Secondary care beyond Tomlinson: an opportunity to be seized or squandered?

The Tomlinson report''s emphasis on primary care and its essentially quantitative analysis of hospital care in London leaves little space for a picture of how secondary care for Londoners should look. In this article Fiona Moss and Martin McNicol argue that most outpatient work does not need to be done in hospitals. With proper organisation and better premises a genuinely specialist consultative service can be provided in primary health care centres, with benefit to patients and communication between primary and secondary care doctors. Hospitals would then house those outpatient services that needed major investigative facilities and much reduced inpatient capacity. It may no longer be necessary for each acute unit to offer a full range of services. Such a pattern of secondary care will have implications for the organisation of accident and emergency services and for postgraduate training. Above all Moss and McNicol argue that Tomlinson''s recommendations demand that general practitioners and specialists should re-examine the services hospitals provide and agree on the best settings for different sorts of health care and the most appropriate skills to provide it.     

Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989.

Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.     

Delivery of postgraduate medical education--who pays?

As the cost of academic postgraduate medical education increases the DHSS may sometimes need to fund established academic posts or sessions within universities, and it must recognise the need for salaried sessional commitments by clinical tutors and encourage universities to integrate them more effectively into regional medical schools. Such activities will otherwise increasingly impose on undergraduate departments teaching demands that are neither practicable nor proper.     

新形势下神经内科研究生专业特色培养的模式探索

：新形势下我国医学教育提出了培养高素质创新人才的要求,医学研究生的培养是医学生培养的最高层次。随着神经病学及其亚专业的迅猛发展,不仅对研究生的临床和科研水平提出了严峻的挑战,而且要求研究生在某一专业领域有较高的造诣。因此,对研究生进行专业特色培养是值得探索的新课题。本研究对我校神经内科研究生专业特色培养的系列探索与实践进行了总结。实践表明,我校神经内科研究生专业特色培养教学改革已取得明显成效：探索出一套行之有效的研究生专业特色培养的新模式,建立并完善了研究生培养中高素质专业人才的质量保障体系,强化了研究生的专业特色。为国内高等医学院校研究生培养模式提供了有价值的参考。     

Other cities,same problems.

London''s health care problems, particularly underfunding, are mirrored in other major cities in the United Kingdom and abroad. None has found the perfect solution, but the debates on the Tomlinson report provide an opportunity to review how to manage the three major areas of service provision, medical education, and research in London. Mr Robert Maxwell suggests that some aspects of the successful ambulatory care initiative in New York could be adapted by the capital''s primary care providers while the secondary services might learn from the rationalisation of specialist services in Paris.     

Career problems of women doctors.

Information was received from 61 women doctors who were having difficulty continuing with medical careers. Two main problems were disclosed. Firstly, despite the special arrangements made for women doctors, it is difficult to obtain postgraduate training. The provision of supernumerary posts does not seem to offer a satisfactory solution. Secondly, doctors who have completed postgraduate training but cannot yet return to full-time work are unable to obtain posts at an appropriate level. Both of these problems stem primarily from the need for part-time work by the mothers of young children. Most of the doctors wish to return to full-time or nearly full-time work when family responsibilities are fewer. In view of the increasing proportion of women doctors it seems important that large numbers are not unnecessarily lost from professional work. Some possible approaches to solving the problems are suggested.     

The American General Practitioner in Hospital

In the U.S.A. and Canada full access of general practitioners to hospital beds and facilities is regarded as an essential privilege of their work. All hospital constitutions require a review of the credentials of staff applicants and continuing evaluation of their performance. Staff appointment carries administrative as well as clinical responsibilities and hospital work occupies a considerable proportion of the general practitioner''s day. The disciplinary machinery for safeguarding standards is strict by comparison with British hospital practice.This system produces an obvious excellence of clinical standards, postgraduate education, and communication between specialist and general practitioner and is attractive to the more able young British graduate. A pilot experiment of hospital staffing on North American lines in one of our new district general hospitals would be a worthwhile proposition.     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.     

Preregistration house officers in the four Thames regions: II. Comparison of education and workload in teaching and non-teaching hospitals.

OBJECTIVE--To detect differences in the education and workload of preregistration house officers working in teaching and non-teaching hospitals. DESIGN--A postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 61% for teaching hospitals and 73% for non-teaching hospitals. House officers in teaching hospitals had significantly fewer inpatients under their care (house physicians 16.9 v 22.9, house surgeons 17.9 v 20.3) and admitted fewer emergency patients per week (house physicians 7.7 v 12.7, house surgeons 6.5 v 9.8). More house officers in teaching hospitals reported that they had too few patients to provide adequate clinical experience. More of their time was consumed by administrative activities devoid of educational value. CONCLUSION--Preregistration house officer posts at teaching hospitals provide less clinical activity and are perceived as less educationally satisfactory by their holders than those elsewhere.     

