteristics and their specialties using the 2013 National Training Survey

OBJECTIVE

To analyse how training doctors' demographic and socioeconomic characteristics vary according to the specialty that they are training for.

DESIGN

Descriptive statistics and mixed logistic regression analysis of cross-sectional survey data to quantify evidence of systematic relationships between doctors' characteristics and their specialty.

SETTING

Doctors in training in the United Kingdom in 2013.

PARTICIPANTS

27 530 doctors in training but not in their foundation year who responded to the National Training Survey 2013.

MAIN OUTCOME MEASURES

Mixed logit regression estimates and the corresponding odds ratios (calculated separately for all doctors in training and a subsample comprising those educated in the UK), relating gender, age, ethnicity, place of studies, socioeconomic background and parental education to the probability of training for a particular specialty.

RESULTS

Being female and being white British increase the chances of being in general practice with respect to any other specialty, while coming from a better-off socioeconomic background and having parents with tertiary education have the opposite effect. Mixed results are found for age and place of studies. For example, the difference between men and women is greatest for surgical specialties for which a man is 12.121 times more likely to be training to a surgical specialty (relative to general practice) than a woman (p-value<0.01). Doctors who attended an independent school which is proxy for doctor's socioeconomic background are 1.789 and 1.413 times more likely to be training for surgical or medical specialties (relative to general practice) than those who attended a state school (p-value<0.01).

CONCLUSIONS

There are systematic and substantial differences between specialties in respect of training doctors' gender, ethnicity, age and socioeconomic background. The persistent underrepresentation in some specialties of women, minority ethnic groups and of those coming from disadvantaged backgrounds will impact on the representativeness of the profession into the future. Further research is needed to understand how the processes of selection and the self-selection of applicants into specialties gives rise to these observed differences.

Referral processes and wait times in primary care

OBJECTIVE

To evaluate the response times to requests for consultations from FPs and the wait times for patient appointments.

DESIGN

Mailed invitation to participate in a survey about non-FP specialist consultation requests from April 28 to May 9, 2014.

SETTING

Hamilton, Ont.

PARTICIPANTS

All active physicians with community practices from the Department of Family Medicine at St Joseph's Healthcare Hamilton and Hamilton Health Sciences.

MAIN OUTCOME MEASURES

All non-FP specialist consultation requests for a 2-week period.

RESULTS

Thirty-four practices (9.6% response rate) collected data on 816 consultation requests. Requests for referrals were most commonly made to the following 5 specialties: dermatology, surgery, gastroenterology, orthopedics, and obstetrics and gynecology. Overall, 36.4% of the requests for consultation received no response from the non-FP specialist's office by the end of the follow-up period. The mean wait time for a patient appointment was 60.1 days (range 23.3 to 168.5 days). Five specialties had particularly lengthy wait times of 105.9 to 168.5 days.

CONCLUSION

Allowing 5 to 7 weeks for a response from a non-FP specialist, there was still a 36.4% nonresponse rate (similar to a pilot survey administered in 2010). Patient and physician frustration is certainly heightened and more office time and energy is expended when no acknowledgment of a referral is received within 7 weeks. This gives our community wait times much longer than those reported by any of the national bodies.

The rural pipeline to longer-term rural practice: General practitioners and specialists

BACKGROUND

Rural medical workforce shortage contributes to health disadvantage experienced by rural communities worldwide. This study aimed to determine the regional results of an Australian Government sponsored national program to enhance the Australian rural medical workforce by recruiting rural background students and establishing rural clinical schools (RCS). In particular, we wished to determine predictors of graduates' longer-term rural practice and whether the predictors differ between general practitioners (GPs) and specialists.

METHODS

A cross-sectional cohort study, conducted in 2012, of 729 medical graduates of The University of Queensland 2002-2011. The outcome of interest was primary place of graduates' practice categorised as rural for at least 50% of time since graduation ('Longer-term Rural Practice', LTRP) among GPs and medical specialists. The main exposures were rural background (RB) or metropolitan background (MB), and attendance at a metropolitan clinical school (MCS) or the Rural Clinical School for one year (RCS-1) or two years (RCS-2).

