The academic health center and the healthy community

US medical care reflects the priorities and influence of academic health centers. This paper describes the leadership role assumed by one academic health center, the State University at Buffalo's School of Medicine and Biomedical Sciences and its eight affiliated hospitals, to serve its region by promoting shared governance in educating graduate physicians and in influencing the cost and quality of patient care. Cooperation among hospitals, health insurance payers, the business community, state government, and physicians helped establish priorities to meet community needs and reduce duplication of resources and services; to train more primary care physicians; to introduce shared governance into rural health care delivery; to develop a regional management information system; and to implement health policy. This approach, spearheaded by an academic health center without walls, may serve as a model for other academic health centers as they adapt to health care reform.     

Patellar reconstruction of the condyles in giant cell tumours of the knee

Training in vascular surgery is inevitably going to change radically over the next few years and we no longer have the luxury of an apprenticeship where the trainee matures and develops by prolonged contact with patients and senior colleagues. The EEC and Department of Health are insisting on a more focused training, by reducing the hours to 72 per week and suggesting accreditation as a surgical specialist after 6 years in higher surgical training. These goals, which have already been accepted by the Royal Colleges (and have been welcomed by the trainees), will inevitably lead to an entirely different approach to training, offering vascular surgeons an opportunity to develop coherent and more uniform programmes. To date many trainees have complained that their experience has been patchy, and sometimes poorly supervised. The task of developing a practical scheme is daunting, but we must start with the patient. Clearly, the patients' needs come first so that the training programme must lock on to the best standards of care. Only in this way can we ensure that the trainee is exposed to the best practice and modern techniques.     

Clinical training of psychologists in family practice settings: an examination of special issues

This article considers issues of education and preparation relevant to psychology trainees in departments of family medicine. Special issues unique to training in a medical setting, such as confusion about professional identity and divergence in world views, are discussed. This article also addresses a range of relational issues, including trainee relationships with residents, patients, and attending physicians. Supervision of the psychology trainee is also considered, eg, teaching, counseling, and advocacy supervisor roles. This article concludes with specific suggestions and guidelines for future training of psychologists in family medicine settings.     

Selective indications of skull radiography after head injury in children

The Permanent Working Group of European Junior Hospital Doctors (PWG) conducted a survey among surgical trainees in member countries with the aim of describing postgraduate training in surgery throughout Europe. In each country, 10 trainees with surgical training of 2-5 years and 10 trainees with surgical training of 6-9 years answered a questionnaire, completed a diary and kept a log book of operations for 1 week. A total of 165 surgeons from 12 countries completed the survey. A trainee had to care for an average patient load varying from 30 to 80 patients at any one time. The average number of working hours ranged from 52 to 88 h per week, including up to 18 h of unpaid work. The different tasks carried out within these working hours varied considerably, as did the proportion of tasks with educational value. Trainees participated in four to 11 major operations each week, but the number of operations a week did not reflect the number of operations conducted under supervision. In some countries, the majority of the trainees stated that they received their training mainly through unsupervised experience. The average number of days spent on courses and congresses varied from 4 to 15 days per year, with great variation in the percentage of expenses paid. Countries with favourable working conditions, such as fewer working hours, shorter shifts and a day off after being on duty, seemed to have gained these advantages by a reduction in working hours with educational value, rather than by a reduction in routine work. It is concluded that conditions of surgical training vary greatly between the European countries in relation to duration, working hours, tasks undertaken, and resources used on training. Every country is capable of improving its surgical training.     

How common is medical training in palliative care? A postal survey of general practitioners

BACKGROUND: General practitioners (GPs) have a central role in palliative care, yet research continues to reveal room for improvement in symptom control at home. There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home. AIM: To evaluate the training in palliative care GPs have received throughout their careers. METHOD: Postal survey of 450 randomly selected East Anglian GP principals, investigating training in five areas of palliative care (pain control, control of other symptoms, communication skills, bereavement care, use of syringe driver), as clinical students, junior hospital doctors, GP trainees (registrars), and GP principals. RESULTS: A response rate of 86.7% was obtained. While GPs were clinical students, training was uncommon, (32% reported no training in pain control, and 58% no training in bereavement care), although there has been a significant increase in more recent years. Training as junior doctors was particularly uncommon (over 70% report no training in communication skills or bereavement care); there was some evidence of an increase in more recent years. During the GP trainee year, training was much more common. For GP principals, most areas had been covered, although over 20% reported no training in communication skills and bereavement care. During the community-based years as trainee and principal, training was significantly more common than during the hospital-based years of training as clinical student and junior doctor. CONCLUSIONS: There is a continuing need for medical education in palliative care. Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors, especially regarding communication skills and bereavement care.     

