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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Active management of severe hyponatraemia is associated with improved mortality

OBJECTIVE

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

Similarities and Differences Between Rural and Urban Telemedicine Utilization

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

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

OBJECTIVE

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

DATA SOURCES

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

STUDY DESIGN

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

DATA COLLECTION/EXTRACTION METHODS

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

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

OBJECTIVES

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

STUDY DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Task specialization across research careers

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Forensic peer specialists: Training, employment, and lived experience

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION AND IMPLICATIONS FOR PRACTICE

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

Preferences of physicians for public and private sector work

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Characteristics of ACGME Residency Programs That Select Osteopathic Medical Graduates

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

Cross-sectional.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOMES

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Physicians' perspective on shared decision-making in Dubai: a cross-sectional study

BACKGROUND

Shared decision-making (SDM) is an integral part of patient-centered delivery of care. Maximizing the opportunity of patients to participate in decisions related to their health is an expectation in care delivery nowadays. The purpose of this study is to explore the perceptions of physicians in regard to SDM in a large private hospital network in Dubai, United Arab Emirates.

METHODS

This study utilized a cross-sectional design, where a survey questionnaire was assembled to capture quantitative and qualitative data on the perception of physicians in relation to SDM. The survey instrument included three sections: the first solicited physicians' personal and professional information, the second entailed a 9-item SDM Questionnaire (SDM-Q-9), and the third included an open-ended section. Statistical analysis assessed whether the average SDM-Q-9 score differed significantly by gender, age, years of experience, professional status-generalist versus specialist, and work location-hospitals versus polyclinics. Non-parametric analysis (two independent variables) with the Mann-Whitney test was utilized. The qualitative data was thematically analyzed.

RESULTS

Fifty physicians from various specialties participated in this study (25 of each gender-85% response rate). Although the quantitative data analysis revealed that most physicians (80%) rated themselves quite highly when it comes to SDM, qualitative analysis underscored a number of barriers that limited the opportunity for SDM. Analysis identified four themes that influence the acceptability of SDM, namely physician-specific (where the physicians' extent of adopting SDM is related to their own belief system and their perception that the presence of evidence negates the need for SDM), patient-related (e.g., patients' unwillingness to be involved in decisions concerning their health), contextual/environmental (e.g., sociocultural impediments), and relational (the information asymmetry and the power gradient that influence how the physician and patient relate to one another).

CONCLUSIONS

SDM and evidence-based management (EBM) are not mutually exclusive. Professional learning and development programs targeting caregivers should focus on the consolidation of the two perspectives. We encourage healthcare managers and leaders to translate declared policies into actionable initiatives supporting patient-centered care. This could be achieved through the dedication of the necessary resources that would enable SDM, and the development of interventions that are designed both to improve health literacy and to educate patients on their rights.

Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database

BACKGROUND

Antidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care.

METHODS

The study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5-17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5-11 years, 12-17 years).

RESULTS

In total, 33,031 5-17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%).

CONCLUSIONS

The results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a Nationwide Cross-Sectional Study in Korea

BACKGROUND

Previous studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage.

METHODS

This was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class.

RESULTS

During the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468).

CONCLUSION

Down-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

How many and which physicians? A comparative study of the evolution of the supply of physicians and specialist training in Brazil and Spain

BACKGROUND

In the face of the medical workforce shortage, several countries have promoted the opening of medical schools and the expansion of undergraduate and specialization education in medicine. Few studies have compared the characteristics and effects of expanding the supply of general practitioners and specialist physicians between countries. Brazil and Spain, two countries with distinct historical processes and socioeconomic scenarios, yet both with universal public health systems and common aspects in training and medical work, have registered a significant increase in the number of physicians and can be used to understand the challenges of strategic planning for the medical workforce.

METHODS

This study provides a descriptive approach using longitudinal data from official databases in Brazil and Spain from 1998 to 2017. Among the comparable indicators, the absolute numbers of physicians, the population size, and the physician's ratio by inhabitants were used. The number of medical schools and undergraduate places in public and private institutions, the supply of residency training posts, and the number of medical specialists and medical residents per 100 000 inhabitants were also used to compare both countries. Seventeen medical specialties with the highest number of specialists and comparability between the two countries were selected for further comparison.

RESULTS

Due to the opening of medical schools, the density of physicians per 1 000 inhabitants grew by 28% in Spain and 51% in Brazil between 1998 and 2017. In that period, Spain and Brazil increased the supply of annual undergraduate places by 60% and 137%, respectively. There is a predominance of private institutions providing available undergraduate places, and the supply of medical residency posts is smaller than the contingent of medical graduates/general practitioners each year.

CONCLUSION

Both countries have similar specialist densities in cardiology, dermatology, and neurosurgery specialties. However, family medicine and community in Spain has 91.27 specialists per 100 000 inhabitants, while in Brazil, the density is only 2.64. The comparative study indicated the complexity of the countries' decisions on increasing the medical supply of general practitioners and specialist physicians. Research and planning policies on the medical workforce must be aligned with the actual health needs of populations and health systems.