RESULTS

Independent predictors of LTRP (odds ratio [95% confidence interval]) were RB (2.10 [1.37-3.20]), RCS-1 (2.85 [1.77-4.58]), RCS-2 (5.38 [3.15-9.20]), GP (3.40 [2.13-5.43]), and bonded scholarship (2.11 [1.19-3.76]). Compared to being single, having a metropolitan background partner was a negative predictor (0.34 [0.21-0.57]). The effects of RB and RCS were additive-compared to MB and MCS (Reference group): RB and RCS-1 (6.58[3.32-13.04]), RB and RCS-2 (10.36[4.89-21.93]). Although specialists were less likely than GPs to be in LTRP, the pattern of the effects of rural exposures was similar, although some significant differences in the effects of the duration of RCS attendance, bonded scholarships and partner's background were apparent.

CONCLUSIONS

Among both specialists and GPs, rural background and rural clinical school attendance are independent, duration-dependent, and additive, predictors of longer-term rural practice. Metropolitan-based medical schools can enhance both specialist and GP rural medical workforce by enrolling rural background medical students and providing them with long-term rural undergraduate clinical training. Policy settings to achieve optimum rural workforce outcomes may differ between specialists and GPs.

Pakistani women's use of mental health services and the role of social networks: a systematic review of quantitative and qualitative research

Pakistani women in the UK are an at-risk group with high levels of mental health problems, but low levels of mental health service use. However, the rates of service use for Pakistani women are unclear, partly because research with South Asian women has been incorrectly generalised to Pakistani women. Further, this research has been largely undertaken within an individualistic paradigm, with little consideration of patients' social networks, and how these may drive decisions to seek help. This systematic review aimed to clarify usage rates, and describe the nature of Pakistani women's social networks and how they may influence mental health service use. Ten journal databases (ASSIA, CINAHL Plus, EMBASE, HMIC, IBSS, MEDLINE, PsycINFO, Social Sciences Abstracts, Social Science Citation Index and Sociological Abstracts) and six sources of grey literature were searched for studies published between 1960 and the end of March 2014. Twenty-one studies met inclusion criteria. Ten studies (quantitative) reported on inpatient or outpatient service use between ethnic groups. Seven studies (four quantitative, three qualitative) investigated the nature of social networks, and four studies (qualitative) commented on how social networks were involved in accessing mental health services. Pakistani women were less likely than white (British) women to use most specialist mental health services. No difference was found between Pakistani and white women for the consultation of general practitioners for mental health problems. Pakistani women's networks displayed high levels of stigmatising attitudes towards mental health problems and mental health services, which acted as a deterrent to seeking help. No studies were found which compared stigma in networks between Pakistani women and women of other ethnic groups. Pakistani women are at a considerable disadvantage in gaining access to and using statutory mental health services, compared with white women; this, in part, is due to negative attitudes to mental health problems evident in social support networks.

Credentialing and retention of visa trainees in post-graduate medical education programs in Canada

BACKGROUND

Visa trainees are international medical graduates (IMG) who come to Canada to train in a post-graduate medical education (PGME) program under a student or employment visa and are expected to return to their country of origin after training. We examined the credentialing and retention of visa trainees who entered PGME programs between 2005 and 2011.

METHODS

Using the Canadian Post-MD Education Registry's National IMG Database linked to Scott's Medical Database, we examined four outcomes: (1) passing the Medical Council of Canada Qualifying Examination Part 2 (MCCQE2), (2) obtaining a specialty designation (CCFP, FRCPC/SC), and (3) working in Canada after training and (4) in 2015. The National IMG Database is the most comprehensive source of information on IMG in Canada; data were provided by physician training and credentialing organizations. Scott's Medical Database provides data on physician locations in Canada.

