Patterns of practice in internal medicine in Ontario.

To determine the feasibility of wholly referral practice in internal medicine within a prepaid health service, the practice profiles of 694 internists in metropolitan, nonmetropolitan urban, and rural areas of Ontario were delineated by analysis of data from questionnaires and health-insurance billing. The questionnaire showed that two thirds of internists, chiefly younger practitioners, confined themselves to a referral consultant practice; the other one third included primary care. Subspecialists practised predominantly in metropolitan areas; most general internists in such areas provided primary care, whereas most general internists elsewhere had an entirely referral practice. This pattern of practice is greatly different from that in the United States but probably similar to that in other provinces in Canada. Extension of wholly referral practice to all internists in Ontario appears feasible, provided the numbers entering residency training are controlled. The present Ontario curricula for internal medicine and its subspecialties appear suitable for such a pattern of practice.     

Coronary thrombolysis--clinical guidelines and public policy: results of an Ontario practitioner survey.

The Ontario Medical Association (OMA) guidelines for intravenous thrombolysis in acute myocardial infarction were released in March 1988 and contributed to a government decision against special per-case funding to assist hospitals using tissue-type plasminogen activator (tPA). In October 1988, 1512 cardiologists, internists and physician-administrators who were OMA members were mailed a questionnaire seeking their views on the OMA guidelines and related issues. Of the 419 questionnaires (28%) that were returned, 392 contained usable responses. Among the respondents 268 (68%) had used thrombolytic drugs in the preceding 12 months; the mean number of cases was 10.6 (standard deviation 12.9). A strong or a mild preference for tPA over streptokinase was registered by 64% of the respondents; 28% had no preference. However, the self-reported ratio of actual streptokinase:tPA use was about 3:1, and 73% indicated that the government''s funding policy had limited the availability of tPA in their hospital. The respondents were almost equally divided as to whether the policy should be changed. The guidelines were deemed helpful by 85% of the noncardiologists, as opposed to 52% of the cardiologists (p less than 0.005). OMA involvement in developing and circulating such guidelines was supported by 74% of the respondents and opposed by 18%; opposition was more likely to come from those who found the guidelines unhelpful (p less than 0.001). Support for involvement by the College of Physicians and Surgeons of Ontario was much weaker (supported by 32%, opposed by 62%). Overwhelming opposition to government involvement was evident.     

Provider Practice Habits And Barriers To Care In Obesity Management In A Large Multicenter Health System

Objective: To identify provider recommendations and barriers in obesity management in a multicenter academic health system with extensive weight-loss management resources.Methods: A 26-question online survey was sent to attending physicians, trainees, and advanced practice providers in primary care specialties (internal medicine, family medicine, women's health) and endocrinology.Results: The survey response rate was 26% (111/430). Of respondents, 50% were internal medicine, 24% family medicine, 16% women's health, and 9% endocrinology. The majority were attending physicians (54%) and residents (40%). About 50% of respondents advised weight loss for a body mass index (BMI) >30 kg/m² in >50% of clinic visits. Limited time (82%) was the most common reason for not discussing weight loss, followed by the perception that discussion would not change patient behavior, insufficient knowledge, and discomfort broaching the subject. Common barriers to prescribing anti-obesity medications included limited experience (57%) and concern for adverse reactions (26%). Only 44% offered bariatric surgery to >50% of their patients who met criteria. Primary reasons for not referring included concerns of high surgical risk from comorbidities (57%) and potential adverse events (32%). Endocrinology had the highest referral to surgery. Attending physicians and fellows were more likely than residents to advise weight loss at lower BMI, offer medications, and refer to bariatric surgery.Conclusion: Our study reveals reluctance and lack of primary care confidence in managing obesity with pharmacotherapy and bariatric surgery, especially in the earlier stages of obesity. Barriers to care include lack of clinic time, limited experience, and concerns about treatment risks.Abbreviations: BMI = body mass index; HbA1c = hemoglobin A1c; IRB = Institutional Review Board     

General practitioners' responsibilities to their patients.