Oncology Training in Rwanda: Challenges and Opportunities for Undergraduate Medical Students (The EDUCAN Project)

A critical shortage of trained cancer specialists is one of the major challenges in addressing the increasing cancer burden in low- and middle-income countries. Inadequate undergraduate cancer education in oncology remains a major obstacle for both task shifting to general practitioners and for training of specialists. We provide the first report of cancer education in Rwanda's undergraduate program to survey how new graduates are prepared to provide care for cancer patients. Anonymous online survey was sent January to June 2017 to medical students in their senior clinical years (years 5 and 6). Questions related to the demographics, medical curriculum, and general oncology exposure were included in the survey. Of 192 eligible students, 42% (n = 80) completed the survey and were analyzed. The majority were 25 to 29 years of age and 41% were female. Internal medicine was cited to provide the most exposure to cancer patients (50%) and cancer bedside teaching (55%). Close to a half (46%) have been taught oncology formally in addition to bedside teaching. A tenth (11%) of the participants felt comfortable in attending a cancer patient, and a fifth (21%) of the students felt comfortable while addressing multimodality treatment approach. The majority (99%) of the participants preferred having a formal oncology rotation. Of particular interest, 61% of the students are interested in pursuing an oncology career path. There is a need to modify the current oncology undergraduate curriculum to prepare future physicians for delivering cancer care in Rwanda. Raising the profile of oncology in undergraduate medical education will complement the on-going efforts to increase the country's capacity in task shifting and in training of cancer specialists.

We Must Graduate Physicians, Not Doctors

Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 nonphysician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education and cannot mitigate the shortfall of 112,000 physicians expected in 2030.To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents', or there could be a token amount for this "internship." Both models decrease the cost of medical education; the second financially unburdens the hospital.Since the Flexner Report (when there was no formal postgraduate training), the end point of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors.

Evidence-based medicine self-assessment, knowledge, and integration into daily practice: a survey among Romanian physicians and comparison between trainees and specialists

BACKGROUND

A gap between the attitude towards evidence-based medicine (EBM), knowledge and awareness has been reported among physicians from different parts of the world. However, no investigation on Romanian physicians is available in the scientific literature. Our study aimed, firstly, to assess EBM awareness and the knowledge used by Romanian physicians, and, secondly, to compare resident trainees with specialists.

METHODS

Romanian trainee and specialist physicians were invited to participate in this cross-sectional study. The study tool was an online questionnaire designed to explore their awareness, knowledge, usefulness, the attitude in medical documentation, and the use of professional EBM resources. Data were collected by Google Form from January 1st to April 30th, 2017, respecting the responders' anonymity. Two groups of physicians were investigated as trainees and specialists, respectively. Descriptive statistics (number, percentage, median and interquartile range) was used to describe the survey-related variables. Statistical significance on qualitative data was calculated with the Chi-square test, Fisher's exact test, or the Z-test for proportions.

RESULTS

Two hundred and 50 physicians participated in this study (68% trainees vs. 32% specialists). In both groups, a significantly high percentage was represented by women as compared to men (trainees 72.4%, specialists 70%). The correct definition of EBM was identified by most respondents (75.6%). Affirmatively, both trainees and specialists always looked at levels of evidence when reading scientific literature, but a small percentage (6.5% trainees and 3% specialists) adequately identified the uppermost types of evidence in the hierarchy. Almost a quarter of the respondents shared the name of mobile EBM resources that they used to support the daily practice. Only six out of the 49 listed mobile resources met the EBM criteria.

CONCLUSIONS

The participants proved to have limited knowledge of EBM and a positive attitude towards the concept. They made use of mobile medical resources without understanding which of these were evidence-based.

An Examination of Self-Reported Assessment Activities Documented by Specialist Physicians for Maintenance of Certification

INTRODUCTION

Specialists in a Maintenance of Certification program are required to participate in assessment activities, such as chart audit, simulation, knowledge assessment, and multisource feedback. This study examined data from five different specialties to identify variation in participation in assessment activities, examine differences in the learning stimulated by assessment, assess the frequency and type of planned changes, and assess the association between learning, discussion, and planned changes.

METHODS

E-portfolio data were categorized and analyzed descriptively. Chi-squared tests examined associations.

RESULTS

A total of 2854 anatomical pathologists, cardiologists, gastroenterologists, ophthalmologists, and orthopedic surgeons provided data about 6063 assessment activities. Although there were differences in the role that learning played by discipline and assessment type, the most common activities documented across all specialties were self-assessment programs (n = 2122), feedback on teaching (n = 1078), personal practice assessments which the physician did themselves (n = 751), annual reviews (n = 682), and reviews by third parties (n = 661). Learning occurred for 93% of the activities and was associated with change. For 2126 activities, there were planned changes. Activities in which there was a discussion with a peer or supervisor were more likely to result in a change.

CONCLUSIONS AND DISCUSSION

Although specialists engaged in many types of assessment activities to meet the Maintenance of Certification program requirements, there was variability in how assessment stimulated learning and planned changes. It seems that peer discussion may be an important component in fostering practice change and forming plans for improvement which bears further study.