Promoting Consistent Clinical Preventive Services Guidelines Among Competing Health Plans

Clinicians are confronted with various and often conflicting sets of practice guidelines that direct provision of preventive care. This conflict among guidelines is detrimental to the delivery of preventive care and creates a major barrier to improving these services. This study used a systematic approach to reach consensus among health plan medical directors on clinical preventive services (CPS) guidelines. A consistent set of 17 CPS guidelines was identified that all health plans could endorse as being a priority for implementation. This approach provides a template for competing health plans nationwide to reach consensus on guidelines that support clinicians in the delivery of CPS.

The impact of self-referral on radiology residency training programs

PURPOSE

The self-referral by nonradiologist physicians of diagnostic imaging and interventional procedures has affected radiology residency training programs. The Association of Program Directors in Radiology surveyed its members to assess the impact on specific areas of training.

METHODS

The authors surveyed 186 residency program directors.

RESULTS

Forty-three percent of those contacted responded. Fifty-two of 80 respondents (65%) said that in their opinion, self-referral had had an impact on residency training. Of the 52 program directors who said that their programs had been affected, 47 (90%) reported that in their opinion, self-referral had a negative impact on their training programs. The areas most affected were vascular interventional radiology, obstetric ultrasound, and nuclear cardiology.

CONCLUSIONS

Self-referral endangers the quality of radiology residencies. The authors discuss strategies to protect radiology residency programs.

The Consultant Pharmacist and the Physician in the Nursing Home: Roles, Relationships, and a Recipe for Success

Nursing homes must provide sophisticated medical and personal care to a broad spectrum of residents and patients. Medications are an increasingly important part of that care. The risks and benefits of medications are widely published, but not necessarily recognized in the care of individual patients. Decisions about medications must be made in the proper context of the patient. Medications are often indicated for various illnesses, symptoms, and risk factors, but clinically significant adverse consequences of medications are common and typically mimic common syndromes. Timely recognition and management of adverse consequences requires vigilance and a high index of suspicion. Many factors influence medication prescribing and use in the nursing home. Newly updated OBRA surveyor guidance emphasizes the importance of following the full care process in implementing, dosing, monitoring, and adjusting medications. Physicians and consultant pharmacists have prominent, complementary roles in addressing medications in the nursing home. The purpose of this article is to clarify these roles, identify their basis (primarily, the care process), and discuss how physicians and consultant pharmacists can collaborate effectively to optimize medication use and minimize preventable adverse consequences.

The value of internship in graduate medical education: survey of emergency medicine residents and program directors

OBJECTIVE

To assess the opinions of emergency medicine (EM) residents and program directors about the value of completing a nonrequired 1-year internship before entering an EM residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME).

METHODS

An eight-question, self-administered online survey was e-mailed to EM residents who had completed a nonrequired internship before entering ACGME-accredited residency programs. A separate, six-question survey was e-mailed to program directors of ACGME-accredited programs that do not require an internship who had ever had a resident who had completed a nonrequired internship.

RESULTS

Forty-six (27 [59%] osteopathic, 19 [41%] allopathic) of 113 residents and 40 of 124 program directors responded to the survey questions. Less than 4% of residents completed a separate nonrequired 1-year internship. The most common reason for completing a nonrequired internship was to obtain licensure by the American Osteopathic Association (19 [41%]). Most residents believed that they were more proficient with history-taking and physical examinations (38 [83%]) and procedures (34 [74%]) during the first year of residency than their colleagues who did not complete an internship, but this percentage decreased over time. The program directors had similar opinions. Most osteopathic residents who completed the internship for osteopathic licensure would not have done so if it were not required. Most (39 of 40) program directors would not recommend taking a nonrequired internship.

CONCLUSION

Completing a 1-year internship before entering an EM residency program may better prepare physicians for their first year of residency in terms of basic clinical competancy, but further study is needed in this area.

General practice research and research skill needs--attitudes of GP supervisors

BACKGROUND

General practice research is an important learning area in general practice registrar training. General practitioner supervisors have a central role in registrar training. Registrar training in Tasmania has the added component of a research project. Little is known about supervisors' research attitudes, confidence to support registrar research projects, and research skill needs.

METHOD

A postal survey was sent to all 40 GP supervisors with General Practice Training Tasmania.

RESULTS

Response rate was 90% (n=36): 33% were interested in becoming involved in general practice research; 53% wanted to improve their research skills; and 55% did not feel confident supporting a registrar with a research project. Those supervisors who were confident were more likely to have previous research involvement.

DISCUSSION

There is potential for increasing research capacity in GP supervisors. It is important to build the confidence of supervisors in their support of general practice registrars engaged in research projects.

End-of-life care for the critically ill: A national intensive care unit survey*

OBJECTIVE

One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care.

DESIGN

Self-administered mail survey.

SETTING

Six hundred intensive care units.

PARTICIPANTS

A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States.

INTERVENTIONS

Mail survey.

MEASUREMENTS AND MAIN RESULTS

We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available.

CONCLUSIONS

Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.

What Should Psychiatry Residents Be Taught About Neurology?

OBJECTIVES

To improve our ability to teach psychiatry residents during their required 2 months on neurology rotations, we investigated the perceived needs of psychiatry program training directors.

METHODS

We contacted the program directors organization of the American Psychiatric Association and disseminated a web-based survey to all program directors. The survey asked questions about the format and content of neurology training desired for psychiatry residents. The survey was sent a second time to increase response rate.

