Competencies required for the practice of geriatric medicine as a consultant physician.

Geriatric medicine in Canada is now being viewed not merely as an academic specialty but, rather, more broadly as a service specialty providing consulting support to other physicians. Any redesigning of training programs will have to be done with this fact in mind. We drew up a list of competencies required for consultant practice in the field and presented them to other practitioners of geriatric medicine and members of the Canadian Society of Geriatric Medicine for feedback. We believe that the resulting list of competencies can be used as a starting point for redesigning training programs in geriatric medicine.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Bodies and borders: a new cultural history of medicine

Both medicine and the history of medicine have seen many changes in the last four decades. The way we tell the story of medical developments no longer concentrates on the important doctors and their ideas. The influences of social history in the 1960s and 1970s and cultural history in the 1980s and 1990s have broadened and enriched the interpretations of our medical past. The social historians have helped us to include politics, economics, and the leading ideas of any period we wanted to study; the cultural approach has added ethnography as well as an emphasis on language or discourse.Today there is a new history of medicine, one far more willing to cross disciplinary boundaries to ask questions about how we know what we know and why we do what we do.This article highlights some of the work in the adjoining fields of medical anthropology and of literature and medicine to demonstrate new interests, new questions, and new methods of inquiry. However, although we have cast our nets far more widely in the process of professionalizing the history of medicine, there is a question about whether we have lost the appeal to one of our core constituencies: medical students and physicians. We need to welcome some of the new changes in medical history as in medicine itself; the common goal is to achieve a better understanding of what we have done and what we are doing.     

Training Physicians for Primary Care: Trends and Hazards

Programs to train physicians more effectively for careers in primary care are being organized within academic departments in internal medicine and pediatrics, while the number of training programs in family practice continues to grow rapidly. However, the field of primary care training is expanding without a common vocabulary and with inadequate communication between the specialties involved.If decisions concerning health care policy are to be made rationally, the development of multiple distinct models for primary health care delivery must be encouraged and these models must then be evaluated.The distinction between family practice and family medicine must be made clear if the latter discipline is to realize its potential application to all specialties.The relative exclusion of family practice from universities and the absence of experienced practitioners in university primary care programs are conditions that threaten the future of both types of programs and deserve thoughtful attention from medical educators.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

The emergence of integrative medicine in Australia: the growing interest of biomedicine and nursing in complementary medicine in a southern developed society

In this article, I examine the process by which some biomedical physicians and nurses in Australia have come to adopt various alternative therapies in their regimens of practice, largely in response to (1) the growing interest on the part of many Australians in what is generally called "complementary medicine", and (2) a recognition that biomedicine is not particularly effective in treating an array of chronic ailments. Some Australian biomedical physicians and nurses have come to embrace "integrative medicine," which purports to blend the best of biomedicine and complementary medicine, and have even created an Australasian Integrative Medical Association and established integrative medical training programs and centers. I argue that the adoption of alternative therapies and the development of integrative medicine on the part of Australian biomedical physicians and nurses constitute another national manifestation of the co-option of complementary and alternative medicine.     

Future role of neurologists.

Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson''s disease, multiple sclerosis, Alzheimer''s disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.     

Prophylactic platelets in dengue: survey responses highlight lack of an evidence base

Dengue is the most important arboviral infection of humans. Thrombocytopenia is frequently observed in the course of infection and haemorrhage may occur in severe disease. The degree of thrombocytopenia correlates with the severity of infection, and may contribute to the risk of haemorrhage. As a result of this prophylactic platelet transfusions are sometimes advocated for the prevention of haemorrhage. There is currently no evidence to support this practice, and platelet transfusions are costly and sometimes harmful. We conducted a global survey to assess the different approaches to the use of platelets in dengue. Respondents were all physicians involved with the treatment of patients with dengue. Respondents were asked that their answers reflected what they would do if they were the treating physician. We received responses from 306 physicians from 20 different countries. The heterogeneity of the responses highlights the variation in clinical practice and lack of an evidence base in this area and underscores the importance of prospective clinical trials to address this key question in the clinical management of patients with dengue.     

