Future training of hospital doctors

Many changes are occurring in the organization and management of postgraduate medical education and training. Hospital Doctors: Training for the Future (Department of Health, 1993) highlights the need for shorter training programmes and structured curricula. A number of issues still require analysis, particularly the resource implications of expanding the consultant grade.

Promoting cost-effective physician behavior

The current demand for cost containment, improved quality of care, and increased efficiency requires the cooperation of hospital administrators and physicians. Too often, however, administrators are frustrated in their attempts to gain the cooperation of physicians in working toward improving a hospital's financial position. In many instances administration efforts are perceived by physicians as promoting economic efficiency at the expense of quality of care. This article offers specific suggestions, from the physician's perspective, regarding how hospitals can develop a successful program to promote cost-effective physician behavior.

[Medical research in Finnmark]

Finnmark county, the most northern in Norway, has suffered from a severe shortage of specialist health services. In order to recruit specialist doctors to Finnmark and to keep them there, a programme for creating opportunities to do medical research in Finnmark was launched by the University of Tromsø. From 1986 to 1992 the Ministry of Health and Social Affairs has contributed a total of 8.5 mill. NOK to the programme, which is administered by the Medical Faculty at the University of Tromsø, in cooperation with the two hospitals in Finnmark. The programme has led to a substantial recruitment of doctors, both for specialist training as well as fully educated specialists. The percentage of unfilled positions has fallen from 81 to 29 in the period. 41 scientific papers have been published from the programme, 22 of them in international journals. The programme seems to have fulfilled its aims, both as regards stabilizing the specialist health service, and in a scientific context. We propose decentralized research programmes as a means of establishing cooperation between university hospitals and remote health care systems.

"Academic" CME and the social contract

The term academic continuing medical education (CME) is defined and explored from the perspective of forces that have made its usage necessary. These forces include the new understandings of the place, impact, and scope of CME, and, in particular, the increasing entrepreneurial interests in the field, unrelated to the improvement of physicians' competence or performance, or to health care outcomes. In addition to principles of CME provision promulgated by the Accreditation Council of CME, and those of ethical CME providers, academic CME implies the critical appraisal of the providers' activities, the creation of new knowledge about how physicians learn and change, and the dissemination of information based on such knowledge. Finally, the nature of academic CME providers is discussed, and the potential role of CME in fostering the social contract between the medical professional and society is explored.

Libraries, postgraduate medical education and the management of change

The changes surrounding the funding of postgraduate medical and dental education are outlined and the funding implications for libraries considered. The management of this period of change is vital if all players are to appreciate the advantages of implementation, not least cost-effectiveness. In conclusion three problem areas in the post-reform NHS are identified and briefly discussed: the need for access and provision of information to all; development of regional librarian role across all regions to ensure effective co-ordination of resources; a national policy which will integrate national, regional and unit structures for the delivery of health-care information needs to be developed.

Postgraduate education allowance: educational attainment of subscribers and non-subscribers to a centrally organized educational scheme

The educational attainment of general practitioners in the west of Scotland region who subscribed to a centrally organized educational scheme for the postgraduate education allowance was compared with that of their colleagues who did not subscribe to the scheme. During the year studied (1990-91) 1712 of the 1830 principals in general practice in the region had sufficient sessions to claim their postgraduate education allowance. Of these 1712 doctors the 1353 who subscribed to the educational scheme attended a mean of 15.7 educational half day sessions during the study year in comparison with a mean of 12.5 half days attended by the 359 doctors who did not subscribe to the scheme. This difference was observed in all three categories of education--disease management, service management and health promotion--and was greatest in health promotion where subscribers attended a mean of 4.7 half days and non-subscribers 3.1. The doctors who were members of the scheme had achieved a better balance of education. A higher number had attended an educational day in each of the three categories, with the increase being 10.5% for subscribers versus non-subscribers for disease management, 20.0% for service management and 39.1% for health promotion. The differences between the two groups were greater for combinations of categories and 66.6% of subscribers had attended an educational day in each of the three categories compared with 40.9% of non-subscribers. A centrally organized educational scheme for a region can give a balanced spread of education and is likely to meet the educational requirements of the new contract for general practitioners.

Postgraduate education allowance: a regional analysis of the first year

A comparison of accredited education sessions attended by general practitioners in the West of Scotland during 1990-91, the first year of the postgraduate education allowance, and during the previous year is presented. During 1990-91 the mean number of half day sessions attended by each practitioner was 14.0. This is an increase of 36% over the number (10.3) attended during the previous year. The mean number of days attended during 1990-91 includes 5.5 devoted to disease management, 4.4 to service management, and 4.1 to health promotion. Eighty five per cent of practitioners attended a full day devoted to disease management, 78% a full day devoted to service management, and 72% to full day devoted to health promotion; 80% a day in two of these three categories, and 57% a day in all three. The average attendance exceeds the requirement of the new contract. The great majority of practitioners in the Region appear to be achieving the spread of attendance over the three categories required by the regulations.