RESULTS

There were 233 visa trainees in the study; 39.5% passed the MCCQE2, 45.9% obtained a specialty designation, 24.0% worked in Canada after their training, and 53.6% worked in Canada in 2015. Family medicine trainees (OR = 8.33; 95% CI = 1.69-33.33) and residents (OR = 3.45; 95% CI = 1.96-6.25) were more likely than other specialist and fellow trainees, respectively, to pass the MCCQE2. Residents (OR = 7.69; 95% CI = 4.35-14.29) were more likely to obtain a specialty credential than fellows. Visa trainees eligible for a full license were more likely than those not eligible for a full license to work in Canada following training (OR = 3.41; 95% CI = 1.80-6.43) and in 2015 (OR = 3.34; 95% CI = 1.78-6.27).

CONCLUSIONS

Visa training programs represent another route for IMG to qualify for and enter the physician workforce in Canada. The growth in the number of visa trainees and the high retention of these physicians warrant further consideration of the oversight and coordination of visa trainee programs in provincial and in pan-Canadian physician workforce planning.

The 2015 Class of Hospice and Palliative Medicine Fellows-From Training to Practice: Implications for HPM Workforce Supply

CONTEXT

A relatively new specialty, hospice and palliative medicine (HPM), is unusual in that physicians can enter from 10 different specialties. This study sought to understand where HPM physicians were coming from, where they were going to practice, and the job market for HPM physicians.

OBJECTIVES

Describe characteristics of the incoming supply of HPM physicians, their practice plans, and experience finding initial jobs.

METHODS

In October 2015, we conducted an online survey of physicians who completed accredited HPM fellowships the previous June. We had electronic mail addresses for 195 of the 243 graduating fellows.

RESULTS

About 112 HPM fellows responded (58% of those invited). The most common prior training was internal medicine (45%), followed by family medicine (23%), pediatrics (12%), and emergency medicine (10%). More than 40% had practiced medicine before their HPM training. After graduation, 97% were providing 20 or more hours per week of patient care, with most hours in palliative care. About 72% devoted more than 20 hours per week to palliative care, whereas only 13% worked that much in hospice care. About 81% reported no difficulty finding a satisfactory practice position. About 98% said that they would recommend HPM to others, and 63% took the time to provide written comments that were highly positive about the specialty.

CONCLUSION

New HPM physicians are finding satisfying jobs. They are enthusiastic in recommending the specialty to others. Most are going into palliative medicine, leaving questions about how the need for hospice physicians will be filled. Although jobs appear to be numerous, there are practice areas with more limited opportunities.

[Evaluation of an outpatient multidisciplinary Neuro-HIV clinic by the patients and referring doctors]

The neurocognitive complaints among HIV infected patients remain frequent, and to establish their etiology can be challenging. We created in 2011 an outpatient Neuro-HIV clinical platform that takes advantage of a multidisciplinary approach with 5 specialists (neuropsychologist, neurologist, psychiatrist, infectiologist and neuroradiologist). In order to estimate its utility, we conducted two questionnaire-based interviews by phone calls with the patients and their referring physicians. Three quarters of both the patients and the physicians interviewed consider the platform useful or essential. Even though there is often no immediate treatment for cognitive disorders, the patients receive from this multidisciplinary approach a better understanding of their disease, which may help them to better cope with their anxieties in daily life.

The first nationwide survey of MD-PhDs in the social sciences and humanities: training patterns and career choices

BACKGROUND

While several articles on MD-PhD trainees in the basic sciences have been published in the past several years, very little research exists on physician-investigators in the social sciences and humanities. However, the numbers of MD-PhDs training in these fields and the number of programs offering training in these fields are increasing, particularly within the US. In addition, accountability for the public funding for MD-PhD programs requires knowledge about this growing population of trainees and their career trajectories. The aim of this paper is to describe the first cohorts of MD-PhDs in the social sciences and humanities, to characterize their training and career paths, and to better understand their experiences of training and subsequent research and practice.

