[Statistics on allergology and environmental medicine in the ENT specialty in Germany]

Environmental medicine and allergy were found to be important in the daily ENT practice after statistical analysis and an inquiry among all ENT doctors in Germany. 64% of ENT colleagues do practice allergy, 20% environmental medicine. With reference to all registered ENT doctors 24% are titled allergists, 4% specialists in environmental medicine. Focussing on the teaching there is a big difference between both groups. Whereas training facilities for allergists are reasonable, there are only a few chief instructors for environmental medicine in the ENT society. This fact has to be considered on educational plannings in future.

The status of diagnostic radiology training programs and their graduates in 1999

OBJECTIVE

To address job market concerns, the American College of Radiology studied the employment of 1999 graduates from diagnostic radiology training programs and the programs' status and plans.

MATERIALS AND METHODS

In late April to the beginning of June 1999, the American College of Radiology surveyed a 50% random sample of diagnostic radiology residency directors about the employment status of their 1999 residency and fellowship graduates as well as about plans for their training programs. Seventy-seven percent responded. We compared findings from the 1999 survey with similar findings from earlier surveys using a p value of less than or equal to 0.05 to define statistical significance.

RESULTS

As of the survey, 95% of residency graduates and 96% of fellowship graduates were reported to have commitments for positions. Ninety-two percent of graduating residents and 95% of graduating fellows reportedly had commitments for positions that reasonably matched their training and personal goals. Completed plus planned changes in residency program size since 1993 would, if implemented, lead to an 8% reduction. Similar to previous years, 96% of the beginning-year residency slots were filled. Program directors reported that the job market had improved compared with that of recent years. The percentage of graduating fellows with commitments for positions was similar in almost all fields.

CONCLUSION

Fellows found jobs earlier than in past years, when unemployment among graduates decreased to 1-2% by 6 months after graduation. Results in 1999 should be at least as good. Employment prospects across all subspecialties are about the same. Planned program reductions are much smaller than those reported in 1998 and may continue to evaporate.

Diagnostic radiology residents in the classes of 1999 and 2000: fellowship and employment

OBJECTIVE

Most diagnostic radiology residents undergo fellowship training. Applications for fellowship positions are submitted during the third year of residency. We compared the number of residents undertaking fellowship, accepting jobs, and rescinding accepted fellowship positions to accept jobs.

MATERIALS AND METHODS

During the 47th Association of University Radiologists meeting, participants from the American Association of Academic Chief Residents in Radiology completed a questionnaire regarding the intentions of third- and fourth-year residents in their programs.

RESULTS

Seventy programs, representing 402 fourth-year and 395 third-year residents, responded. Of fourth-year residents, 322 (80.1%) accepted fellowships and 41 (10.2%) accepted jobs. Of third-year residents, 335 (84.8%) accepted fellowships. Eighty-eight (27.3%) fourth-year residents and 95 third-year residents (28.4%) accepted interventional radiology fellowships, and 104 (32.3%) fourth-year residents and 96 (28.7%) third-year residents accepted body imaging fellowships. Most residents who accepted fellowships did so in the same city in which they completed their residency training. Of fourth-year residents who accepted fellowship positions the year before, 14 (4.3%) withdrew their acceptance to pursue employment.

CONCLUSION

Most residents opt for fellowship training in interventional radiology or body imaging. We postulate that the practice of accepting fellowships during the third year of residency may contribute to the percentage of residents who rescind fellowship acceptance to pursue employment. We suggest that consideration be given to changing this practice.

Diagnostic radiologists' subspecialization and fields of practice

OBJECTIVE

The purpose of this study was to explore the diagnostic radiology profession from the perspective of subspecialization and fields of practice.

MATERIALS AND METHODS

Data for 1244 practicing diagnostic radiologists were gathered from the American College of Radiology's 1995 Survey of Radiologists. Radiation oncologists, the retired, and residents and fellows were excluded. Responses were weighted to represent all practicing diagnostic radiologists in the United States and were compared with a similar previous survey.

RESULTS

More than one quarter (28%) of diagnostic radiologists are subspecialists. Diagnostic radiology subspecialists were more likely than generalists to have fellowship training, work in center cities, work in large groups, and be employed by an academic institution. They were also generally younger and provided a narrower range of imaging services than generalists.