The effects of pharmaceutical firm enticements on physician prescribing patterns. There's no such thing as a free lunch

We examined the impact on physician prescribing patterns of pharmaceutical firms offering all-expenses-paid trips to popular sunbelt vacation sites to attend symposia sponsored by a pharmaceutical company. The impact was assessed by tracking the pharmacy inventory usage reports for two drugs before and after the symposia. Both drugs were available only as intravenous preparations and could be used only on hospitalized patients. The usage patterns were tracked for 22 months preceding each symposium and for 17 months after each symposium. Ten physicians invited to each symposium were interviewed about the likelihood that such an enticement would affect their prescribing patterns. A significant increase in the prescribing pattern of both drugs occurred following the symposia. The usage of drug A increased from a mean of 81 +/- 44 units before the symposium to a mean of 272 +/- 117 after the symposium (p less than 0.001). The usage of drug B changed from 34 +/- 30 units before the symposium to 87 +/- 24 units (p less than 0.001) after the symposium. These changed prescribing patterns were also significantly different from the national usage patterns of the two drugs by hospitals with more than 500 beds and major medical centers over the same period of time. These alterations in prescribing patterns occurred even though the majority of physicians who attended the symposia believed that such enticements would not alter their prescribing patterns.

General practitioners' attendance at courses accredited for the postgraduate education allowance

An analysis was undertaken in the northern half of the South Western Regional Health Authority of general practitioners' attendance at courses accredited for the postgraduate educational allowance over one year. A total of 358 courses provided 2341 hours of accredited education and produced a total general practitioner attendance of 50,389 hours. The mean attendance per principal in the area was 49.2 hours although the region may be a net importer of attenders from outside the area. Of the 50,389 total hours of attendance, 28.3% were in health promotion, 48.2% in disease management and 23.5% in service management. Course provision and attendance varied considerably over the year. September, October and November accounted for 42.7% of the total hours of attendance, compared with 6.8% in June, July and August. Courses of two to four days or of one week duration accounted for 48.3% of total attendance hours; 10.1% of total attendance hours were at commercially organized courses and 5.6% at courses organized by practices. A total of 66.1% of attendance hours were in postgraduate centres and 6.8% in the practice. Courses with more than 30 participants accounted for 15.9% of courses attended. A total of 174 general practitioners and others organized courses, 21 of them influencing 33,521 hours of general practitioner education. The study shows that in this area, there was an encouraging provision, range and uptake of continuing education courses for general practitioners. The concentration of educational activities in postgraduate centres underlines the need for increased provision for developing educational skills for clinical tutors.

Cost-benefit analysis of an educational program for general practitioners by the Swedish Committee for the Prevention and Treatment of Depression

In 1983-1984 the Swedish Committee for the Prevention and Treatment of Depression launched an educational program on the diagnosis and treatment of depressive disorders for all general practitioners on the island of Gotland. The baseline year chosen was 1982 and the immediate effects were evaluated in 1985. In 1988 the long-term effects were evaluated. These two evaluations indicated strictly time-related beneficial effects on the frequency of sick leave and inpatient care for depressive disorders, the pattern of prescription of psychopharmacologic drugs and the frequency of suicide. This article describes a cost-benefit analysis of the program. The cost of the educational program, changes in drug prescription and inpatient care were calculated as well as indirect costs concerning changes in morbidity and mortality. The calculation of the savings to society was subject to a sensitivity analysis. This shows that the educational program resulted in savings to society on the order of about SEK 155 million (USD 26 million). It is concluded that educational programs of this kind should be repeated every second to third year.

Clinical neurosurgery as it relates to the lumbar spine: what it does versus what it says

Neurosurgeons may derive as much as 62% of their professional income from and perform proportionately as large a number of procedures on the lumbar spine. Publications in neurosurgical journals, presentations at national and international neurosurgical meetings, and participation in organized neurosurgical symposia are, however, relatively sparse in this area of activity. It appears, therefore, that the lumbar spine must have minimal academic interest to neurosurgeons, as compared with the surgical areas where they have clinical domain, i.e., the brain and spinal cord. In that this clear discrepancy between what they do (their source of income) and what they talk about and publish is apparently not well known to neurosurgeons or their professional society directors, this paper is presented as objective, awakening evidence. The potential impact on future patient draw, professional prowess, and income, which may result from a continuation of this wide gap, is also discussed.

