What do hospital consultants value about their jobs? A discrete choice experiment

Objective To examine the strength of hospital consultants'' preferences for various aspects of their work.Design Questionnaire survey including a discrete choice experiment.Setting NHS Scotland.Participants 2923 hospital consultants in Scotland.Main outcome measures Monetary valuations or prices for each job characteristic, based on consultants'' willingness to pay and willingness to accept extra income for a change in each job characteristic, calculated from regression coefficients.Results The response rate was 61% (1793 resspondents). Being on call was the most important attribute, as consultants would need to be compensated up to £18 000 (30% of their average net income) (P < 0.001) for a high on-call workload. Compensation of up to £9700 (16% of their net income) (P < 0.001) would be required for consultants to forgo opportunities to undertake non-NHS work. Consultants would be willing to accept £7000 (12% of net income) (P < 0.001) in compensation for fair rather than good working relationships with staff, and £6500 (11% of net income) (P < 0.001) to compensate them for a shortage of staff. The least important characteristic was hours of work, with £562 per year (0.9% of their net income) (P < 0.001) required to induce consultants to work one extra hour per week. These preferences also varied among specific subgroups of consultants.Conclusions Important information on consultants'' strength of preferences for characteristics of their job should be used to help to address recruitment and retention problems. Consultants would require increased payment to cover more intensive on-call commitments. Other aspects of working conditions would require smaller increases.     

Communication of results of necropsies in north east Thames region.

OBJECTIVE--To evaluate the adequacy of reporting of results of necropsy to referring clinicians and to general practitioners. DESIGN--Questionnaire survey of referring clinicians and general practitioners of deceased patients in four districts in North East Thames region. Patients were selected by retrospective systematic sampling of 50 or more necropsy reports in each district. SETTING--One teaching hospital, one inner London district general hospital, and two outer London district general hospitals. PARTICIPANTS--70 consultants and 146 general practitioners who were asked about 214 necropsy reports; coroners'' reports were excluded. MAIN OUTCOME MEASURES--Time taken for dispatch of final reports after necropsy, consultants'' recognition of the reports, general practitioners'' recognition of the reports or of their findings, and consultants'' recall of having discussed the findings with relatives. RESULTS--Only two hospitals dispatched final reports including histological findings (mean time to dispatch 144 days and 22 days respectively). 42 (60%) consultants and 83 (57%) general practitioners responded to the survey. The percentage of reports seen by consultants varied from 37% (n = 13) to 87% (n = 36); in all, only 47% (39/83) of general practitioners had been informed of the findings by any method. Consultants could recall having discussed findings with only 42% (47/112) of relatives. CONCLUSIONS--Communication of results of necropsies to hospital clinicians, general practitioners, and relatives is currently inadequate in these hospitals. IMPLICATIONS AND ACTION--A report of the macroscopic findings should be dispatched immediately after necropsy to clinicians and general practitioners; relatives should routinely be invited to discuss the necroscopic findings. One department has already altered its practice.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Physicians' perceptions of the effect on clinical services of an alternative funding plan at an academic health sciences centre