研究型医院研究生培养的几点想法

研究型医院是指以完成临床医疗工作为基本任务,以培养优秀人才为突出优势,以创新性科学研究为重要使命,以制定和修定临床医学标准和规范为水平标志的大型综合型医院。其是我国医院管理界的新生事物。要走研究型医院快速、持续发展之路,提高医院的整体诊治水平,就必须大力培育复合型人才。研究生培养作为研究型医院优秀人才培养的重要组成部分,在培养过程中必然需要新的培养方式。建立与研究型医院发展相适应的研究生培养机制,诱导研究生国际视野,培养研究生创新意识,激发研究生求知欲望,训练研究生专项特长,树立研究生转化医学思维,才能培养出适应研究型医院发展需要的研究生。本文就研究型医院研究生培养的几点想法与同行共享。     

Undergraduate medical education.

Pressures from students and teachers, from professional bodies, and from changes in the way health care is delivered are all forcing a rethink of how medical students should be taught. These pressures may be more intense in London but are not confined to it. The recommendation the Tomlinson report advocates that has been generally welcomed is for more investment in primary care in London. General practitioners have much to teach medical schools about effective ways of learning, but incentives for teaching students in general practice are currently low, organising such teaching is difficult and needs resources, and resistance within traditional medical school hierarchies needs to be overcome. Likewise, students value learning within local communities, but the effort demanded of public health departments and community organisations is great at a time when they are under greater pressure than ever before. The arguments over research that favour concentration in four multifaculty schools are less clear cut for undergraduate education, where personal support for students is important. An immediate concern is that the effort demanded for reorganising along the lines suggested by Tomlinson will not leave medical schools much energy for innovating.     

Why general practitioners and consultants change their clinical practice: a critical incident study.

OBJECTIVE: To describe the complete range of factors which doctors recognise as changing their clinical practice and provide a measure of how often education is involved in change. DESIGN: Interviews using the critical incident technique. SETTING: Primary and secondary care. SUBJECTS: Random sample of 50 general practitioners and 50 consultants. MAIN OUTCOME MEASURES: Categories of reasons for change in clinical practice. RESULTS: Doctors described 361 changes in clinical practice, with an average of 3.0 reasons per change. The three most frequently mentioned reasons were organisational factors, education, and contact with professionals, together accounting for 47.9% of the total number of reasons for change. Education accounted for one sixth (16.9%) of the reasons for change and was involved in one third (37.1%) of the changes. Education was seldom mentioned as a reason for change in referral practice but was more often mentioned in management and prescribing changes. Consultants were influenced by medical journals and scientific conferences, while general practitioners were more influenced by medical newspapers and postgraduate meetings. CONCLUSIONS: Education is involved in about a third of changes in clinical practice. The wide range of other factors affecting changes in practice need to be taken into account in providing and evaluating education. The role of education in the numerous changes in clinical practice that currently have no educational component should also be considered.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Advice to a Moscow children's hospital.

At the request of the largest children''s hospital in Moscow, McKenzie and colleagues made recommendations for improving the service. Restrictions on visiting and fears of contracting illness from non-disposable needles have discouraged the local population from using the hospital. Consequently the hospital is underused and overstaffed. Serious shortages of drugs and surgical supplies compromise care. Fundamental changes are needed in nursing and postgraduate education. The authors encouraged their Russian colleagues to address the health care needs of their local population and to develop family centred care, and they offered training in London.     

Fatigue and concerns about quality of care among Ontario interns and residents.

In postgraduate medical training the heavy and irregular workloads are thought to result in fatigue and a potential decrease in the quality of care provided by interns and residents. We investigated these concerns among Ontario interns and residents. Information from 1805 house staff in all specialties and different years of postgraduate education suggested a relation between hours of work, fatigue and concerns about the quality of care.     

Canadian medical education: 50 years of innovation and leadership.

Over the past 50 years, many Canadian medical educators have pursued ideas and visions, as individuals in the 1950s and 1960s and later in partnership with various national bodies. Relations between universities and national medical organizations have been productive in dealing with issues of postgraduate education and clinical assessment, in particular. From 1970 to 1990, strong education offices and formally trained educators led to many successes in the areas of research in cognition, continuing medical education and clinical assessment. Canadian medical education has now achieved international recognition for its work in all aspects of the continuum of the physician''s education through vision, initiative and cooperation.     

