Women doctors in medical professional organisations in South Africa--a report by the Women in Medicine workgroup

OBJECTIVES

To determine the level of representation of women doctors in medical professional organisations in South Africa historically and currently, and if not adequate, to ascertain the reasons for women's limited participation in medico-political activities.

DESIGN

A descriptive study of the membership of South African medical professional organisations and their executive structures.

OUTCOME MEASURES

The number and percentages of women doctors as members and at executive level in medical professional organisations compared with the number of registered women practitioners.

RESULTS AND CONCLUSIONS

Women are inadequately represented at all levels in the great majority of organisations for which information was provided. In view of the rapidly increasing number of women doctors the profession and its professional bodies need to take active steps to promote the participation of women in these organisations.

Health care reform in Russia: a survey of head doctors and insurance administrators

In keeping with the introduction of market-oriented reforms since the collapse of the Soviet Union, Russia's health care system has undergone a series of sweeping changes since 1992. These reforms, intended to overhaul socialized methods of health care financing and delivery and to replace them with a structure of competitive incentives to improve efficiency and quality of care, have met with mixed levels of implementation and results. This article probes some of the sources of support for and resistance to change in Russia's system of health care financing and delivery. It does so through a national survey of two key groups of participants in that system: head doctors in Russian clinics and hospitals, and the heads of the regional-level quasi-governmental medical insurance Funds. The survey results demonstrate that, on the whole, both head doctors and health insurance Fund directors claim to support the recent health care system reforms, although the latter's support is consistently statistically significantly stronger than that of the former. In addition, the insurance Fund directors' responses to the survey questions tend consistently to fall in the shape of a standard bell curve around the average responses, with a small number of respondents more in agreement with the survey statements than average, and a similarly small number of respondents less so. By contrast, the head doctors, along a wide variety of reform measures, split into two camps: one that strongly favors the marketization of health care, and one that would prefer a return to Soviet-style socialized medicine. The survey results show remarkable national consistency, with no variance according to the respondents' geographic location, regional population levels or other demographic or health characteristics, age of respondents, or size of health facility represented. These findings demonstrate the emergence of well-defined bureaucratic and political constituencies, their composition mixed depending on the particular element of reform under discussion, for and against specific avenues of continuity and change in Russia's health policy. As Russia struggles to devise policy strategies and tactics that balance access, equity, quality, and efficiency, it confronts not only policy choices but also political challenges that look not dissimilar to those faced by health reformers elsewhere in the world.

The role of the institutional review board in quality improvement: a survey of quality officers, institutional review board chairs, and journal editors

PURPOSE

There has been growing concern about whether and when quality improvement activities require Institutional Review Board (IRB) review and informed consent. We sought to determine whether quality officers, IRB chairs, and journal editors share similar views about the role of IRB review and informed consent in quality improvement.

METHODS

A survey consisting of six quality improvement scenarios detailing the development, implementation, and evaluation of a clinical practice guideline for the management of patients with acute myocardial infarction was mailed to all medical directors of quality and IRB chairpersons at hospitals with at least 400 beds that are members of the Council of Teaching Hospitals of the Association of American Medical Colleges. The same survey was mailed to the editors of all U.S. medical journals that appear in Abridged Index Medicus.

RESULTS

Quality officers were less likely than IRB chairs to believe that IRB review was required for all but one of the scenarios. When a clinical practice guideline developed by a national specialty society was implemented locally and its effects evaluated by chart review and telephone calls to patients, 47% (44/94) of IRB chairs, 66% (25/38) of journal editors, but only 20% (20/100) of quality officers believed the activity should be subjected to IRB review. Among those who thought that IRB review was required, there were similar but less striking differences in the perceived need for informed consent. Agreement between quality officers and IRB chairs within the same institution was poor, ranging from 44% to 52% for three of the six scenarios.

CONCLUSION

In light of the pressing need to improve quality while protecting the rights of patients, efforts should be supported to clarify the role of the IRB in quality improvement activities.

A qualitative study of the cultural changes in primary care organisations needed to implement clinical governance

BACKGROUND

It is commony claimed that changing the culture of health organisations is a fundamental prerequisite for improving the National Health Service (NHS). Little is currently known about the nature or importance of culture and cultural change in primary care groups and trusts (PCG/Ts) or their constituent general practices.

AIMS

To investigate the importance of culture and cultural change for the implementation of clinical governance in general practice by PCG/Ts, to identify perceived desirable and undesirable cultural attributes of general practice, and to describe potential facilitators and barriers to changing culture.

DESIGN

Qualitative: case studies using data derived from semi-structured interviews and review of documentary evidence.

SETTING

Fifty senior non-clinical and clinical managers from 12 purposely sampled PCGs or trusts in England.

RESULTS

Senior primary care managers regard culture and cultural change as fundamental aspects of clinical governance. The most important desirable cultural traits were the value placed on a commitment to public accountability by the practices, their willingness to work together and learn from each other, and the ability to be self-critical and learn from mistakes. The main barriers to cultural change were the high level of autonomy of practices and the perceived pressure to deliver rapid measurable changes in general practice.