BACKGROUND: In July 1994 an alternative funding plan for clinical services (global funding instead of fee-for-service payment) was established at the Southeastern Ontario Health Sciences Centre, Kingston, Ont. This study describes the perceptions of the referring physicians and consultants of the effects of the alternative funding plan 2.5 years after it was initiated. METHODS: A questionnaire was mailed to all physicians in the Kingston area in November 1996. Information was collected on demographics, referring physicians'' perceptions of the funding plan''s impact on their practices, consultants'' perceptions of its impact on their activities, perceptions of referring and consultant physicians of its impact on services provided by consultants, and attitudes toward alternative funding in the context of the Ontario health care system. RESULTS: Of the 772 physicians 531 (68.8%) returned a completed questionnaire (323 referring physicians and 208 consultants). A sizeable proportion of the referring physicians (126 [39.0%]) indicated that they were referring fewer patients to consultants at the study centre. They did not think that their practice volume had increased, but they did report spending more time on complex cases and on patient care after referral or hospital stay, and more time coordinating community care after hospital stay. Of the consultants 81 (38.9%) believed that their time spent on patient care had increased. No consistent impact on time spent on research or teaching activities was perceived. A total of 54 (26.0%) of the consultants were concerned about the impact of the alternative funding plan on quality of care. A significant proportion of the respondents (399 [75.1%]) believed that outpatient waiting times had increased, and 116 (35.9%) of the referring physicians believed that consultants were not as available by telephone. Most (220 [68.1%]) of the referring physicians believed that the funding change had had a negative effect on health care services in the region, and 87 (41.8%) of the consultants agreed. Nevertheless, the respondents believed that other factors such as funding cuts, hospital bed closures and staff layoffs were much more responsible than the alternative funding plan for their negative perceptions. INTERPRETATION: The alternative funding plan appears to have had an impact on the practices of individual physicians. However, it was not the focus for significant opposition or support from either consultants participating in the funding plan or referring physicians.     

La loi sur la vasectomie est peu connue

Objective

To determine vasectomy practices and knowledge of the law governing these procedures.

Material

A 17-item questionnaire was sent to 262 surgeons likely to perform vasectomies, including 149 urologists and 68 gynaecologists.

Results

Sixty one per cent of doctors had received requests for vasectomy and 40% performed this procedure, as an outpatient procedure in 60% of cases, in hospital in 29% of cases and as an office procedure in 11% of cases. Fifty five per cent of doctors thought that vasectomy was covered by medical insurance, and 60% wrongly believed that a declaration must be made to theOrdre des Médecins (Medical Board). Twenty nine per cent were not aware of the need for written information of the patient. Only 28% were aware of the 4-month period of reflection before the procedure and 45% were aware of the need for written consent.

Conclusion

in this survey, 14% of practitioners were simultaneously aware of the need for a 4-month period of reflection, consent and written information. Wider diffusion of information about the law governing sterilization is required.     

Prescribing new drugs: qualitative study of influences on consultants and general practitioners

ObjectiveTo explore consultants'' and general practitioners'' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.DesignQualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.SettingTeaching hospital and nearby general hospital plus general practices in Birmingham.Participants38 consultants and 56 general practitioners who regularly referred to the teaching hospital.ResultsConsultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.ConclusionsThe factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.

What is already known on this topic

UK studies show that use of new drugs by general practitioners is influenced by consultants, the nature of the drug, and perceived risk

What this study adds

Consultants generally introduced fewer drugs than general practitioners, usually within their specialtyDecisions were said to be based mainly on the evidence from the scientific literature and meetingsGeneral practitioners prescribed more new drugs and the basis of decisions was more variedDoctors'' interpretations of using a new drug were not consistent     

THE THORNY CHILD

Too many physicians—and parents—hide behind the overworked excuse that “Johnny is just going through a stage.” If the remark is inaccurate a great disservice can be done to both mother and child, and ultimately to society. The well oriented physician would no more permit a young mother to unwittingly feel “guilty” because her two-year-old “little stinker” behaves like a two-year-old little stinker than he would casually reassure when a ten-year-old behaves as though he were two.Actually much of the unpleasant behavior of children is quite normal. If physicians would help all young mothers to recognize this without dismissing abnormal behavior, it would do much to avert the overwhelming sense of inadequacy that so many modern young mothers feel—especially with their first baby. If they can be made comfortable with their first the others usually come easily. Many physicians who care for children are not trained in the rudiments of developmental behavior. By means of a simple outline and drawing of “the thorny child” even the least of the experts can better understand some of the chronologic variations in developmental behavior.     