CONCLUSION

Although most diagnostic radiologists are generalists, subspecialization will likely continue to grow.

Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment

To examine influences of medical factors (e.g., viral load) and nonmedical factors (e.g., patient characteristics) on treatment decisions for highly active antiretroviral therapy (HAART), we sent a survey to a random sample of 995 infectious disease physicians who treat patients with HIV/AIDS in the United States in August, 1998. The response rate was 53%. Respondents were asked to report their current practices with respect to antiretroviral treatment and the extent to which each of three medical and 17 nonmedical factors would influence them for or against prescribing HAART to a hypothetical HIV-positive patient. Most reported initiating HAART with findings of low CD4+ cell counts and high viral loads, and weighing CD4+ cell counts, viral load, and opportunistic infection heavily in their decisions to prescribe HAART. Patients' prior history of poor adherence was weighed very much against initiating HAART. Patient homelessness, heavy alcohol use, injection drug use, and prior psychiatric hospitalization were cited by most physicians as weighing against HAART initiation. Thus, most physicians in this sample follow guidelines for the use of HAART, and nonmedical factors related to patients' life situations are weighed as heavily as disease severity in treatment decisions. As HIV increasingly becomes a disease associated with economic disadvantage and other social health problems, it will be essential to develop interventions and care support systems to enable patients experiencing these problems to benefit from HIV treatment advances.

Self-reported differences between cardiologists and heart failure specialists in the management of chronic heart failure

BACKGROUND

Heart failure (HF) is responsible for considerable mortality morbidity rates and resource utilization. Recently, several studies have reported improved outcomes when patients are managed by special HF clinics, but it is uncertain whether this improvement reflects differences in physician practices or other aspects of the operation of these clinics.

OBJECTIVES

This study was designed to identify differences in HF management practices between general cardiologists and cardiologists specializing in the treatment of patients with HF.

METHODS

A survey examining diagnostic and treatment practices in patients with HF was sent to a sample of cardiologists derived from the American Medical Association Masterfile and to HF specialists who were members of the Society of Transplant Cardiologists or principal investigators in HF trials. Responses were examined in relation to guidelines issued by the Agency for Health care Policy and Research released 9 months previously.

RESULTS

In general both groups practice in conformity with published guidelines. However, there were important differences between the practice patterns of general cardiologists and HF specialists. For instance, in patients being evaluated for the first time, cardiologists reported using a chest radiograph to assist in the diagnosis more than did HF specialists (47% vs 12%), whereas HF specialists were more likely to use an echocardiogram (73% vs 48%). Both groups were likely to evaluate their patients for ischemia and possible revascularization, even in patients not having angina. However, HF specialists tended to use coronary angiography as the initial diagnostic test, whereas cardiologists were more likely to use stress testing. HF specialists more often used angiotensin-converting enzyme inhibitors as part of their initial therapy in patients with mild to moderate HF (94% vs 86%) and during maintenance therapy (91% vs 80%). Also, HF specialists were more likely than cardiologists to titrate angiotensin-converting enzyme inhibitors to higher doses (75% vs 35%), even in the presence of renal dysfunction.

CONCLUSION

Cardiologists and HF specialists generally manage their patients in conformity with guidelines. However, in many areas, such as angiotensin-converting enzyme inhibitor use, HF specialists do so more aggressively. These approaches may, in part, explain the success of the HF clinic model and raise the possibility that some portion of the HF population may be more optimally managed by cardiologists with a special interest in and additional training or experience with this condition.

Referral patterns, lesion prevalence, and patient care parameters in a clinical oral pathology practice

OBJECTIVE

The purpose of this study was to determine the following parameters in a referral-based private practice oral and maxillofacial pathology clinic: (1) sources of clinical referrals; (2) types of problems referred; and (3) clinical effectiveness of treatment.

STUDY DESIGN

Clinical charts were reviewed for a cohort of 362 patients seen over a 2 1/2-year period (1993-1995). From these charts, we determined the source of referral and the final diagnosis for each patient. In addition, 50 patients were randomly selected and surveyed by telephone; each was asked a series of questions to determine the following: (1) the number of health care practitioners previously seen with regard to the patient's condition; (2) the length of time that the condition had been present before the patient came to the oral and maxillofacial pathology clinic; (3) the costs associated with medications and office visits that had been incurred before the patient came to the oral and maxillofacial pathology clinic; (4) the costs associated with medications and office visits that were incurred at the oral and maxillofacial pathology clinic; and (5) the patient's level of satisfaction with the oral and maxillofacial pathology clinic.