METHODS

This paper utilizes a multi-pronged recruitment method and novel survey instrument to examine an understudied population of MD-PhD trainees in the social sciences and humanities, many of whom completed both degrees without formal programmatic support. The survey instrument was designed to collect demographic, training and career trajectory data, as well as experiences of and perspectives on training and career. It describes their routes to professional development, characterizes obstacles to and predictors of success, and explores career trends.

RESULTS

The average length of time to complete both degrees was 9 years. The vast majority (90%) completed a clinical residency, almost all (98%) were engaged in research, the vast majority (88%) were employed in academic institutions, and several others (9%) held leadership positions in national and international health organizations. Very few (4%) went into private practice. The survey responses supply recommendations for supporting current trainees as well as areas for future research.

CONCLUSIONS

In general, MD-PhDs in the social sciences and humanities have careers that fit the goals of agencies providing public funding for training physician-investigators: they are involved in mutually-informative medical research, clinical practice, and teaching - working to improve our responses to the social, cultural, and political determinants of health and health care. These findings provide strong evidence for continued and improved funding and programmatic support for MD-PhD trainees in the social sciences and humanities.

National survey of Canadian ophthalmology residency education

OBJECTIVE

To describe the current clinical, surgical, and other educational activities of Canadian ophthalmology residents.

DESIGN

Cross-sectional study.

PARTICIPANTS

Canadian ophthalmology residents postgraduate year (PGY) 2 to 5.

METHODS

An online survey was sent to residents in 2011 and 2014. The data sets were merged and analyzed using descriptive statistics.

RESULTS

The response rate was 41% with an equal distribution across sexes and PGY level. Residents from each program responded. Clinical rotations were led by emergency and comprehensive ophthalmology. The least number of days were spent in oncology, refractive, and low-vision clinics. The mean number of full cases performed by PGY5 was 324 cataracts, 9 trabeculectomies, and 48 horizontal muscles. Most PGY2 to PGY5 students performed more than 10 laser procedures of each type surveyed. Subspecialty surgical volumes varied and were lowest for scleral buckle, refractive laser, penetrating keratoplasty, and floor fracture. The majority of residents received up to 10 hours per week of teaching and 4 to 6 weeks of Royal College study time. Most respondents attended at least 1 funded conference annually and met with program directors twice a year. Research time and grand rounds presentations varied greatly. Forty-six percent of residents had fellowship plans.

CONCLUSIONS

This study describes the current clinical, surgical, and other educational activities across Canadian ophthalmology residency programs. The data allows individual programs to evaluate their training models in relation to broader national trends.

Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists

STUDY OBJECTIVE

Many adolescents with chronic medical conditions (CMCs) are at risk of human papillomavirus (HPV) infection, associated complications, and underimmunization and often identify a pediatric subspecialist as their main provider. This study aimed to assess the HPV-related understanding, beliefs, and practices of pediatric subspecialists, which are largely unknown.

DESIGN AND SETTING

National cross-sectional study.

PARTICIPANTS

Pediatric endocrinologists, hematologist/oncologists, pulmonologists, and rheumatologists identified using the American Medical Association Physician Masterfile (n = 418).

INTERVENTIONS

Subspecialists who care for adolescents with CMCs in the outpatient setting were recruited to complete a Web-based survey on their HPV-related knowledge, attitudes, comfort, and practices.

MAIN OUTCOME MEASURES

HPV vaccination recommendation.

RESULTS

Over half of respondents (50.4%; n = 196/389) reported sometimes or always recommending HPV vaccination to adolescent patients with CMCs. Factors positively associated with recommendation included hematology/oncology (adjusted odds ratio [AOR], 4.69; 95% confidence interval [CI], 1.86-11.81) or rheumatology (AOR, 6.55; 95% CI, 1.67-25.74) specialization, seeing more adolescent patients with CMCs (AOR, 1.01; 95% CI, 1.00-1.02), and sometimes or always discussing sexual health (AOR, 2.53; 95% CI, 1.05-6.08) or checking vaccine status (AOR, 3.83; 95% CI, 1.59-9.20) with these patients. Those who thought it was important, but were uncomfortable discussing sexual health when recommending HPV vaccination (AOR, 0.28; 95% CI, 0.12-0.70) or who reported insufficient HPV vaccine information (AOR, 0.45; 95% CI, 0.23-0.88) or lack of primary-subspecialty care provider communication (AOR, 0.38; 95% CI, 0.16-0.93) as barriers to HPV vaccination were less likely to recommend HPV vaccination.