Vasectomy in Guatemala: A follow‐up study of five hundred acceptors

Abstract

Over a thousand vasectomies are performed yearly by the private family planning association (APROFAM) of Guatemala. This study surveyed the experience of five hundred men interviewed 12 to 36 months after vasectomy. Overall, the experience was reported to be positive. Most wives approved of the operation; the attention received at the clinic was satisfactory; and most men considered their general health, sex drive, and marital relations to be unchanged or improved. Negative aspects included post‐operative discomfort one month later (9 per cent) and failure of the operation (2 per cent). Reported satisfaction with the operation was high: 97 per cent expressed no regret. Further analysis indicates that satisfaction was not a function of sociodemographic characteristics, attitudes toward the clinic experience, post‐operative discomfort, or wife's attitude. Rather, dissatisfaction stemmed from failure of the operation or a perceived negative effect of the operation on one's health and sex life.     

Inpatient Management: Variations in some Aspects of Practice in Scotland

Data for four aspects of inpatient management—namely, variations in length of stay, the time patients spend in hospital before or after operation, and the proportion of patients operated on in surgical units—show considerable variations in certain aspects of practice by Scottish consultants. It is suggested that there may be simple explanations for some of the observed variations. The differences could be due to great variation in the constraints encountered by the consultants in their work, or to wide differences of opinion about the optimum treatment for specific diagnoses.     

CYTOLOGIC DETECTION OF CERVICAL CANCER—Four Years' Experience with Routine Smear Examination in Private Practice

Simplified Papanicolaou smear techniques appear to be adaptable to private clinical practice when experienced cytodetection laboratory facilities are available. A private physician''s office seems potentially an efficient, economical and practical place for detection of cervical cancer by use of the smear technique as a routine part of examination of patients.In a series here reported upon, examination of 11,207 cervical smears taken at the first examination of patients of all ages led to diagnosis of unsuspected malignant disease in 80 cases—in all instances at a stage when it should be easily curable. Cancer was not detected in examination of 6,060 smears taken later from women who had had a “negative” smear at the time of first examination, which seems to indicate that the first screening was reasonably accurate.In a few cases, early cancer was detected when smears were reported as “atypical” or “suspicious.” Such reports demand as careful follow-up as do “positive” reports.There are dangers and limitations in wide-spread clinical application of screening by this method. Care must be observed in the development of programs for its use lest the potential benefits in early detection be outweighed by the dangers from misuse.     

“HIDDEN” ALCOHOLICS—Medical Implications of Undiscovered Addiction

“Hidden alcoholics”—those who drink surreptitiously to keep their addiction secret—far out-number the overt habitues of skid rows. The former rather than the latter should be considered “typical” alcoholics. Even though they have severe problems, they maintain fairly good employment stability and stability in marriage. Yet they steadily deteriorate.Often “hidden” alcoholics go to physicians because of symptoms referable to alcoholism but contrive to conceal their addiction and so make diagnosis difficult. Hence, physicians observing certain kinds of symptoms that cannot be attributed to a readily observable or demonstrable pathologic change should make searching inquiry as to the patient''s drinking habits. For not until the proper diagnosis is made in such cases can there be hope of effective treatment.     

Preregistration house officers in the Thames regions: changes in quality of training after four years.

OBJECTIVE--To measure changes in the training and workload of preregistration house officers over four years. DESIGN--Postal questionnaire. SETTING--The Thames health regions. PARTICIPANTS--1049 preregistration house officers. RESULTS--Response rate was 69% (725 replies). The proportion of house officers officially on duty > 83 hours a week fell from at least 42% to 21%, and the proportion officially on duty < or = 72 hours rose from no more than 9% to 40%. Adequate guidance in breaking bad news increased from 25% to 46% (p < 0.0001; 95% confidence interval for difference, 16.2% to 25.8%) and guidance in pain control increased from 36% to 46% (p < 0.01; 5.0% to 15.0%). The number of house officers attending an induction course increased from 61% to 94% (p < 0.001; 28.9% to 37.1%). There was no change in the proportion unable to attend formal educational sessions because of clinical commitments or in levels of satisfaction with consultants'' educational supervision. The median number of inpatients under house officers'' care fell from 20 to 17, but the numbers of patients clerked in an average week showed little change. House officers were less satisfied with the clinical experience their post provided (proportion dissatisfied rose from 30% to 39%; p < 0.01; 4.2% to 13.8%) and less enthusiastic about recommending their post to a friend (proportion neutral or not recommending rose from 30% to 42%, p < 0.0001; 7.9% to 16.9%). CONCLUSION--Despite progress in reducing hours of duty and providing induction courses, the training that hospitals and consultants provide for house officers is still unsatisfactory and inconsistent with the General Medical Council''s recommendations.     