The hospital component of vocational training for general practice.

Trainees and educationalists in general practice have some grounds for suggesting that the hospital component of vocational training should be restructured and teaching improved. However, the implications for other trainees and secondary care have to be considered. Changes that are needed include a curriculum for senior house officers in each specialty; appointment of training consultants with the necessary skills; and a different attitude by everyone towards study leave, including arrangements for funding. The optimum duration of hospital posts for trainees in general practice might be shorter than now, but the effects on others must be considered and competencies guaranteed in a briefer training period. Changes in the regulations for vocational training could help to improve specialist experience if trainees in general practice were allowed to be supernumerary. Alternatively, senior house officer posts for trainees in general practice could be split between secondary and primary care, thus encouraging a broader perspective.     

A randomized controlled trial investigation of a non-stimulant in attention deficit hyperactivity disorder (ACTION): Rationale and design

Background

Patients with delirium and dementia admitted to general hospitals have poor outcomes, and their carers report poor experiences. We developed an acute geriatric medical ward into a specialist Medical and Mental Health Unit over an eighteen month period. Additional specialist mental health staff were employed, other staff were trained in the 'person-centred' dementia care approach, a programme of meaningful activity was devised, the environment adapted to the needs of people with cognitive impairment, and attention given to communication with family carers. We hypothesise that patients managed on this ward will have better outcomes than those receiving standard care, and that such care will be cost-effective.

Methods/design

We will perform a controlled clinical trial comparing in-patient management on a specialist Medical and Mental Health Unit with standard care. Study participants are patients over the age of 65, admitted as an emergency to a single general hospital, and identified on the Acute Medical Admissions Unit as being 'confused'. Sample size is 300 per group. The evaluation design has been adapted to accommodate pressures on bed management and patient flows. If beds are available on the specialist Unit, the clinical service allocates patients at random between the Unit and standard care on general or geriatric medical wards. Once admitted, randomised patients and their carers are invited to take part in a follow up study, and baseline data are collected. Quality of care and patient experience are assessed in a non-participant observer study. Outcomes are ascertained at a follow up home visit 90 days after randomisation, by a researcher blind to allocation. The primary outcome is days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, resource use, and scaled outcome measures, including quality of life, cognitive function, disability, behavioural and psychological symptoms, carer strain and carer satisfaction with hospital care. Analyses will comprise comparisons of process, outcomes and costs between the specialist unit and standard care treatment groups.

Trial Registration number

ClinicalTrials.gov: NCT01136148     

Multicentre criterion based audit of the management of induced abortion in Scotland.

OBJECTIVES--To assess and improve the quality of care provided to women undergoing induced abortion. DESIGN--Two rounds of prospective, criterion based case note review audit. SETTING--Ten NHS gynaecology units throughout Scotland. SUBJECTS--2004 patient episodes of abortion care identified consecutively during two rounds of audit. The first round comprised 967 cases and the second round 1037. INTERVENTIONS--Dissemination of results from the first round of audit and recommendations for change in the form of a written report and at postgraduate meetings in participating hospitals. MAIN OUTCOME MEASURES--Improvements in quality of care as assessed against 16 previously agreed criteria, both overall across the 10 study hospitals and within individual hospitals. RESULTS--Overall, four significant improvements occurred: increased availability of early medical abortion, decreased utilisation of surgical abortion at very early gestation, increased use of mifepristone priming before second trimester medical abortion, and increased provision of follow up. At the individual hospital level 42 of 150 elements of care studied were "close to optimal" at the time of the first round of audit, rising to 54 at the second round (NS). A total of 31 significant improvements in individual elements of care occurred, but 11 significant deteriorations also occurred (at the P < 0.05 level). CONCLUSIONS--The prospective multicentre audit proved feasible and achieved the aims of any form of audit in terms of identifying deficiencies and variations in care. The audit results prompted objective review of local abortion services in participating hospitals. At least for some elements of care in some hospitals significant improvements were detectable.     

医学研究生"高通量测序技术"应用能力的培养

高通量测序技术目前已广泛的应用于临床研究领域。与传统测序方式相比,该技术具有通量高、耗时短、成本低等特点。研究生教育中对高通量测序技术的新进展及其在疾病研究、临床诊断等方面的应用方面的介绍较少。培养医学研究生对高通量测序技术的应用能力,可以增强研究生对高通量测序技术的方法、原理、应用范围、数据分析的理解,为医学研究生应用高通量测序技术发现及解决临床问题打下一定的基础。