The views of general practitioners about their responsibilities for patient care have not been canvassed. A survey of general practitioners was therefore carried out to determine their views. A postal questionnaire, in which general practitioners were asked what they saw as their responsibilities, was sent to 525 principals in Avon and completed by 424, giving a response rate of 81%. The doctors generally agreed that their responsibilities for patient care included problems related to internal medicine, such as managing diabetes and hypertension. Less consensus was found in the replies to questions about technical procedures, such as resection of ingrowing toenails, and gynaecological, orthopaedic, or psychosocial problems. The results supported the view that general practitioners are gradually abandoning technical aspects of medicine to specialists without a compensating role having been defined. In the light of this trend the responsibilities of general practitioners should be clearly defined by the profession.     

Expectations and perceived barriers to widespread implementation of e‑Health in cardiology practice: Results from a national survey in the Netherlands

Introduction

Expectations of physicians concerning e‑Health and perceived barriers to implementation in clinical practice are scarcely reported in the literature. The purpose of this study was to assess these aspects of cardiovascular e‑Health.

Methods

A survey was sent to members of the Netherlands Society of Cardiology. In total, the questionnaire contained 30 questions about five topics: personal use of smartphones, digital communication between respondents and patients, current e‑Health implementation in clinical practice, expectations about e‑Health and perceived barriers for e‑Health implementation. Age, personal use of smartphones and professional environment were noted as baseline characteristics.

Results

In total, 255 respondents filled out the questionnaire (response rate 25%); 89.4% of respondents indicated that they considered e‑Health to be clinically beneficial, improving patient satisfaction (90.2%), but also that it will increase the workload (83.9%). Age was a negative predictor and personal use of smartphones was a positive predictor of having high expectations. Lack of reimbursement was identified by 66.7% of respondents as a barrier to e‑Health implementation, as well as a lack of reliable devices (52.9%) and a lack of data integration with electronic medical records (EMRs) (69.4%).

Conclusion

Cardiologists are in general positive about the possibilities of e‑Health implementation in routine clinical care; however, they identify deficient data integration into the EMR, reimbursement issues and lack of reliable devices as major barriers. Age and personal use of smartphones are predictors of expectations of e‑Health, but the professional working environment is not.

     

Medical grand rounds: alive and well and living in Canada.

Grand rounds have long been the principal educational activity of departments of medicine at teaching hospitals. Several recent articles have suggested that there has been a general deterioration in the quality of grand rounds. To evaluate their status in Canada we mailed a questionnaire to the chairmen of the departments of medicine at the 53 Canadian teaching hospitals; of the 48 responses received (91%), 38 were from chairmen, 5 were from senior department members, and 5 were from chief residents. The results indicated that grand rounds continued to be the principal teaching exercise of the departments. Of the respondents 98% felt that the quality had improved or stayed the same. The overall attendance was considered to have improved or remained unchanged for the past decade by 75%; 25% thought that it had declined. The diminished emphasis on patient-related topics concerned 10%. The respondents gave numerous suggestions, which should help organizers to improve the impact of grand rounds on learning.     

Who Will Manage American Patients With Diabetes? Residents’ Career Preferences and Perceptions of Diabetes Care

ObjectiveTo identify the factors that encourage or discourage internal medicine and pediatric residents regarding specializing in endocrinology with a focus on diabetes.MethodsWe conducted an electronic survey of internal medicine and pediatric residents using a $10 participation incentive. A total of 653 residents responded to the survey (estimated response rate of 9.2%)—626 from residency programs that were contacted for our survey and 27 from referrals.ResultsAmong internal medicine and pediatric residents surveyed, 39 respondents (6.0%) planned to specialize in endocrinology, and 27 of these (4.1% of total respondents) planned to focus on diabetes. “Intellectual satisfaction, ” “emotional satisfaction, ” and “work-life balance” were identified by respondents as the most important factors in their choice of a specialty, with ratings of 5.5, 5.4, and 5.3 on a 6-point Likert scale. Among these factors identified as most important to a medical career, endocrinology with a focus on diabetes scored poorly with regard to intellectual and emotional satisfaction but received high ranking with regard to lifestyle. With regard to other factors, endocrinology was rated negatively on “compensation, ” “number of procedures, ” and “patient adherence to prescribed treatment.” Exposure to diabetes during training had no major influence on the decision to enter endocrinology.ConclusionEndocrinology with a focus on diabetes care is not an attractive specialty for most internal medicine and pediatric residents. Therefore, new strategies to attract residents to the field of diabetes care are needed. (Endocr Pract. 2011;17:235-239)     

Personal and professional development of teachers in family medicine.