CONCLUSIONS

The culture of general practice is perceived to be an important component of health system reform and quality improvement. This study develops our understanding of a changing organisational culture in primary care; however, further work is required to determine whether culture is a useful practical lever for initiating or managing improvement.

Hemodialysis vascular access preferences and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND

Synthetic grafts have generally been found to exhibit lower survival rates and higher complication rates than native arteriovenous fistulae. We investigated whether survival of grafts relative to fistulae was better in facilities with a preference for grafts, hypothesizing that such facilities may place more grafts because grafts produced superior outcomes.

METHODS

The study was based on a national U.S. sample of 133 hemodialysis facilities participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS), a prospective, observational study of dialysis treatment practices and outcomes. Vascular access preferences were ascertained from medical directors, nurse managers, and actual practice within each facility (% graft use among prevalent patients). Logistic regression was used to model the odds ratio (OR) of graft placement (vs. fistula) and Cox regression was used to model time from access creation to initial failure.

RESULTS

Grafts were preferred by 21% of medical directors and 40% of nurse managers. Patients in facilities in which the medical director or nurse manager expressed a preference for grafts were more than twice as likely to have a graft than a fistula (AOR = 2.3, P < 0.01; reference group = facilities that did not prefer grafts), suggesting that facility preferences influence the type of access created. Overall, grafts were more prevalent than fistulae in dialysis facilities, but displayed a higher relative risk of failure (RR 1.33, P < 0.0001). However, the risk of graft versus fistula failure did not vary by expressed preference of the medical director: the relative risk of graft versus fistula failure was 1.39 in facilities in which the medical director preferred grafts and 1.39 in facilities in which the medical director preferred fistulae. Moreover, the relative risk of graft versus fistula failure was 1.57 in facilities that used more than the median percentage of grafts and 1.19 in facilities that used less than the median percentage of grafts.

CONCLUSIONS

No evidence was found that graft outcomes are superior in facilities that prefer grafts to fistulae. The observed variation in vascular access practice patterns suggests opportunities for quality improvement if optimal practices can be defined.

Teaching end-of-life issues: current status in United Kingdom and United States medical schools

Our objective was to determine how broadly end-of-life issues are represented in the undergraduate medical school curricula of the United Kingdom (UK) and the United States (US). Mailed surveys yielded response rates of 100 percent in the UK and 92 percent in the US. With one exception, all medical schools in the survey offered some exposure to dying, death, and bereavement and most addressed the topic of palliative care. Hospice involvement was found in 96 percent of UK medical schools but in only 50 percent of US schools. Overall, the UK appears to provide more exposure to end-of-life issues in medical schools, although the US appears to be moving in that direction.

Making the most of your career--and your life

Take a look at a simple way to evaluate your job. Start figuring out how to take on more tasks that you like and get rid of those you dislike.

Satisfaction higher for physician executives who treat patients, survey finds

If you're satisfied with your physician executive job, one factor contributing to your happiness may be that you're still seeing some patients. Check out the results of a national survey that examines why some physician executives are more satisfied with their jobs.

Leadership and followership

Along with the well-known leadership traits, there are some subtle characteristics of true leaders. Managing managers, making decisions, tolerating diversity, and showing a sense of humor are other marks of leadership that physician executives should possess.

The role of the psychiatrist: job satisfaction of medical directors and staff psychiatrists

In a previous survey of Columbia University Public Psychiatry Fellowship alumni, medical directors reported experiencing higher job satisfaction compared to staff psychiatrists. To further this inquiry, the authors conducted an expanded survey among the membership of the American Association of Community Psychiatrists (AACP). We mailed a questionnaire to all AACP members. Respondents categorized their positions as staff psychiatrist, program medical director or agency medical director, and rated their overall job satisfaction. The form also included a number of demographic and job characteristic items. Of 479 questionnaires mailed, a total of 286 individuals returned questionnaires (61%-12 forms were undeliverable). As in our previous survey, medical directors experience significantly higher job satisfaction compared to staff psychiatrists. Program and agency medical directors do not differ significantly. In addition, job satisfaction is strongly and negatively correlated with age for staff psychiatrists but not for medical directors. This survey strengthens the previously reported advantage medical directors have over staff psychiatrists regarding job satisfaction. The finding that job satisfaction decreases with increasing age of staff psychiatrists but not medical directors is particularly interesting, suggesting that staff psychiatrist positions may come to be regarded as "dead-end" over time. Psychiatrists are advised to seek promotions to program medical director positions early in their careers, since these positions are far more available, and provide equal job satisfaction, compared to agency medical director positions.

Leaders as combat fighter pilots. Research project targets leaders who support money-losing business strategies

When strategic plans go awry and begin losing money, the smart thing to do is change course. But some leaders get so involved with the plan, they fail to navigate properly and fly right into the target. The organization can lose millions. Examine why this happens and what you can do to prevent it from happening in your organization.