A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes

Background

Osteopathic philosophy is consistent with an emphasis on primary care and suggests that osteopathic physicians may have distinctive ways of interacting with their patients.

Methods

The National Ambulatory Medical Care Survey (NAMCS) was used to derive national estimates of utilization of osteopathic general and family medicine physicians during 2003 and 2004 and to examine the patient characteristics and physician-patient interactions of these osteopathic physicians. All analyses were performed using complex samples software to appropriately weigh outcomes according to the multistage probability sample design used in NAMCS and multivariate modeling was used to control for potential confounders.

Results and discussion

When weighted according to the multistage probability sample design used, the 6939 patient visits studied represented an estimated 341.4 million patient visits to general and family medicine specialists in the United States, including 64.9 million (19%) visits to osteopathic physicians and 276.5 million (81%) visits to allopathic physicians. Osteopathic physicians were a major source of care in the Northeast (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.42–6.08), providing more than one-third of general and family medicine patient visits in this geographic region. Pediatric and young adult patients (OR, 0.64; 95% CI, 0.45–0.91), Hispanics (OR, 0.63; 95% CI, 0.40–1.00), and non-Black racial minority groups (OR, 0.39; 95% CI, 0.18–0.82) were less likely to visit osteopathic physicians. There were no significant differences between osteopathic and allopathic physicians with regard to the time spent with patients, provision of five common preventive medicine counseling services, or a focus on preventive care during office visits.

Conclusion

Osteopathic physicians are a major source of general and family medicine care in the United States, particularly in the Northeast. However, pediatric and young adult patients, Hispanics, and non-Black racial minorities underutilize osteopathic physicians. There is little evidence to support a distinctive approach to physician-patient interactions among osteopathic physicians in general and family medicine, particularly with regard to time spent with patients and preventive medicine services.     

Continuing medical education in family medicine: a report of eight years' experience

A practical method of providing continuing education for family physicians is described. Some of the problems and benefits of an eight-year experience are discussed. Changes in behaviour and activities in the group have led to some concrete achievements, including the foundation for a peer review program. It is suggested that this program could provide the basis for more comprehensive programs in continuing education in family medicine.     

Jehovah's Witnesses leading education drive as hospitals adjust to no blood requests.

Jehovah''s Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about nonblood medicine. The trend is becoming more popular since the advent of HIV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah''s Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs.     

Challenges and advice for MD/PhD applicants who are underrepresented in medicine

The importance of diversity is self-evident in medicine and medical research. Not only does diversity result in more impactful scientific work, but diverse teams of researchers and clinicians are necessary to address health disparities and improve the health of underserved communities. MD/PhD programs serve an important role in training physician-scientists, so it is critical to ensure that MD/PhD students represent diverse backgrounds and experiences. Groups who are underrepresented in medicine and the biomedical sciences include individuals from certain racial and ethnic backgrounds, individuals with disabilities, individuals from disadvantaged backgrounds, and women. However, underrepresented students are routinely discouraged from applying to MD/PhD programs due to a range of factors. These factors include the significant cost of applying, which can be prohibitive for many students, the paucity of diverse mentors who share common experiences, as well as applicants’ perceptions that there is inadequate support and inclusion from within MD/PhD programs. By providing advice to students who are underrepresented in medicine and describing steps programs can take to recruit and support minority applicants, we hope to encourage more students to consider the MD/PhD career path that will yield a more productive and equitable scientific and medical community.     

Community medicine for clinicians in Canada: a recommendation for postgraduate training.

A large gap presently exists between the predominantly biologic expertise of the medical profession and the complex mixture of biologic, behavioural and epidemiologic components of health problems today. Furthermore, the development of community medicine in Canada has been relatively separate from that of the clinical disciplines. To enable clinicians to acquire the knowledge and skills to manage these health problems, much more community-oriented research, applied behavioural science and clinical epidemiology is needed within the clinical sector of medicine. I have proposed a definition of clinical community medicine and presented a strategy for training clinicians in community medicine skills that calls for administrators of clinical postgraduate programs to develop training in clinical community medicine. Residency programs in community medicine cannot be expected to provide such training given their nonclinical priorities, which focus mainly on the training of public health physicians.     