While medical educators have devoted considerable effort to examining the optimal learning environment for teaching family medicine, less attention has been paid to "blocks" that prevent teachers of family medicine from being effective. This paper considers three major aspects of this problem: the personal and professional development of the teacher; blocks that impede this development; and the value of intervening in the teaching-learning process. These concerns are discussed in relation to an intervention program developed at the Byron Family Medical Centre, a family practice teaching unit affiliated with Victoria Hospital Corporation and the Department of Family Medicine, University of Western Ontario, London.     

Barriers to Participation in a Patient Satisfaction Survey: Who Are We Missing?

Background

A common weakness of patient satisfaction surveys is a suboptimal participation rate. Some patients may be unable to participate, because of language barriers, physical limitations, or mental problems. As the role of these barriers is poorly understood, we aimed to identify patient characteristics that are associated with non-participation in a patient satisfaction survey.

Methodology

At the University Hospitals of Geneva, Switzerland, a patient satisfaction survey is regularly conducted among all adult patients hospitalized for >24 hours on a one-month period in the departments of internal medicine, geriatrics, surgery, neurosciences, psychiatry, and gynaecology-obstetrics. In order to assess the factors associated with non-participation to the patient satisfaction survey, a case-control study was conducted among patients selected for the 2005 survey. Cases (non respondents, n = 195) and controls (respondents, n = 205) were randomly selected from the satisfaction survey, and information about potential barriers to participation was abstracted in a blinded fashion from the patients'' medical and nursing charts.

Principal Findings

Non-participation in the satisfaction survey was independently associated with the presence of a language barrier (odds ratio [OR] 4.53, 95% confidence interval [CI95%]: 2.14–9.59), substance abuse (OR 3.75, CI95%: 1.97–7.14), cognitive limitations (OR 3.72, CI95%: 1.64–8.42), a psychiatric diagnosis (OR 1.99, CI95%: 1.23–3.23) and a sight deficiency (OR 2.07, CI95%: 0.98–4.36). The odds ratio for non-participation increased gradually with the number of predictors.

Conclusions

Five barriers to non-participation in a mail survey were identified. Gathering patient feedback through mailed surveys may lead to an under-representation of some patient subgroups.     

An Assessment of Diversity,Inclusion, and Health Equity Training in Endocrinology Fellowship Programs in the United States

ContextThe Accreditation Council for Graduate Medical Education has instituted common program requirements related to diversity, equity, and inclusion (DEI) for postgraduate trainees in the United States; however, the extent to which DEI training is being incorporated across endocrinology fellowship programs is unknown.ObjectivesTo describe the sociodemographic representation and DEI training experiences within endocrinology fellowship programs.Design, setting, and participantsNational cross-sectional survey study of fellows and fellowship program leaders in the United States whose fellowships were members of the Association of Program Directors in Endocrinology and Metabolism.Main outcome measures(1) Demographics of fellows and program leaders and (2) programs’ experience, confidence, and interest in formal DEI training.ResultsA total of 108 and 106 fellow and faculty responded to the survey, respectively. The majority of fellows and faculty are female. Less than 3% of fellows and 3.7% of faculty identify as Black. More than 90% of fellows/faculty are heterosexual and no respondents identified as transgender/nonbinary; however, 5% and 2% of all respondents preferred not to disclose their sexual orientation and gender identity, respectively. While 85% of faculty received institutional diversity and inclusion training, 67.6% of fellows did. Fellows are more likely to have received training in health equity than program leaders. Both fellows and program leaders express a high interest in health equity curriculum.ConclusionsWithin the diversity of endocrinology training programs, Black physicians are underrepresented in medicine, which persists in endocrinology fellowships. Fellowship programs express enthusiasm for national diversity and health equity curricula, with the majority of programs reporting institutional DEI training.     

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.     

First-year family medicine residents' use of computers: knowledge,skills and attitudes.