RESULTS

Fifty-five percent of the referrals came from dentists, and 45% came from physicians. The 3 problems most commonly seen were candidiasis (12%), burning mouth syndrome (10%), and lichen planus (8%). For the 50 patients who were interviewed, the mean number of health care practitioners seen previously was 2.2 (range, 1-9). The mean time from initial symptoms to evaluation by an oral pathologist was 15 months. The mean approximate cost of medications and office visits before evaluation by an oral pathologist was $350 (range, $30-$4,000; median, $100); this compared with a cost of $94 (range, $50-$300; median, $70) for the patient visit and medications associated with the oral pathology appointment. The difference was statistically significant (P < or = .001).

CONCLUSIONS

This preliminary study suggests that the clinical evaluation of oral lesions by an oral pathologist appears to be cost-effective and should be an integral part of a comprehensive health management system. These results should be corroborated by similar multicenter studies.

Hospital specialization and cost efficiency: benefits of trimming product lines

Trends in hospital specialization are studied using multiple regression analysis for the period 1983-1990. The observed 26.9 percent rise in specialization was associated with a 6.9 percent decline in unit cost per admission. Specialization is also associated with improved quality of care. Specialization has been highest in competitive West Coast markets and lowest in the rate-regulated states (New York and Massachusetts). Hospitals have less incentive to contain costs by decreasing the array of services offered in stringent rate-setting states. The term "underspecialization" is advanced to capture the inability of some hospitals to selectively prune out product lines in order to specialize. Such hospitals spread resources so thin that many good departments suffer. Unit cost per case (DRG-adjusted) is higher in the less specialized hospitals.

[Medical and non-medical ambulatory psychotherapy in the Hannover area. A specialty, school and sex related comparison]

The result of an investigation of 128 from 283 (45.2%) medical and psychological psychotherapists established in the city of Hannover is presented. The aim of the study is to characterize the situation of psychotherapeutical care not only by the number of psychotherapists in relation to inhabitants but also by the working time spent for psychotherapy. Besides we found gender, school of psychotherapy and professional experience as factor influencing the patients waiting time for beginning a psychotherapy. In contrast to other studies, the number of medical and psychological psychotherapists is not different, nevertheless the psychotherapeutical care in Hannover is not ensured.

Children referred for specialist care: a nationwide study in Dutch general practice

BACKGROUND

Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available.

AIM

To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice.

METHOD

From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care.

RESULTS

The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals.

CONCLUSIONS

The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.

How many residents shall we train--the situation in Germany

The situation of training neurosurgeons in Germany is reviewed taking into consideration the current figures of finished residencies, the development in the number of training neurosurgical units in Germany, and the personnel and structure of a neurosurgery unit allowed to train. The jurisdiction for specialist training as well as typical problems encountered in training residents are being discussed. In 1992; 130,364 patients, equivalent to 0.94% of all patients in Germany were treated in 4.792 dedicated neurosurgical beds. A total of 644 working neurosurgeons were registered. Between 1986 and 1993, 349 residents qualified as neurosurgeons, an average of 43.5 per year. 57% of neurosurgical units employ non-trainee junior doctors, 13% have no residents, and 62% of departments trained less than one resident per year on average. Only 57% of units finish residency training always on time and only 79% of major units have full training permission. The figures provided in this article do not substantiate the assumption that we have trained too many specialists in the past. The problems which some residency programmes encounter however do suggest that it could be wise not to continue to train specialists at the same rate as in the past.

Does the doctors' professional experience reduce referral rates? Evidence from the Finnish referral study

OBJECTIVE

To examine hospital referral rates in Finnish health centres according to doctors' and health centres characteristics.

DESIGN

Survey of all general practice hospital referrals over one week.

SETTING

Central and northern part of Finland, in a region comprising 72% of the area of the country and one-third of the population.

PARTICIPANTS

851 health centre doctors.

OUTCOME MEASURES

Referral rates in terms of characteristics of doctors and health centres.