CONCLUSION

This study revealed that many subspecialists fail to recommend HPV vaccination to adolescents with CMCs and highlights potential targets for future interventions.

Randomized Trial of Population-Based Clinical Decision Support to Facilitate Care Transitions

Medicaid beneficiaries in 6 North Carolina counties were randomly assigned to 1 of 3 clinical decision support (CDS) care transition strategies: (1) usual care (Control), (2) CDS messaging to patients and their medical homes (Reports), or (3) CDS messaging to patients, their medical homes, and their care managers (Reports+). We included 7146 Medicaid patients and evaluated transitions from specialist visit, ER and hospital encounters back to the patient's medical home. Patients enrolled in Medicare and Medicaid were not eligible. The number of care manager contacts was greater for patients in the Reports+ Group than in the Control Group. However, there were no treatment-related differences in emergency department (ED) encounter rates, or in the secondary outcomes of outpatient and hospital encounter rates and medical costs. Study monitors found study intervention documentation in approximately 60% of patient charts. These results highlight the importance of effectively integrating information interventions into healthcare delivery workflow systems.

Orthopedic Surgeons' Management of Elective Surgery for Patients Who Use Nicotine

Despite significant research documenting the detrimental effects of tobacco, the orthopedic literature lacks evidence regarding how surgeons alter their management of elective surgery when patients use nicotine. To better understand how patients' use of nicotine influences orthopedic surgeons' pre- and postoperative management of elective surgery, a 9-question paper survey was distributed at the 2012 annual meeting of the American Academy of Orthopaedic Surgeons among attending US orthopedic surgeons, including general orthopedists and specialty-trained orthopedic surgeons. Survey questions focused on attitudes and practice management regarding patients who use nicotine. Using a chi-square test, no statistically significant variation was observed between subspecialists and general orthopedists or among different subspecialties. Ninety-eight percent of the orthopedic surgeons surveyed counseled tobacco users about the adverse effects of nicotine. However, approximately half of all of the respondents spent less than 5 minutes on perioperative nicotine counseling. Forty-one percent of all of the respondents never delayed elective surgery because of a patient's nicotine use, followed closely by 39% delaying surgery for less than 3 months. Subspecialty had little influence on how orthopedic surgeons managed nicotine users. The high rate of counseling on the adverse effects of nicotine suggested agreement regarding the detrimental effects of smoking. However, the study population infrequently delayed surgery or used smoking cessation measures. Studies are needed to determine why few surgeons frequently alter the management of nicotine users and what modifications in orthopedic practice could improve outcomes for these patients. [Orthopedics. 2017; 40(1):e90-e94.].

Gender difference in preference of specialty as a career choice among Japanese medical students

BACKGROUND

In Japan, the absolute deficiency of doctors and maldistribution of doctors by specialty is a significant problem in the Japanese health care system. The purpose of this study was to investigate the factors contributing to specialty preference in career choice among Japanese medical students.

METHODS

A total of 368 medical students completed the survey giving an 88.2 % response rate. The subjects comprised 141 women aged 21 ± 3 (range, 18-34) years and 227 men aged 22 ± 4 (range, 18-44) years. Binary Logistic regression analysis was performed using specialty preferences as the criterion variable and the factors in brackets as six motivational variables (e.g., Factor 1: educational experience; Factor 2: job security; Factor 3: advice from others; Factor 4: work-life balance; Factor 5: technical and research specialty; and Factor 6: personal reasons).