RESULTS

Sixty (32%) training directors responded. Overall satisfaction with neurologic education was rated at 3.6 out of 5 (standard deviation +/- 0.96). The specific content areas which elicited the most interest for focused training modules were differential diagnosis and biologic substrates of dementia, evaluation and treatment of drug-related and spontaneous movement disorders, evaluation and management of sleep disorders, cognitive and mood effects of stroke, and inherited disorders. Many program directors commented on perceived weaknesses of inpatient-based exposure to neurology; 78% of responders favored outpatient and consultation settings.

CONCLUSIONS

In an era of deliberation about neurobehavioral integration and cross-training of neurologists and psychiatrists, neurologists should strive to provide the best possible multidisciplinary education to psychiatry trainees.

The view of surgery department chairs on part time faculty in academic practice: results of a national survey

BACKGROUND

Reduced resident work hours sparked debate regarding lifestyle of clinical faculty. We hypothesized surgery department chairs would not be supportive of part-time clinical faculty (PTF) and would be reluctant to grant requests to reduce total institutional commitment (TIC) or total professional effort.

METHOD

A 16-question survey was mailed to 202 surgery chairs requesting department demographics, and perception of PTF. Chairs were given the option of identifying themselves. PTF referred to full-time equivalent clinicians who reduce their TIC for personal/family reasons and did not include clinicians with research or teaching commitments limiting clinical responsibilities.

RESULTS

A total of 112 of 186 (61.2%) delivered surveys were returned. Of these, 48.2% of respondents indicated clinicians had requested reduced TIC and 40.2% of departments had PTF. Only 1 chair was unable to grant a request to reduce TIC. A total of 42.8% of respondents indicated that PTF receive reduced salary-linked benefits but (58.9%) no change in either academic status or (52.7%) eligibility for promotion/tenure. The percentage of women faculty was 12.0% in departments with PTF and 10.5% in departments without PTF. A total of 42.8% of chairs agreed facilitating PTF would improve faculty retention versus 24.1% who disagreed (P<.0001). When compared with departments without PTF, chairs with PTF were more supportive that facilitating PTF would improve faculty retention (53.3% vs 32.7%, P<.001) and would be beneficial to their departments (57.8% vs 22.4%, P<.001). Sixty-two percent of respondents volunteered their names and contact information for follow-up.

CONCLUSIONS

Contrary to our hypothesis, surgery department chairs appear to be supportive of PTF and were interested in discussing this further.

The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors

OBJECTIVE

The purpose of this study was to characterize residency program director baseline perceptions regarding the effect of resident duty hour limitations on key components of the graduate medical education environment.

STUDY DESIGN

This was a survey of directors of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) between June 21st and July 16th, 2004. Participants were queried on views regarding the need for duty hour limitations, and the perceived effect of these changes on various issues related to the residency environment.

RESULTS

Fifty-eight percent (123/211) of the study population completed the questionnaire. Seventy-one percent of respondents supported duty hour restrictions, 19% opposed restrictions, and 10% were undecided. Forty-one percent of respondents preferred a maximum duty hour limitation of 80 hrs/wk or less, 55% preferred one at least 90 hrs/wk, and 4% preferred no upper limit. A significantly greater proportion of female program directors supported limits > 80 hrs/wk than males (73% vs 53%, P = .04). A majority of participants believed resident education, surgical skills, and work ethic have been negatively impacted by the limitations, while patient safety and the overall quality of patient care have remained unchanged or declined, and resident well-being has improved. Opposition to duty hour regulations and a preference for higher limits was associated with a higher prevalence of negative impressions regarding the impact of duty hour regulations on the residency environment.

CONCLUSION

Variations in current opinions regarding the impact of residency duty hour restrictions reflect ongoing bias in those most influential to resident education.

Hospital ethics committees: is it time to expand our access to managed care organizations?

Hospital ethics committees provide important services to their institutions, often including review of clinical cases for which an ethical issue or dilemma has been recognized.Traditionally, such case reviews or consults by the ethics committee may be called by the patient and/or family and institutional healthcare providers. Recently, managed care organizations have requested an ethics committee case review at a Chicago area institution. This article will explore whether or not the time has come to expand hospital ethics committees access to managed care organizations.

Working conditions, psychosocial resources and work stress in nurses and physicians in chief managers' positions

The study investigated whether psychosocial work conditions, professional network, job support, social network and support, sick leave and salary were associated with work stress in nurses in chief manager' positions above ward level and physicians in clinical director positions. A sample consisting of 205 nurses and 274 physicians in chief managers' positions at higher structural level answered a questionnaire. Odds ratios were used for estimating the bivariate association between work stress and psychosocial resources. The result showed that both nurse managers (OR 6.8; 95% CI: 3.5-13.5) and clinical directors (OR 6.7; 95% CI: 3.6-12.5) exposed to high job demands had a significantly higher probability of high level of work stress. The results also indicated that the available psychosocial resources taken together inside and outside work did not balance the experienced work stress in nurse managers and the clinical directors who were exposed to high work demands. No relation was found between work stress and sick leave and salary.

Department directors' perceptions of the roles and functions of hospital chaplains: a national survey

A national survey of hospital directors of medicine, nursing, social services, and pastoral care was conducted to obtain opinions about the importance of various chaplain roles. On average, directors in all four disciplines rated three of the seven chaplain roles (grief and death, prayer, and emotional support) to be "very" to "extremely" important. Most of the others roles were rated between "moderately" and "very" important (religious services-rituals consultation and advocacy, community liaison-outreach). Several significant differences were found among disciplines, as physicians rated the importance of most chaplains' roles lower than did other disciplines. Overall, there was a tendency for directors in smaller hospitals, especially those with fewer than 100 patients, to place less importance on most of the chaplain roles investigated here.