RESULTS

During the study period, the 851 health centre doctors had 58 760 consultations (mean 69 patients/week), and 2 921 (5%) patients were referred to secondary care. The variation between the highest and lowest referral quintile of the doctors was almost 17-fold, and of the health centres 2.4-fold. Relatively more referrals were made by locums, young, not yet graduated and female doctors than by specialized, more experienced and male doctors.

CONCLUSION

A low referral rate is closely connetected with the extent of the general practitioners' professional experience and specialist training. Investing in specialist training and continuing medical education seems to be the best way to reduce high referral rates.

Identification and certification of extracorporeal membrane oxygenation specialists in the United States

Extracorporeal membrane oxygenation (ECMO) is a highly specialized technique widely practiced in many hospitals. Despite the proliferation of ECMO, little information has been generated relating to ECMO specialists, a new professional group responsible for managing the extracorporeal life support (ELS) system. A telephone survey of ECMO centers in the United States was conducted to determine the number of ECMO specialists, team composition by profession, and clinical components of ECMO specialist certification. Data were obtained in May 1991 from all 63 (100%) active ELS centers. The survey found that the average ECMO program performs 3,770 +/- 1,019 clinical hours of ELS per year with a team of 23 +/- 11 specialists. There are 1,431 practicing ECMO specialists in the United States: 73% registered nurses, 22% respiratory therapists, and 5% others. Most ECMO specialist teams (56%) are comprised of a single profession, with 44% of programs using a mixture of professions. The average ECMO specialist manages the ELS system 171 +/- 91 hr/yr. Thirty-six (57%) programs have a mean yearly clinical requirement of 77 +/- 23 ELS hours per specialist. These results represent the first complete report identifying the number of ECMO specialists in the United States. In addition, program demographics demonstrate variability in ECMO experience and certification requirements.

Case-mix specialization in the market for hospital services

Historically, cost-based reimbursement encouraged hospitals to compete on the basis of quality, leading to duplication of services and other inefficient behavior. More recently, prospective payment, selective contracting, and other innovations in reimbursement have strengthened incentives for more efficient hospital operations. In principle, hospitals may be able to reduce their costs by limiting the array of services they provide, but there has been little empirical evidence that U.S. hospitals are moving toward greater specialization or that specialization leads to cost savings. This article explores recent changes in case-mix specialization and the relationship of these changes to hospital costs. It first describes an index of specialization derived from Information Theory and shows that this index provides intuitively reasonable results in characterizing patterns of specialization across hospitals. The analysis then demonstrates that specialization, as measured by this index, in fact increased from 1980 through 1985; that specialization can indeed lower hospital costs; and that increases in specialization have been largest in those hospitals with the greatest incentives to reduce costs.

Anesthesiologists in North Carolina: a survey reflecting emerging subspecialization

This North Carolina case study addresses the migration of anesthesiologists into subspecialty, clinical areas of anesthesiology over a 4-year period (1984 to 1987). Three hundred fourteen members of the North Carolina Society of Anesthesiologists (NCSA) were surveyed using a one-page questionnaire. The response rate was 93.6%. The questionnaire elicited data to characterize the magnitude of change in anesthesiologist manpower, to assess emerging subspecialization, to describe the flux of anesthesiologists entering and leaving practice, and to detail evolving modes of practice. Results indicated a net increase in manpower averaging 8.8% per year in academic programs, whereas clinical community practitioners increased physician positions at a rate three times the former (27% increase per year). Of 184 anesthesiologists recruited to North Carolina over 4 years, 75 different residency programs were represented; 48% of new anesthesiologists were from southern educational programs and 44% entered practice with fellowships (i.e., postgraduate year 4 to 5). The principal fellowship was cardiac (33%). Subspecialty areas were represented in all 53 reporting clinical practices. The principal practice mode emerging was hospital-based, same day surgery (85%) followed by pediatric anesthesia (81%), perioperative pain management (68%), obstetric anesthesia (63%), and an anesthesia "clinic" (54%). Respondents expected additional practice options over the next 3 years with anesthesia for ambulatory diagnostic and therapeutic modalities projected to emerge at the fastest rate. In conclusion, anesthesiologists in North Carolina seem to be filling unmet needs in obstetric and cardiac anesthesia, critical care, ambulatory surgery, and pain therapy units. These observations may represent a vignette of the national scene.