RESULTS

Women significantly preferred pediatrics, obstetrics & gynecology, and psychology than the men. Men significantly preferred surgery and orthopedics than the women. For both genders, a high odds ratio (OR) of "technical & research specialty" and a low OR for "personal reasons" were associated with preference for surgery. "Technical & research specialty" was positively associated with preference for special internal medicine and negatively for pediatrics. "Work-life balance" was positively associated with preference for psychology and negatively for emergency medicine. Among the women only, "technical & research specialty" was negatively associated with preference for general medicine/family medicine and obstetrics & gynecology, and "job security" was positively associated for general medicine/family medicine and negatively for psychology. Among men only, "educational experience" and "personal reasons" were positively, and "job security" was negatively associated with preference for pediatrics. For both genders, "work-life balance" was positively associated with preference for controllable lifestyle specialties.

CONCLUSION

We must acknowledge that Japanese medical students have dichotomized some motivations for their specialty preference based on gender. Systematic improvements in the working environment are necessary to solve these issues.

Do You See It My Way? The Clinical Evaluation of ADHD by the Different Pediatric Subspecialties

BACKGROUND

Six medical disciplines are responsible for assessment, diagnosis and treatment of people with attention deficiency hyperactivity disorder (ADHD) in Israel: family doctors, pediatricians, adult and child neurologists, adult and child psychiatrists.

OBJECTIVES

To investigate differences in ADHD diagnostic practices between three different pediatric subspecialties in the clinical setting in order to establish a common ground for a future unified approach.

METHODS

An anonymous web-based questionnaire was administered to child psychiatrists, pediatric neurologists and general pediatricians who are actively involved in ADHD diagnosis (n=104).

RESULTS

Neurologists and pediatricians rarely use the mental status examination, while psychiatrists rarely perform a neurological or physical examination (P < 0.0001). A general clinical impression of learning abilities and/or neurodevelopmental skills was implemented more often by pediatric neurologists (P < 0.04).

CONCLUSIONS

The significant differences found between the three medical specialties with regard to the clinical evaluation of ADHD could be attributed, at least in part, to the ambiguity of available guidelines concerning the clinical examination, and to the adherence of each specialty to its own "skills." Larger surveys in other countries should be considered and an effort made to create a common, "inter-disciplinary" ground on this important part of ADHD evaluation, differential diagnosis, and research.

Specialty preferences among final year medical students in medical schools of southeast Nigeria: need for career guidance

BACKGROUND

In resource-poor settings with low doctor-population ratio, there is need for equitable distribution of healthcare workforce. The specialty preferences of medical students determine the future composition of physician workforce hence its relevance in career guidance, healthcare planning and policy formulation. This study was aimed at determining the specialty preferences of final year medical students in medical schools of southeast Nigeria, the gender differences in choice of specialty and the availability of career guidance to the students during the period of training.

METHODS

A descriptive cross-sectional study was conducted among final year medical students in the six accredited medical schools in southeast Nigeria using self-administered semi-structured questionnaire. Information on reason for studying Medicine, specialty preference and career guidance were obtained. Chi-square test of statistical significance was used in the analysis.

RESULTS

A total of 457 students participated in the study with a response rate of 86.7 %. The mean age was 25.5 ± 2.9 years and 57.1 % were male. Majority (51 %) opted to study Medicine in-order to save lives while 89.5 % intended to pursue postgraduate medical training. A higher proportion (51.8 %) made the decision during the period of clinical rotation. The five most preferred specialties among the students were Surgery (24.0 %); Paediatrics (18.8 %); Obstetrics and Gynaecology (15.6 %); Internal Medicine (11.0 %) and Community Medicine (6.8 %) while Pathology (2.0 %); Anaesthesia (0.7 %) and Ear, Nose and Throat (0.2 %), were the least preferred. Compared to females, a higher proportion of male students intended to specialise in Surgery (32.3 % vs 13.0 %, p < 0.001) in contrast to Paediatrics (11.2 % vs 28.8 %, p < 0.001). Majority of the students, 74.6 % had no form of career guidance during their stay in medical school and 11.2 % were undecided on choice of specialty.