Expert systems in treating substance abuse.

Computer programs can assist humans in solving complex problems that cannot be solved by traditional computational techniques using mathematic formulas. These programs, or "expert systems," are commonly used in finance, engineering, and computer design. Although not routinely used in medicine at present, medical expert systems have been developed to assist physicians in solving many kinds of medical problems that traditionally require consultation from a physician specialist. No expert systems are available specifically for drug abuse treatment, but at least one is under development. Where access to a physician specialist in substance abuse is not available for consultation, this expert system will extend specialized substance abuse treatment expertise to nonspecialists. Medical expert systems are a developing technologic tool that can assist physicians in practicing better medicine.     

REFLECTIONS ON CONTEMPORARY PSYCHIATRY

Valid data on the effectiveness of preventive programs in psychiatry are badly needed but cannot be obtained until reliable statistics on incidence and frequency of emotional disorders are available.There is a suggestion that clear cut neuroses are less frequent but an equally strong suggestion that psychosomatic disorders are increasing in frequency. There is a tendency to look upon the increasing freedom of some aspects of our culture as a great advance over Victorian rigidity and restraint—but to what extent is this related to seeming increases in delinquency?Parents seem to have become increasingly fearful of disciplining, training or frustrating children as a result of what is considered psychiatric teaching. Psychiatry has the responsibility for correcting such a misunderstanding. Psychotherapists who have not resolved their own dependency needs are in no position to help others with the dependency problems which underlie their neurotic difficulties. Psychotherapy involves more than just arranging the world to accommodate itself to the patient (which occasionally needs to be done). The patient too, has a responsibility for his illness and its treatment and must learn that life is characterized by the need to take some chances, by dangers, difficulties, frustrations and unknowns, as well as pleasures, safety, comfort and the familiar. The responsibility for meeting the need for psychiatric services belongs to all of medicine and not just to psychiatry.     

Ethically problematic treatment decisions: a physician survey

BACKGROUND: Experiencing ethical problems requires both ethically problematic situations and ethical sensitivity. Ethically problematic treatment decisions are distressing and might reflect health care quality problems. Whether all physicians actually experience ethical problems, what these problems are and how they vary according to physician age, gender and work sector are largely unknown. METHODS: A mail survey of all non-retired physicians licensed in Finland (n = 17,172, response rate 75.6%). RESULTS: The proportion of physicians reporting having made ethically problematic treatment decisions decreased in linear fashion from 60% at ages below 30 years to 21% at ages over 63 years. The only problem that did not decrease in frequency with age was having withdrawn necessary treatments. Women and primary care physicians reported problematic decisions most often, although gender differences were small. Primary care physicians most often reported having performed too many investigations or having pressured patients, whereas hospital physicians emphasized having withdrawn necessary treatments. Performing unnecessary treatments or investigations was explained by pressure from patients or relatives, and performing too few treatments or investigations was explained by inadequate resources. CONCLUSIONS: In general, young physicians felt pressured to do too much, whereas older physicians felt they could not do enough due to inadequate resources. Older physicians might be less exposed to ethically problematic situations, be more able to handle them or have lower ethical sensitivity. Young physicians could benefit from support in resisting pressure to perform unnecessary treatments, whereas older physicians might benefit from training in recognizing ethical issues.     

Continuing medical education in Maritime Canada: the methods physicians use,would prefer and find most effective.