PYOGENIC INFECTIONS IN ORTHOPEDIC SURGERY—Prevention and Management

A problem that confronts surgeons in clinical practice is that a patient may acquire new infections while in the hospital. When such infections occur they are predominantly staphylococcal and these bacteria are often, but not always resistant to penicillin, streptomycin and the tetracycline antibiotics. They are often but neither completely nor uniformly sensitive to the newer or less frequently used antimicrobial agents.The extension of antibiotic usage from proven situations to “routine” prophylaxis has been a widespread practice. There are many reasons to discourage and to reexamine the validity and purpose, as well as the safety of this practice. We now have sufficient background and experience to revert from widespread and indiscriminate use to a practice of discriminate prophylactic therapy.In general, soft tissue lacerations and clean wounds do not require operation under an “antibiotic umbrella.” Similarly, elective orthopedic surgical procedures of soft tissues such as muscle biopsy, tenorrhaphy and muscle and tendon transplants as well as plastic surgical procedures can be safely performed without antibiotic therapy if technique is good and operation not prolonged. Operations of major magnitude on the motor-skeletal system, such as open fractures, internal fixation of fractures with bone grafts, and major operations of joints are indication for antibiotic therapy for impending infection postoperatively for five days. Reliance is mainly on antistaphylococcal drugs to which hospital organisms are predominantly sensitive. The two remaining indications for antibiotic therapy against impending infection are: (1) major crush injury—for example, to the thigh—and (2) the need for a patient with a healing fracture to have other surgical procedures such as tooth extraction or excision of an infected area which might predispose to transient bacteremia and embolic infection in bone or joint.     

Experience in a Maternal Mortality Study in Nova Scotia

Material from a three-year Maternal Mortality Study in the Province of Nova Scotia is presented. Thirty-eight maternal deaths were studied; the chief cause was hemorrhage—either antepartum or postpartum—in 52% of all cases. Seventy-six per cent of the cases were due to practically preventable factors. Inadequate prenatal care in which the family was at fault had existed in 35% of the cases studied. Physician error in judgment and/or technique was present in 65%. Efforts to correct this situation have been described briefly. The need for public education, increased numbers of consultants, continued physician education, critical hospital analysis and improved hospital facilities is stressed.     

Anonymity versus Privacy in the Dictator Game: Revealing Donor Decisions to Recipients Does Not Substantially Impact Donor Behavior

Anonymity is often offered in economic experiments in order to eliminate observer effects and induce behavior that would be exhibited under private circumstances. However, anonymity differs from privacy in that interactants are only unaware of each others'' identities, while having full knowledge of each others'' actions. Such situations are rare outside the laboratory and anonymity might not meet the requirements of some participants to psychologically engage as if their actions were private. In order to explore the impact of a lack of privacy on prosocial behaviors, I expand on a study reported in Dana et al. (2006) in which recipients were left unaware of the Dictator Game and given donations as “bonuses” to their show-up fees for other tasks. In the current study, I explore whether differences between a private Dictator Game (sensu Dana et al. (2006)) and a standard anonymous one are due to a desire by dictators to avoid shame or to pursue prestige. Participants of a Dictator Game were randomly assigned to one of four categories—one in which the recipient knew of (1) any donation by an anonymous donor (including zero donations), (2) nothing at all, (3) only zero donations, and (4) and only non-zero donations. The results suggest that a lack of privacy increases the shame that selfish-acting participants experience, but that removing such a cost has only minimal effects on actual behavior.     