Higher professional education courses in the United Kingdom

The need for higher professional education courses has been well established by young principals, medical educationalists and the Royal College of General Practitioners (RCGP, 1985a, 1987 and 1990; Regional Advisers, 1989). In recent years there has been an increase in their development. However there is still a small number catering for a very small group of potential learners. These courses have often been seen as an extension of vocational training. Seven such courses were identified and evaluated during this project. The method and the results of the evaluation are presented. The development of higher professional education courses needs to be tailored to particular local needs and any central planning can be stifling. In our project there was often inadequate organizational and financial support available. The courses proved to be demanding for the participants in terms of time and required motivation. Despite this, attendance was good. Much of the content of the courses laid emphasis on practice management, human behaviour, and medicine and society, which reflected the perceived needs of both organizers and participants. Where formative evaluation of the courses was carried out, this appeared to have an important effect on course development. However fewer than 50% of the participants were involved to any extent in any planning of the courses, which is clearly contrary to the recognized principles of adult of self-directed learning (Brookfield, 1986). Despite this, participants as a whole appreciated the courses and the effect these had on their work, a large proportion reporting a significant change in cognitive and affective areas of learning. Recommendations are made for future organizers of higher professional education courses.

Impact of college of pharmacy-based educational services within the hospital

Using a pharmacy intervention form, we measured the influence that university-based pharmacy educational personnel had on the pharmacy department's drug costs and on patient charges over a three-month period. A total of 278 interventions were made; 88.8 percent were implemented. Implemented interventions decreased drug costs by $1661.99 and decreased patient charges by $5938.37. The average implemented intervention decreased drug cost by $6.73 and patient cost by $24.04. Regardless of economic benefits, 218 of the 247 implemented interventions were considered to have positive clinical effects on patient care. Educational personnel were responsible for generating $6028.27 of fee revenues to the pharmacy department through generation of pharmacokinetic drug dosing consults. We conclude that the educational programs provided by the pharmacy department through affiliation with a college of pharmacy directly contributed $7690.26 to the pharmacy department in the form of cost-avoided dollars and revenue generation over a three-month period. The provision of educational services by a hospital pharmacy department results in financial rewards as well as other benefits that have been previously described.

Desirable behaviours in the office management of hypertension addressed through continuing medical education

Twenty family physicians in Saskatchewan participated in this randomized controlled study which examined the effects of relatively low-cost educational techniques on the office management of hypertension. We measured 1,538 episodes of care relating to the office management of hypertension by chart review, prior to, and at six and 12 months following education. The family physicians who participated in the education were found to perform the recommended behaviours significantly more often at six and 12 months post education than those physicians who did not have the education. Our findings indicate that carefully planned, inexpensive educational techniques can improve clinical behaviour in areas where there is identified educational need.

NJHA and continuing education

Founded in 1918, the New Jersey Hospital Association (NJHA) has, as its mission, the advocacy for health care services provided by New Jersey hospitals, nursing homes, and other health care institutions. Through its current membership of 126 institutions, the Association seeks to provide guidance in shaping policy and in improving the organization and delivery of quality health care. Along with other affiliated organizations, based at its Center for Health Affairs in Princeton, NJHA offers a variety of services. For example, NJHA: represents member institutions on legislative and regulatory problems before the Health Care Administration Board, Hospital Rate-Setting Commission, and other regulatory and legislative bodies; assists member hospitals in assessing and providing solutions to manpower needs; communicates common problems and accomplishments among member institutions through several publications and other media; and joins with MSNJ in conducting continuing medical education programs for physicians and hospital administrators, jointly working to develop position papers on health care issues. The following article presents an opinion piece by the president of NJHA, in which he addresses a current major concern of his organization, that is, how quality CME can be maintained given the severe economic constraints imposed by today's health care economy.

A policy-based CE resource allocation algorithm

The cost of a health facility's continuing education (CE) program varies with facility size, mission, and its location or accessibility to sources of CE. This paper describes the development and use of a policy model and algorithm for allocating CE dollar resources in a large national health system. The algorithm uses a two-factor model, basing facility CE dollar allocations on the amount of CE need and price differences in accessing CE sources.

Utilization of resources for the maintenance of excellence in neurological surgery. The 1988 American Association of Neurological Surgeons presidential address

In order to maintain the highest standards of care, neurosurgeons commit significant monies and time to continuing education. Significant time is devoted to national and regional organizations that work to assure standards for neurosurgical training, certification, and patient care. The continued increase in the sum of these efforts, both in money and time, indicates that a more efficient approach will be necessary in the future if neurosurgery and neurosurgeons are not to be overwhelmed or standards compromised.