A study of the continuing medical education of practising physicians in Nova Scotia, New Brunswick and Prince Edward Island was conducted in 1979-80 by means of a mailed questionnaire. Most of the responding physicians ranked reading as the method most used to update knowledge (73.3%) and skills (55.7%); courses and informal instruction were in second place for updating knowledge and skills respectively, ranked most used by 9.3% and 17.1%. With unlimited time and funds 38.0% and 20.5% of the physicians would still most prefer to read to update knowledge and skills respectively. However, 35.2% would most prefer to attend courses to update knowledge and 26.9% and 24.8% would most prefer to do clinical traineeships or attend courses to update skills. When asked what method of learning had provided the most impetus to change their ways of managing patients, 42.5% chose reading, 18.8% courses, 14.6% informal discussions and 12.4% formal consultations. Appropriate developments would therefore include improving methods of providing physicians with the best information available when it is needed, removing roadblocks to participation in continuing education programs, matching individual learning styles to programs of learning, training physicians as peer tutors and helping consultants become better instructors through written consultations.     

Interest in physician-buyout packages grows as more doctors contemplate retirement

Provincial governments are turning to voluntary retirement programs, buyouts and phase-outs to help manage physician supply. Demographic data show that in 1996 nearly 27% of Canada''s active physicians were aged 55 or older and that the average age of retiring physicians was 68. Although 1 goal of such programs is to give willing older physicians the financial ability to retire, provinces also hope to do away with some billing numbers.     

Continuing Medical Education Tuition: A Survey of Charges

A survey was carried out on the tuition charged for continuing medical education (CME) programs offered by a variety of providers. These included schools of medicine throughout the United States, national organizations and societies, state-wide organizations and societies located in California, and a small group of hospitals in or near Sacramento, California.The fees charged for continuing medical education (expressed in this article as the amount in dollars that a physician must pay for one hour of approved Category I credit) may vary from nothing to more than $20 an hour. The average charge per hour for CME courses sponsored by medical colleges in the United States ranged from none to $11.19 during 1976 and 1977. Recent data indicate that most schools have increased tuition for CME courses because of inflation. Many schools of medicine provide CME through grand rounds, conferences and special lectures at no cost to participants. Similarly, in a small sample of hospitals in California, CME was found to be available at a minimal charge to physicians.Some CME programs are more costly because fees may include the expenses of honored visiting faculty, and costs of food or social activities. There may be further expense if travel is required, although these additional costs may be offset by the benefits of study in a relaxed atmosphere away from practice and office pressures.     

Pay, pride, and public purpose: why America's doctors should support universal healthcare

Discussion of universal healthcare is nothing new for US politicians or among reform advocates, policy experts, or the general public. Physicians, however, have been minor voices in the discussion. Their relative silence has been detrimental both to the public and to physicians themselves. We pose 3 arguments as to why physicians should support universal access grounded in medicine's own self-interest, arguments that are largely ignored in the current debate. These are: (1) the need for paying patients, (2) the need for a sense of self-esteem rooted in professionalism rather than commercialism, and (3) the urgency to affirm a public purpose for medicine by promoting the nation's health through universal care. Who has a stake in universal healthcare? Some groups, such as those lacking insurance, are obviously at risk and have a keen interest. Others, such as insured workers, have a less obvious but demonstrable concern. Arguments that urge adoption of an inclusive system typically focus on "healthcare horror stories" designed to evoke sympathy for the unfortunate persons whose lives are forever changed by unmet health needs or unpaid health bills. Our focus is different. We ask, regarding universal healthcare, "What's in it for physicians?" While the active support of doctors may not be a sufficient force to change the US system, it is probably a necessary one. At a minimum, universal coverage will be far less likely if physicians are opposed to it. Our aim here is to explore and discuss some of the reasons that should motivate active physician involvement in a more just and equitable system. We will discuss 3 reasons in particular. They are: (1) the need for paying patients; (2) the need to take pride in what one does--that is, the need to be nurtured by recognition of skillful professional performance in medical work, and not just rewarded monetarily; and (3) the importance of embracing a public purpose for medicine and thus engaging the trust and esteem of the population. We will examine each of these in turn, but first we will discuss briefly the other constituencies for universal coverage, since their reasons for supporting an inclusive system are often shared by doctors.