Differences in managerial behaviour between head nurses and medical directors in intensive care units in Europe

We attempt to determine whether differences appear between the managerial behaviour of European intensive care head nurses on the one side and medical directors on the other. In order to come up with a managerial job and competency analysis of ICU managers, observations and interviews were performed. Additionally, focus groups consisting of ICU experts were organized. The results are discussed according to managerial behaviour taxonomies and existing competency models. There seems to be some differentiation between the two managerial positions studied. Head nurses are more involved in planning/coordinating and motivating/reinforcing activities, whereas medical directors are more involved in socializing/politicking, decision making/problem solving, interaction with others and disciplining.

The value of case management in the publicly funded substance abuse treatment system. The perspective of program directors, case managers and clients

The many purposes of this article is to understand the role and value of case management from the perspective of program directors, case managers and clients. A survey of program directors from publicly funded substance abuse treatment programs in Boston was administered, and in-depth interviews with a sample of program directors, case managers, and clients were conducted. Case management allowed programs to serve more complex clients and increased time available for counselors to focus on the clinical needs of clients. From the perspective of case managers and clients, much of the value of case management came from educating clients about steps they could take to meet their needs and then supporting them in their efforts as they took these steps. Successful steps taken to deal with these needs helped lay the foundation necessary to confront the challenges of treatment. Program directors, case managers, and clients considered case management a valuable enhancement to substance abuse treatment.

Physician executives report high job satisfaction. Summary of findings from a survey of senior physician executives

The role of the senior physician executive is well established in American hospitals and health systems. There is little research, however, on overall physician executive job satisfaction, their perceptions of their organizational role and job performance, or their views of the medical staffs with which they work. A recent survey of physician executives examined these and other areas. It found physician executives to be quite satisfied with their jobs. What follows is a summary of the findings. An article based on the survey will be featured in a future issue of The Physician Executive.

Working with recruiters. Physicians sound off in CyberForums about their experiences with recruiters

Searching for your next job is never easy. You generally need all the help you can get. Often, that means working with physician recruiters who have the connections to help you land a great position. But dealing with recruiters can be both rewarding and frustrating. In two ACPE CyberForums facilitated by Barry Herman--one in 1999 and another just a few months ago--participants talked about the role of recruiters, offering advice and tips that can help physician executives carry out a successful job search.

What do you owe your team? Survival tips for people who dread teamwork

Team building and teamwork are well entrenched in the American workplace. If you're independent, shy, or short on time, making decisions with a team may be one of the toughest situations you face. Learn how to get along with the rest of the group even if you don't buy in to the team concept. Teamwork may be one of your most useful career skills.

Controlled burn! Physician executives must be ready to handle job burnout, career stress

Job burnout for workers in any career can be frightening. It's truly debilitating to think that your job and career are worthless, that your future isn't bright. There are, however, some steps you can take to recognize, avoid or overcome the stress and anxiety that leads to job burnout.

Outcome of patients experiencing cardiac arrest with carbon monoxide poisoning treated with hyperbaric oxygen

STUDY OBJECTIVE

We sought to examine the outcome of a subgroup of patients with extreme carbon monoxide (CO) poisoning, specifically those discovered in cardiac arrest, resuscitated, and subsequently treated with hyperbaric oxygen (HBO(2)). Opinions of hyperbaric medicine physicians regarding the treatment of such patients were also sought.

METHODS

Records of patients treated with HBO(2) for acute CO poisoning at Virginia Mason Medical Center in Seattle from September 1987 to August 2000 were reviewed. Those who were resuscitated from cardiac arrest in the field before HBO(2) treatment were selected for detailed analysis. Patient demographic data and information regarding circumstances of the poisoning, resuscitation, HBO(2) treatment, and subsequent course were extracted and collated. In addition, a postal survey of medical directors of North American HBO(2) treatment facilities regarding opinions about the management and outcome of such patients was performed.

RESULTS

A total of 18 patients were treated with HBO(2) after resuscitation from CO-associated cardiac arrest. They included 10 female and 8 male patients ranging in age from 3 to 72 years. Sources of CO included house fires (10 patients) and automobile exhaust (8 patients). Patient carboxyhemoglobin levels averaged 31.7%+/-11.0% (mean+/-SD), and arterial pH averaged 7.14+/-0.19. Presenting cardiac rhythm was a bradydysrhythmia in 10 of 18 patients. HBO(2) treatment was administered an average of 4.3 hours after poisoning (< or = 3 hours in 10 patients and < or = 6 hours in 15 patients). Despite this, all 18 patients died during their hospitalizations. Medical directors of hyperbaric treatment facilities estimated a 74% likelihood of survival for a hypothetical patient with this presentation.

CONCLUSION

In this consecutive case series, cardiac arrest complicating CO poisoning was uniformly fatal, despite administration of HBO(2) therapy after initial resuscitation. Survey results suggest that physician education regarding this subset of CO-poisoned patients is needed. The prognosis of this condition should be considered when making triage and treatment decisions for patients poisoned to this severity.