The consultant's role in continuing medical education of general practitioners: the case of rheumatology.

Consultant rheumatologists were surveyed by questionnaire about their contribution to the continuing education of general practitioners, and 84% (203/243) replied. Altogether 157 respondents had participated in some form of teaching, 147 in collective teaching sessions such as lectures and 99 in the teaching of small groups. Arthritis comprised 44% of the rheumatological topics taught; there was a noticeable lack of teaching on problems commonly encountered in general practice, such as soft tissue rheumatism and injury and back pain, and on clinical skills including examination and injection of joints. Eighty eight respondents made comments and suggestions. The favoured educational strategies were small group teaching, apprenticeship schemes, and interchange between general practitioners and consultants about shared cases. This contrasts with what was typically done--namely, formal lectures on rheumatoid arthritis in postgraduate medical centres. These findings raise questions about the continuing education of consultants themselves as well as about the consultants'' role in teaching others.     

B.M.A. Deputizing Service in Sheffield, 1970

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers'' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of “personal doctoring” was not threatened.     

Funding in the firing line

With large charities such as the Wellcome Trust or the Gates Foundation committed to funding research, is there a risk that politicians could cut public funding for science?Towards the end of 2010, with the British economy reeling from the combined effects of the global recession, the burst bubble of property speculation and a banking crisis, the country came close to cutting its national science and research budget by up to 25%. UK Business Secretary Vince Cable argued, “there is no justification for taxpayers'' money being used to support research which is neither commercially useful nor theoretically outstanding” (BBC, 2010). The outcry from UK scientists was both passionate and reasoned until, in the end, the British budget slashers blinked and the UK government backed down. The Chancellor of the Exchequer, George Osborne, announced in October that the government would freeze science and research funding at £4.6 billion per annum for four years, although even this represents about a 10% cut in real terms, because of inflation.“there is no justification for taxpayers'' money being used to support research which is neither commercially useful nor theoretically outstanding”There has been a collective sigh of relief. Sir John Savill, Chief Executive of the Medical Research Council (UK), said: “The worst projections for cuts to the science budget have not been realised. It''s clear that the government has listened to and acted on the evidence showing investment in science is vital to securing a healthy, sustainable and prosperous future.”Yet Britain is unusual compared with its counterparts elsewhere in the European Union (EU) and the USA, because private charities, such as the Wellcome Trust (London, UK) and Cancer Research UK (London, UK), already have budgets that rival those of their government counterparts. It was this fact, coupled with UK Prime Minister David Cameron''s idea of the ‘big society''—a vision of smaller government, increased government–private partnerships and a bigger role for non-profit organizations, such as single-disease-focused charities—that led the British government to contemplate reducing its contribution to research, relying on the private sector to pick up the slack.Jonathan Grant, president of RAND Europe (London, UK)—a not-for-profit research institute that advises on policy and decision-making—commented: “There was a strong backlash and [the UK Government] pulled back from that position [to cut funding]. But that''s the first time I''ve really ever seen it floated as a political idea; that government doesn''t need to fund cancer research because we''ve got all these not-for-profits funding it.”“…that''s the first time I''ve really ever seen it floated as a political idea; that government doesn''t need to fund cancer research because we''ve got all these not-for-profits funding it”But the UK was not alone in mooting the idea that research budgets might have to suffer under the financial crisis. Some had worried that declining government funding of research would spread across the developed world, although the worst of these fears have not been realized.Peter Gruss, President of the Max Planck Society (Munich, Germany), explained that his organization receives 85% of its more-than €1.5 billion budget from the public purses of the German federal government, German state ministries and the EU, and that not all governments have backed away from their commitment to research. In fact, during the crisis, the