CONCLUSION

In spite of the high proportion of students willing to pursue specialist medical training after graduation, most opted for the four core clinical specialities of Surgery, Paediatrics, Obstetrics and Gynaecology and Internal Medicine. Majority of the students made these decisions during clinical rotations. Also, majority had no form of career guidance throughout their stay in medical school. To ensure an equitable distribution of a limited physician workforce in a resource-poor setting, there is need for proper career guidance for the students and this should be in line with the national health needs.

Physician Attitudes About Maintenance of Certification: A Cross-Specialty National Survey

OBJECTIVES

To determine physicians' perceptions of current maintenance of certification (MOC) activities and to explore how perceptions vary across specialties, practice characteristics, and physician characteristics, including burnout.

PATIENTS AND METHODS

We conducted an Internet and paper survey among a national cross-specialty random sample of licensed US physicians from September 23, 2015, through April 18, 2016. The questionnaire included 13 MOC items, 2 burnout items, and demographic variables.

RESULTS

Of 4583 potential respondents, we received 988 responses (response rate 21.6%) closely reflecting the distribution of US physician specialties. Twenty-four percent of physicians (200 of 842) agreed that MOC activities are relevant to their patients, and 15% (122 of 824) felt they are worth the time and effort. Although 27% (223 of 834) perceived adequate support for MOC activities, only 12% (101 of 832) perceived that they are well-integrated in their daily routine and 81% (673 of 835) believed they are a burden. Nine percent (76 of 834) believed that patients care about their MOC status. Forty percent or fewer agreed that various MOC activities contribute to their professional development. Attitudes varied statistically significantly (P<.001) across specialties, but reflected low perceived relevance and value in nearly all specialties. Thirty-eight percent of respondents met criteria for being burned out. We found no association of attitudes toward MOC with burnout, certification status, practice size, rural or urban practice location, compensation model, or time since completion of training.

CONCLUSION

Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.

Surgeon specialization and operative mortality in United States: retrospective analysis

OBJECTIVE

 To measure the association between a surgeon's degree of specialization in a specific procedure and patient mortality.

DESIGN

 Retrospective analysis of Medicare data.

SETTING

 US patients aged 66 or older enrolled in traditional fee for service Medicare.

PARTICIPANTS

 25 152 US surgeons who performed one of eight procedures (carotid endarterectomy, coronary artery bypass grafting, valve replacement, abdominal aortic aneurysm repair, lung resection, cystectomy, pancreatic resection, or esophagectomy) on 695 987 patients in 2008-13.

MAIN OUTCOME MEASURE

 Relative risk reduction in risk adjusted and volume adjusted 30 day operative mortality between surgeons in the bottom quarter and top quarter of surgeon specialization (defined as the number of times the surgeon performed the specific procedure divided by his/her total operative volume across all procedures).

RESULTS

 For all four cardiovascular procedures and two out of four cancer resections, a surgeon's degree of specialization was a significant predictor of operative mortality independent of the number of times he or she performed that procedure: carotid endarterectomy (relative risk reduction between bottom and top quarter of surgeons 28%, 95% confidence interval 0% to 48%); coronary artery bypass grafting (15%, 4% to 25%); valve replacement (46%, 37% to 53%); abdominal aortic aneurysm repair (42%, 29% to 53%); lung resection (28%, 5% to 46%); and cystectomy (41%, 8% to 63%). In five procedures (carotid endarterectomy, valve replacement, lung resection, cystectomy, and esophagectomy), the relative risk reduction from surgeon specialization was greater than that from surgeon volume for that specific procedure. Furthermore, surgeon specialization accounted for 9% (coronary artery bypass grafting) to 100% (cystectomy) of the relative risk reduction otherwise attributable to volume in that specific procedure.

CONCLUSION

 For several common procedures, surgeon specialization was an important predictor of operative mortality independent of volume in that specific procedure. When selecting a surgeon, patients, referring physicians, and administrators assigning operative workload may want to consider a surgeon's procedure specific volume as well as the degree to which a surgeon specializes in that procedure.

Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study

BACKGROUND

Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service.

METHODS

Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile.

