The Effect of an Individualized Practice-Based CME Program on Physician Performance and Patient Outcomes

The Professional Competence Assurance Program (PROCAP) is an individualized educational program that examines physicians'' performance in ambulatory practice. It uses medical record review to identify deficiencies in the care process that guides development of the educational intervention. Medical care is reassessed one year later. This program was used with 51 private practitioners to assess the care of 1,229 hypertensive patients. The educational program included a computer printout comparing one physician''s performance with that of peers, readings targeted to management problems, and a conference call or group seminar with an expert stressing issues relevant to each physician''s performance. Postintervention assessment showed that physicians prescribed beta-blockers (P<.01) and vasodilators (P<.01) more often. Improvement (P<.05) occurred in the control of diastolic blood pressure (≤90 mm of mercury) and in several other criteria. These results show that well-designed, individualized continuing medical education addressing specific deficiencies can change physicians'' performance and patients'' intermediate outcome.     

General practitioners' continuing medical education within and outside their practice.

To study continuing medical education 96 out of 101 general practitioners chosen at random from the list held by a family practitioner committee were interviewed. The results provided little evidence of regular attendance at local postgraduate centre meetings, though practice based educational meetings were common. Thirty one of the general practitioners worked in practices that held one or more practice based educational meetings each month at which the doctors provided the main educational content. Performance review was undertaken in the practices of 51 of the general practitioners, and 80 of the doctors recognised its value. The general practitioners considered that the most valuable educational activities occurred within the practice, the most valued being contact with partners. They asked for increased contact with hospital doctors. The development of general practitioners'' continuing medical education should be based on the content of the individual general practitioner''s day to day work and entail contact with his or her professional colleagues.     

No to mandatory continuing medical education,Yes to mandatory practice auditing and professional educational development

The issue of mandatory continuing medical education (CME) is controversial. Traditional measures mandate only attendance, not learning, and have no measurable performance end points. There is no evidence that current approaches to CME, mandatory or voluntary, produce sustainable changes in physician practices or application of current knowledge. Ongoing educational development is an important value in a professional, and there is an ethical obligation to keep up to date. Mandating self-audit of the effect of individual learning on physician''s practices and evaluation by the licensing authority are effective ways of ensuring the public are protected. The author recommends the use of a personal portfolio to document sources of learning, the effect of learning and the auditing of their applications on practice patterns and patient outcomes. A series of principles are proposed to govern its application.     

Patient Attitudes Toward Physician's Assistants

A study was conducted in urban Los Angeles to assess patient acceptance of the use of physician''s assistants. Data collection was facilitated by the development of an attitude scale and responses were analyzed to determine differences between various socioeconomic stratifications. With a few exceptions, acceptance was highest among non-married middle-class respondents who have had some exposure to college. As to the perceived complexity of procedures a physician''s assistant might perform, 91 percent of all respondents would not object to injections administered by a physician''s assistant, but this tolerance diminishes to 34 percent in the case of first examination of a patient by a physician''s assistant if there appeared to be a serious head injury.     

Family Planning in the Hospital Setting

Although the availability of oral contraceptives and the development of improved intrauterine contraceptive devices have greatly increased the general utilization of family planning services, there are still great segments of our population which are not yet reached, especially in the economically deprived areas. Since over 98 percent of all obstetrical deliveries now occur in hospitals, it seems logical that it is on hospital maternity services that these deficiencies might often be best overcome. Although this is primarily a medical problem, the use of paramedical personnel can greatly augment the physician''s practice in these areas. Family planning services should be an integral part of comprehensive maternity care, not alone in the physician''s office but also in the hospital setting.     

Managing uncertainty in family practice.

Because patients present in the early stages of undifferentiated problems, the family physician often faces uncertainty, especially in diagnosis and management. The physician''s uncertainty may be unacceptable to the patient and may lead to inappropriate use of diagnostic procedures. The problem is intensified by the physician''s hospital training, which emphasizes mastery of available knowledge and decision-making based on certainty. Strategies by which a physician may manage uncertainty include (a) a more open doctor-patient relationship, (b) understanding the patient''s reason for attending the office, (c) a thorough assessment of the problem, (d) a commitment to reassessment and (e) appropriate consultation.     

Training and Experience of Physicians in the Management of Adequate Anticoagulant Therapy

In a group of seven physicians engaged on a full-time basis in the anticoagulant unit of a teaching hospital, it was demonstrated that errors occur frequently in the management of anticoagulant therapy and that the incidence of such errors decreases during the course of the physician''s training period. Expert supervision and proper organization of the unit permit detection and correction of a high percentage of these errors.     