German and US governments boosted their funding of research with the goal of helping the economic recovery. In 2009, German Chancellor Angela Merkel''s government, through negotiation with the German state science ministries, approved a windfall of €18 billion in new science funding, to be spread over the next decade. Similarly, US President Barack Obama''s administration boosted spending on research with a temporary stimulus package for science, through the American Recovery and Reinvestment Act.Even so, Harry Greenberg, Senior Associate Dean for Research at Stanford University (California, USA) pointed out that until the US government injected stimulus funding, the budget at the National Institutes of Health (NIH; Bethesda, Maryland, USA) had essentially “been flat as a pancake for five or six years, and that means that it''s actually gone down and it''s having an effect on people being able to sustain their research mission.”Similarly, Gruss said that the research community should remain vigilant. “I think one could phrase it as there is a danger. If you look at Great Britain, there is the Wellcome Trust, a very strong funding organization for life sciences and medical-oriented, health-oriented research. I think it''s in the back of the minds of the politicians that there is a gigantic foundation that supports that [kind of research]. I don''t think one can deny that. There is an atmosphere that people like the Gates family [Bill and Melinda Gates Foundation] invests in health-related issues, particularly in the poorer countries [and that] maybe that is something that suffices.”The money available for research from private foundations and charities is growing in both size and scope. According to Iain Mattaj, Director General of the European Molecular Biology Laboratory (EMBL; Heidelberg, Germany), this growth might not be a bad thing. As he pointed out, private funding often complements government funding, with charities such as the Wellcome Trust going out of their way to leverage government spending without reducing government contributions. “My feeling is that the reason that the UK government is freezing research funding has all to do with economics and nothing to do with the fact that there are potentially private funders,” he said. “Several very large charities in particular are putting a lot of money into health research. The Gates Foundation is the biggest that has just come on the scene, but the Howard Hughes Medical Institute [HHMI; Chevy Chase, Maryland, USA] and the Wellcome Trust are very big, essentially private charities which have their own agendas.”…charities such as the Wellcome Trust [go] out of their way to leverage government spending without reducing government contributions​contributionsOpen in a separate window© CorbisBut, as he explained, these charities actually contribute to the overall health research budget, rather than substituting funds from one area to another. In fact, they often team up to tackle difficult research questions in partnership with each other and with government. Two-thirds of the €140 million annual budget of EMBL comes from the European states that agree to fund it, with additional contributions from private sources such as the Wellcome Trust and public sources such as the NIH.Yet over the years, as priorities have changed, the focus of those partnerships and the willingness to spend money on certain research themes or approaches has shifted, both within governments and in the private sector. Belief in the success of US President Richard Nixon''s famous ‘war on cancer'', for example, has waned over the years, although the fight and the funding continues. “I don''t want to use the word political, because of course the decisions are sometimes political, but actually it was a social priority to fight cancer. It was a social priority to fight AIDS,” Mattaj commented. “For the Wellcome Trust and the Gates Foundation, which are fighting tropical diseases, they see that as a social necessity, rather than a personal interest if you like.”Nevertheless, Mattaj is not surprised that there is an inclination to reduce research spending in the UK and many smaller countries battered by the economic downturn. “Most countries have to reduce public spending, and research is public spending. It may be less badly hit than other aspects of public spending. [As such] it''s much better off than many other aspects of public spending.”A shift away from government funding to private funding, especially from disease-focused charities, worries some that less funding will be available for basic, curiosity-driven research—a move from pure research to ‘cure'' research. Moreover, charities are often just as vulnerable to economic downturns, so relying on them is not a guarantee of funding in harsh economic times. Indeed, greater reliance on private funding would be a return to the era of ‘gentlemen scientists'' and their benefactors (Sidebar A).