OBJECTIVE: To identify the computer knowledge, skills and attitudes of first-year family medicine residents. DESIGN: Cross-sectional survey of family medicine residents during the academic year 1993-94; sampling began in July 1993 and ended in October 1993. SETTING: Canada. PARTICIPANTS: All 727 first-year family medicine residents, of whom 433 (60%) responded. OUTCOME MEASURES: Previous computer experience or training, current use, barriers to use, and comfort with and attitudes regarding computers. RESULTS: There was no difference in age or sex between the respondents and all first-year family medicine residents in Canada. French-speaking respondents from Quebec were underrepresented (p < 0.001). Only 56 respondents (13%) felt extremely or very comfortable with computer use. The most commonly cited barriers to obtaining computer training were lack of time (243 respondents [56%]) and the high cost of computers (214 [49%]) but not lack of interest (69 [16%]). Most residents wanted more computer training (367 [85%]) and felt that computer training should be a mandatory component of family medicine training programs (308 [71%]). CONCLUSIONS: Computer knowledge and skills and comfort with computer use appear low among first-year family medicine residents in Canada, and barriers to acquisition of computer knowledge are impressive. Computer training should become an integral part of family medicine training in Canada, and user-friendly applicable computer systems are needed.     

House Calls in Utah

To learn the criteria Utah physicians use in making or not making house calls and their specialty, age and frequency of calls, a random sample of half of Utah''s physicians in family practice, general practice and general medicine was surveyed. Of 225 respondents, 70% reported making house calls at an average rate of 2.6 per month. More family practitioners made house calls than did internists; older physicians made more house calls than their younger counterparts. An estimated 82% of the calls were for patients aged 65 years and older. The most frequently stated reasons for making house calls were that patients were homebound and to assess the family or home situation. Reasons given for not making house calls were inefficient use of time and lack of equipment or necessary facilities.     

口腔微生物学实验教学体系初探

目的实验教学在培养复合型和创新型人才中具有不可替代的重要作用,为了提高口腔医学教育质量,培养适应新世纪要求的高素质创新型的医学人才,增设口腔微生物学实验课。方法根据口腔医学特色设计实验,培养学生的基础、专业、综合、创新能力。教学内容包括：牙菌斑的采集和处理、致龋菌的分离和培养、致龋菌的鉴定。教学方式采用学生两两配对模式。分析2011年度教学的实验结果。结果实验课程有利于培养学生专业能力和科研能力,加深对疾病发生机制的理解;35．7％的学生具有较好的综合能力和创新能力,30．4％的学生表现出专业能力不足,33．9％学生需要提高基础和专业能力。结论口腔微生物学实验教学体系对完善教学、促进改革具有重要意义。     

Can different patient satisfaction survey methods yield consistent results? Comparison of three surveys.

OBJECTIVE: To examine the consistency of survey estimates of patient satisfaction with interpersonal aspects of hospital experience. DESIGN: Interview and postal surveys, evidence from three independent population surveys being compared. SETTING: Scotland and Lothian. SUBJECTS: Randomly selected members of the general adult population who had received hospital care in the past 12 months. MAIN OUTCOME MEASURES: Percentages of respondents dissatisfied with aspects of patient care. RESULTS: For items covering respect for privacy, treatment with dignity, sensitivity to feelings, treatment as an individual, and clear explanation of care there was good agreement among the surveys despite differences in wording. But for items to do with being encouraged and given time to ask questions and being listened to by doctors there was substantial disagreement. CONCLUSIONS: Evidence regarding levels of patient dissatisfaction from national or local surveys should be calibrated against evidence from other surveys to improve reliability. Some important aspects of patient satisfaction seem to have been reliably estimated by surveys of all Scottish NHS users commissioned by the management executive, but certain questions may have underestimated the extent of dissatisfaction, possibly as a result of choice of wording.     

Poem: the prophet in his own country

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians'' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians'' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians'' financial and nonfinancial concerns about providing care for poor patients.     

“分子与细胞”翻转课堂教学模式在临床专业教学中的探究

提高医学创新人才培养手段是医学教育改革的重点内容之一。"分子与细胞"是临床医学教育改革的重点专业基础课,也是一门全新的整合课程,具有学时多、难度大且要求和临床专业紧密结合的特点。如何转变临床专业课程的传统教学模式,是临床专业课程改革创新的焦点。该研究通过基于嵌入式文献阅读和临床案例式的翻转课堂教学模式,将传统的面对面授课转化为以学生为中心的授课方式,将课堂主阵地由线下转移至线上,为线下课堂提供了更多创新融合的方式,同时增强了医学生对于生命学基本原理的理解,为培养具有精准医学专业背景的医学生提供了理论基础。通过三年的翻转课堂实施,临床专业卓越医生试点班学生对教学满意度以及学生成绩显著提升,说明在临床专业整合课程开展翻转课堂教学具有积极意义。