Assistants to Primary Physicians in California

The mid-level practitioner movement is no longer experimental; nurse practitioners and physician''s assistants in California have proved to fill a necessary and viable professional role in the delivery of primary health care. The physician''s assistant law (AB2109) and the Experimental Manpower Act (AB1503) have facilitated the training and functioning of these new health care professionals; more comprehensive laws are still needed to permit optimal utilization. National agencies for approval of teaching programs and testing of individual graduates will play an increasing role in the accreditation and certification procedures. Professional role difficulties, issues of sex and questions of delegation of responsibility are being resolved and it is hoped that a more equitable and patient-oriented system is evolving.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Nuremberg lamentation: for the forgotten victims of medical science.

Fifty years after the Nuremberg medical trial there remain many unanswered questions about the role of the German medical profession during the Third Reich. Other than the question of human experimentation, important ethical challenges arising from medicine in Nazi Germany which have continuing relevance were not addressed at Nuremberg. The underlying moral question is that of the exercise of professional power and its impact on vulnerable people seeking medical care. Sensitisation to the obligations of professional power may be achieved by an annual commemoration and lament to the memory of the victims of medical abuse which would serve as a recurring reminder of the physician''s vulnerability and fallibility.     

Diagnosis of dyspepsia from data collected by a physician's assistant.

This paper presents a study of the diagnosis of "dyspepsia" in 154 patients based on data collected at their initial outpatient attendance via an interview with a non-medically qualified physician''s assistant. The reactions of patients to this type of interview were favourable, and the data recorded were as reliable as those recorded by clinicians. We conclude (1) that the data recorded by the physician''s assistant are valuable diagnostically; (2) where these cannot be collected by a qualified physician, this task may be delegated to a non-medically qualified person; but (3) this interview should augment and not replace the traditional clinical interview.     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country''s health care system prompted experimental changes in the operation and training procedures at St. Mary''s of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country''s dismal rate of institutionalization.     

How Physicians Can Improve Patients' Participation and Maintenance in Self-Care

A protocol for the stepped education and support of patients is derived from the cumulative experience of more than 200 clinical trials of patient education and behavioral change interventions. The recommended procedure entails assessing a patient''s educational needs by asking a sequence of “diagnostic” questions to assure patient motivation, skill and resources and to reinforce adherence to the prescribed medical regimen or life-style modifications. The sequence of questions and interventions is also designed to minimize a physician''s time commitment and to maximize the medical benefit to the patient.     

Babies with spina bifida treated without surgery: parents' views on home versus hospital care.

From 1971 to 1981, 98 babies born with meningomyelocoele at the North Staffordshire Hospital Centre''s district maternity hospital, were thought not suitable for surgery. Sixty three survived for more than one week. Over the period the hospital''s policy changed: initially all such babies were kept in hospital, but later parents were given the choice of taking their baby home for palliative and terminal care. In an attempt to determine parents'' views on the care of their baby the parents of 44 of the babies who survived to one week were traced in 1985-6, five to 14 years later; 80 of them were asked how they felt about the lives and deaths of their babies. Eighteen babies had been taken home, and they had lived longer than the 26 who had been cared for in hospital. Parents whose baby had remained in hospital were sadder than those who had taken their baby home when they looked back at their experiences, and they also considered that their baby''s life had been of poor quality. Most of those who had taken their baby home had a more positive view of their child''s life. The figures suggest that the bereavement process after a baby''s death is longer than has been thought, but despite residual sadness just over half of the parents interviewed thought that something positive had come out of their experience.     

THE HIGH SCHOOL FOOTBALL TEAM PHYSICIAN

Mutual confidence is necessary between the football coach and the team physician. The physician''s decision in the matter of a boy''s condition must always be final. The coach should also consider the physician''s advice in shaping his psychological appeals to the players in before-game and between-halves talks. The physician should be on his way to a man injured on the field as soon as the play is ended. It is up to him and not the trainer or coach to make the diagnosis. The physician must have the ability to make an immediate evaluation of the extent of injury and use appropriate measures to get the player off the field. To see a semi-conscious man with dangling head being half dragged off the field is far worse from the patient''s standpoint and from the spectator''s standpoint than removal by stretcher.     

Attachment of a physician's assistant to an English general practice.

A final-year student from the physician''s associate programme at Duke University in North Carolina, USA, worked in an English health centre for eight weeks between May and July. He managed 221 cases under supervision, and they were typical in terms of sex ratio, diagnosis, and the preponderance of children. Current social and economic trends in Britain suggest that selective under-doctoring, especially in inner urban areas, may become acute, and a type of physician''s assistant specially selected and trained for the work in areas with serious and unusual problems should be considered as among the possible, even desirable, solutions.     