Sidebar A | Gentlemen scientists

Greater reliance on private funding would return science to a bygone age of gentlemen scientists relying on the largesse of their wealthy sponsors. In 1831, for example, naturalist Charles Darwin''s (1809–1882) passage on the HMS Beagle was paid for by his father, albeit reluctantly. According to Laura Snyder, an expert on Victorian science and culture at St John''s University (New York, USA), by the time Darwin returned to England in 1836, the funding game had changed and government and private scientific societies had begun to have a bigger role. When Sir John Frederick William Herschel (1791–1871), an English mathematician, astronomer, chemist, experimental photographer and inventor, journeyed to Cape Colony in 1833, the British government offered to give him a free ride aboard an Admiralty ship. “Herschel turned them down because he wanted to be free to do whatever he wanted once he got to South Africa, and he didn''t want to feel beholden to government to do what they wanted him to do,” Snyder explained, drawing from her new book The Philosophical Breakfast Club, which covers the creation of the modern concept of science.Charles Babbage (1791–1871), the mathematician, philosopher, inventor and mechanical engineer who originated the concept of a programmable computer, was a member of the same circle as Herschel and William Whewell (1794–1866), a polymath, geologist, astronomer and theologian, who coined the word ''scientist''. Although he was wealthy, having inherited £100,000 in 1827—valued at about £13.3 million in 2008—Babbage felt that government should help pay for his research that served the public interest.“Babbage was asking the government constantly for money to build his difference engine,” Snyder said. Babbage griped about feeling like a tradesman begging to be paid. “It annoyed him. He felt that the government should just have said, ''We will support the engine, whatever it is that you need, just tell us and we''ll write you a check''. But that''s not what the government was about to do.”Instead, the British government expected Babbage to report on his progress before it loosened its purse strings. Snyder explained, “What the government was doing was a little bit more like grants today, in the sense that you have to justify getting more money and you have to account for spending the money. Babbage just wanted an open pocketbook at his disposal.”In the end the government donated £17,000, and Babbage never completed the machine.Janet Rowley, a geneticist at the University of Chicago, is worried that the change in funding will make it more difficult to obtain money for the kind of research that led to her discovery in the 1970s of the first chromosomal translocations that cause cancer. She calls such work ‘fishing expeditions''. She said that the Leukemia & Lymphoma Society (White Plains, New York, USA), for example—a non-profit funder of research—has modified its emphasis: “They have now said that they are going to put most of their resources into translational work and trying to take ideas that are close to clinical application, but need what are called incubator funds to ramp up from a laboratory to small-scale industrial production to increase the amount of compound or whatever is required to do studies on more patients.”This echoes Vince Cable''s view that taxpayers should not have to spend money on research that is not of direct economic, technological or health benefit to them. But if neither charities nor governments are willing to fund basic research, then who will pay the bill?…if neither charities nor governments are willing to fund basic research, then who will pay the bill?Iain Mattaj believes that the line between pure research and cure research is actually too blurred to make these kinds of funding distinctions. “In my view, it''s very much a continuum. I think many people who do basic research are actually very interested in the applications of their research. That''s just not their expertise,” he said. “I think many people who are at the basic end of research are more than happy to see things that they find out contributing towards things that are useful for society.”Jack Dixon, Vice President and Chief Scientific Officer at HHMI, also thinks that the line is blurry: “This divide between basic research and translational research is somewhat arbitrary, somewhat artificial in nature. I think every scientist I know who makes important, basic discoveries likes to [...] see their efforts translate into things that help humankind. Our focus at the Hughes has always been on basic things, but we love to see them translated into interesting products.” Even so, HHMI spends less than US $1 billion annually on research, which is overshadowed by the $30 billion spent by the NIH and the relatively huge budgets of the Wellcome Trust and Cancer Research UK. “We''re a small player in terms of the total research funding in the US, so I just don''t see the NIH pulling back on supporting research,” Dixon said.By way of example, Brian Druker, Professor of Medicine at the Oregon Health & Science University (Portland, Oregon, USA) and a HHMI scientist, picked up on Rowley''s work with cancer-causing chromosomal translocations and developed the blockbuster anti-cancer drug, imatinib, marketed by Novartis. “Brian Druker is one of our poster boys in terms of the work he''s done and how that is translated into helping people live longer lives that have this disease,” Dixon commented.There is a similar view at Stanford. The distinction between basic and applied is “in the eye of the beholder,” Greenberg said. “Basic discovery is the grist for the mill that leads to translational research and new breakthroughs. It''s always been a little difficult to convey, but at least here at Stanford, that''s number one. Number two, many of our very basic researchers enjoy thinking about the translational or clinical implications of their basic findings and some of them want to be part of doing it. They want some benefit for mankind other than pure knowledge.”“Basic discovery is the grist for the mill that leads to translational research and new breakthroughs”If it had not backed down from the massive cuts to the research budget that were proposed, the intention of the UK Government to cut funding for basic, rather than applied, research might have proven difficult to implement. Identifying which research will be of no value to society is like trying to decide which child will grow up to be Prime Minister. Nevertheless, most would agree that governments have a duty to get value-for-money for the taxpayer, but defining the value of research in purely economic or translational terms is both short-sighted and near impossible. Even so, science is feeling the economic downturn and budgets are tighter than they have been for a long time. As Greenberg concluded, “It''s human nature when everybody is feeling the pinch that you think [yours] is bigger than the next guy''s, but I would be hard pressed to say who is getting pinched, at least in the biomedical agenda, more than who else.”     