FINDINGS

127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34,350 clinicians surveyed, 15,537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40-58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08-1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0·042; p=0·654).

INTERPRETATION

This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing.

FUNDING

National Institute for Health Research Health Services and Delivery Research Programme.

Female specialists in intensive care medicine: job satisfaction, challenges and work-life balance

OBJECTIVE

Women are under-represented in the intensive care medicine (ICM) specialist workforce. I aimed to better understand the challenges these women face so they can be considered in the training and support of ICM specialists.

DESIGN AND PARTICIPANTS

All female Fellows of the College of Intensive Care Medicine (CICM) of Australia and New Zealand were surveyed using an online questionnaire. The study was approved by the Cabrini Human Research Ethics Committee. Thirty respondents with children volunteered to complete a second questionnaire.

MAIN OUTCOME MEASURES

I surveyed demographic and workforce data and women's experiences in the ICM specialist workforce in the first survey, and experiences with child-rearing in the second survey.

RESULTS

The response rate was 80.3% (127/158). The median age bracket was 40-45 years, and 118 respondents were practising ICM, 85 full-time in a tertiary intensive care unit. Eighteen were ICU directors and 23 were CICM-appointed supervisors of training. Sixty-five women were mothers, and 70% returned to full-time work after their maternity leave. Child care was most commonly undertaken by family members or a nanny. Overall, 81% were satisfied with their experiences, but 37% felt they had been disadvantaged because of their sex. Fewer women with leadership roles felt disadvantaged. Their major challenges included the on-call work affecting child-rearing and family life, sexism in the workplace and difficulties with academic advancement.

CONCLUSION

The participation and satisfaction rates of women working in the ICM specialist workforce are encouraging. Although challenges exist, women contemplating a career in ICM should see it as achievable and rewarding.

Cost-efficiency of specialist inpatient rehabilitation for working-aged adults with complex neurological disabilities: a multicentre cohort analysis of a national clinical data set

OBJECTIVES

To evaluate functional outcomes, care needs and cost-efficiency of specialist rehabilitation for a multicentre cohort of inpatients with complex neurological disability, comparing different diagnostic groups across 3 levels of dependency.

DESIGN

A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2010-2015.

SETTING

All 62 specialist (levels 1 and 2) rehabilitation services in England.

PARTICIPANTS

Working-aged adults (16-65 years) with complex neurological disability.

INCLUSION CRITERIA

all episodes with length of stay (LOS) 8-400 days and complete outcome measures recorded on admission and discharge. Total N=5739: acquired brain injury n=4182 (73%); spinal cord injury n=506 (9%); peripheral neurological conditions n=282 (5%); progressive conditions n=769 (13%).

INTERVENTION

Specialist inpatient multidisciplinary rehabilitation.

OUTCOME MEASURES

Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK Functional Independence Measure (FIM)+FAM). Cost-efficiency: (1) time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of ongoing care, (2) FIM efficiency (FIM gain/LOS days), (3) FIM+FAM efficiency (FIM+FAM gain/LOS days). Patients were analysed in 3 groups of dependency.

RESULTS

Mean LOS 90.1 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in 'weekly care costs' was greatest in the high-dependency group at £760/week (95% CI 726 to 794)), compared with the medium-dependency (£408/week (95% CI 370 to 445)), and low-dependency (£130/week (95% CI 82 to 178)), groups. Despite longer LOS, time taken to offset the cost of rehabilitation was 14.2 (95% CI 9.9 to 18.8) months in the high-dependency group, compared with 22.3 (95% CI 16.9 to 29.2) months (medium dependency), and 27.7 (95% CI 15.9 to 39.7) months (low dependency). FIM efficiency appeared greatest in medium-dependency patients (0.54), compared with the low-dependency (0.37) and high-dependency (0.38) groups. Broadly similar patterns were seen across all 4 diagnostic groups.

CONCLUSIONS

Specialist rehabilitation can be highly cost-efficient for all neurological conditions, producing substantial savings in ongoing care costs, especially in high-dependency patients.