Multi-purpose HealthCare Telemedicine Systems with mobile communication link support

The provision of effective emergency telemedicine and home monitoring solutions are the major fields of interest discussed in this study. Ambulances, Rural Health Centers (RHC) or other remote health location such as Ships navigating in wide seas are common examples of possible emergency sites, while critical care telemetry and telemedicine home follow-ups are important issues of telemonitoring. In order to support the above different growing application fields we created a combined real-time and store and forward facility that consists of a base unit and a telemedicine (mobile) unit. This integrated system: can be used when handling emergency cases in ambulances, RHC or ships by using a mobile telemedicine unit at the emergency site and a base unit at the hospital-expert's site, enhances intensive health care provision by giving a mobile base unit to the ICU doctor while the telemedicine unit remains at the ICU patient site and enables home telemonitoring, by installing the telemedicine unit at the patient's home while the base unit remains at the physician's office or hospital. The system allows the transmission of vital biosignals (3–12 lead ECG, SPO2, NIBP, IBP, Temp) and still images of the patient. The transmission is performed through GSM mobile telecommunication network, through satellite links (where GSM is not available) or through Plain Old Telephony Systems (POTS) where available. Using this device a specialist doctor can telematically "move" to the patient's site and instruct unspecialized personnel when handling an emergency or telemonitoring case. Due to the need of storing and archiving of all data interchanged during the telemedicine sessions, we have equipped the consultation site with a multimedia database able to store and manage the data collected by the system. The performance of the system has been technically tested over several telecommunication means; in addition the system has been clinically validated in three different countries using a standardized medical protocol.     

Basic Training Program in Medical Pedagogy: a 1-year program for medical faculty.

In 1979 université de Montréal developed the Basic Training Program in Medical Pedagogy; the program has since been offered at two other Canadian medical schools. The learning activities are spread over an academic year so that the teachers are able to continue their clinical or research duties. The program, which follows a model of systematic instruction, comprises 17 self-instructional modules on basic educational topics adapted to medical teaching. The topics are related to four components of an integrated system: student needs and learning objectives, instructional methods, student evaluation and program evaluation. The instructional format is aimed at three levels--understanding, analysis and application--to which assignments and assessments are related. In addition to the modules, the program offers 15 half-day sessions for small groups (five participants and one instructor) to discuss aspects of the program, especially home assignments and the application of personal educational projects. A minimum of 100 hours of personal time is requested. The program''s main goal is that students be placed at the centre of the educational process. Of 215 participants since 1979, 171 (80%) have completed the program and reported high satisfaction. Issues related to any faculty development program are discussed.     

Major merger gives London Canada's second-largest teaching hospital.

Two of London''s three major teaching hospitals joined forces recently to form Canada''s second-largest teaching hospital. The merger is considered a harbinger as teaching hospitals strive to maintain current teaching, research and clinical activities in the face of decreasing government spending.     

Physician Presence in an Ambulance Car Is Associated with Increased Survival in Out-of-Hospital Cardiac Arrest: A Prospective Cohort Analysis

The presence of a physician seems to be beneficial for pre-hospital cardiopulmonary resuscitation (CPR) of patients with out-of-hospital cardiac arrest. However, the effectiveness of a physician''s presence during CPR before hospital arrival has not been established. We conducted a prospective, non-randomized, observational study using national data from out-of-hospital cardiac arrests between 2005 and 2010 in Japan. We performed a propensity analysis and examined the association between a physician''s presence during an ambulance car ride and short- and long-term survival from out-of-hospital cardiac arrest. Specifically, a full non-parsimonious logistic regression model was fitted with the physician presence in the ambulance as the dependent variable; the independent variables included all study variables except for endpoint variables plus dummy variables for the 47 prefectures in Japan (i.e., 46 variables). In total, 619,928 out-of-hospital cardiac arrest cases that met the inclusion criteria were analyzed. Among propensity-matched patients, a positive association was observed between a physician''s presence during an ambulance car ride and return of spontaneous circulation (ROSC) before hospital arrival, 1-month survival, and 1-month survival with minimal neurological or physical impairment (ROSC: OR = 1.84, 95% CI 1.63–2.07, p = 0.00 in adjusted for propensity and all covariates); 1-month survival: OR = 1.29, 95% CI 1.04–1.61, p = 0.02 in adjusted for propensity and all covariates); cerebral performance category (1 or 2): OR = 1.54, 95% CI 1.03–2.29, p = 0.04 in adjusted for propensity and all covariates); and overall performance category (1 or 2): OR = 1.50, 95% CI 1.01–2.24, p = 0.05 in adjusted for propensity and all covariates). A prospective observational study using national data from out-of-hospital cardiac arrests shows that a physician''s presence during an ambulance car ride was independently associated with increased short- and long-term survival.