The Effect of Framing and Normative Messages in Building Support for Climate Policies

Deep cuts in greenhouse gas emissions are required to mitigate climate change. However, there is low willingness amongst the public to prioritise climate policies for reducing emissions. Here we show that the extent to which Australians are prepared to reduce their country''s CO₂ emissions is greater when the costs to future national income are framed as a “foregone-gain”—incomes rise in the future but not by as much as in the absence of emission cuts—rather than as a “loss”—incomes decrease relative to the baseline expected future levels (Studies 1 & 2). The provision of a normative message identifying Australia as one of the world''s largest CO₂ emitters did not increase the amount by which individuals were prepared to reduce emissions (Study 1), whereas a normative message revealing the emission policy preferences of other Australians did (Study 2). The results suggest that framing the costs of reducing emissions as a smaller increase in future income and communicating normative information about others'' emission policy preferences are effective methods for leveraging public support for emission cuts.     

Volume-Outcome Relation for Acute Appendicitis: Evidence from a Nationwide Population-Based Study

Background

Although procedures like appendectomy have been studied extensively, the relative importance of each surgeon''s surgical volume-to-ruptured appendicitis has not been explored. The purpose of this study was to investigate the rate of ruptured appendicitis by surgeon-volume groups as a measure of quality of care for appendicitis by using a nationwide population-based dataset.

Methods

We identified 65,339 first-time hospitalizations with a discharge diagnosis of acute appendicitis (International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes 540, 540.0, 540.1 and 540.9) between January 2007 and December 2009. We used “whether or not a patient had a perforated appendicitis” as the outcome measure. A conditional (fixed-effect) logistic regression model was performed to explore the odds of perforated appendicitis among surgeon case volume groups.

Results

Patients treated by low-volume surgeons had significantly higher morbidity rates than those treated by high-volume (28.1% vs. 26.15, p<0.001) and very-high-volume surgeons (28.1% vs. 21.4%, p<0.001). After adjusting for surgeon practice location, and teaching status of practice hospital, and patient age, gender, and Charlson Comorbidity Index, and hospital acute appendicitis volume, patients treated by low-volume surgeons had significantly higher rates of perforated appendicitis than those treated by medium-volume surgeons (OR = 1.09, p<0.001), high-volume surgeons (OR = 1.16, p<0.001), or very-high-volume surgeons (OR = 1.54, p<0.001).

Conclusion

Our study suggested that surgeon volume is an important factor with regard to the rate of ruptured appendicitis.