Evaluating a training-for-action job health and safety program

This paper describes an action research evaluation method developed to assess a worker training program which encourages trainees to use knowledge acquired to correct health and safety problems in their workplaces. The project teaches trainees from the same workplace to identify problem areas collectively using a tool called a Risk Chart and then to prioritize problems to work on with the aid of an Action Plan. Follow-up trainee interviews are conducted to determine what impact the training has on trainees. The methodology is presented and preliminary results are discussed, with particular emphasis on the advantages and limitations of this method.     

A spreadsheet method for calculating maximum caseload and intake capacity for CMHC psychiatrists

OBJECTIVE: A method was sought to help administrators of community mental health centers determine a level of psychiatric staffing that is both cost-efficient and ensures high quality of care. METHODS: A survey of staff psychiatrists was conducted at a large community mental health center with seven outpatient clinics. The survey measured variables that can affect staffing requirements, including the number of hours psychiatrists have available for direct care, their preferred intervals between a patient's return visits, and the duration of appointments for an initial psychiatric assessment and for medication maintenance. A computer spreadsheet was developed to calculate the caseload capacity and intake capacity for clinics of the center. RESULTS: The survey indicated that the psychiatrists at the center had an average of 33 hours a week available for direct care. The mean preferred time between a patient's medication maintenance visits was 7.3 weeks. The mean time required for a psychiatric assessment was 80 minutes, and for a medication maintenance visit it was 33 minutes. With these data, the spreadsheet method was used to calculate intake and caseload capacity for psychiatric staff at three of the center's clinics. CONCLUSIONS: The data-based approach to calculating capacity can be modified to meet local needs. It brings objectivity to decision making about staffing, and the methods can improve resource management and enhance relationships between stakeholders and physicians.     

Health center-supplier team approach to solving i.v. equipment problems

A team approach to problem solving in which a health care center and a supplier worked together to improve product quality is described and a detailed example is provided. When the health care center began using a new supplier for i.v. solutions and equipment, the supplier's incomplete product line and recurrent functional problems with products led to dissatisfaction of staff members. The supplier suggested that the health care center and supplier form a quality action team. The team addressed eight product concerns by using a total quality management process. For each concern, the team defined the problem and formulated a problem statement, collected data and determined the contributing factors to the problem, developed an action plan for solving the problem, and executed the plan and monitored its impact. After the first meeting, the team met monthly to monitor progress and discuss new ways they could work together to improve product quality and reduce costs. The implementation of the action plans allowed the health care center to realize cost savings and increased staff members' satisfaction with the supplier's products. A quality action team, composed of representatives from a health care center and one of its suppliers, used a total quality management process to solve problems to the satisfaction of both sets of participants.     

Surgical training: an objective assessment of recent changes for a single health board

The reduction in doctors' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (of pounds 1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.     

Glomerular basement membrane-derived perlecan inhibits mesangial cell adhesion to fibronectin

Weight and height data of Madurese children from two longitudinal studies, the East Java Pregnancy Studies I and II, are analyzed cross-sectionally and compared with the NCHS reference and a rural population in Kasongo, Zaire. A total of 1945 children are included in the analysis, giving 25,202 weight and 17,196 height measurements. Madurese children start to accumulate a weight deficit compared with NCHS data at the age of 4 months. A linear deficit is already noticeable at 1 month, increasing rapidly in the 1st year of life. This period is responsible for most of the linear deficit accumulated by the age of 5 years. Madurese children are relatively fatter than NCHS children up to the age of 12 months. Comparing the Madurese children with those in Kasongo reveals that the accumulation of their linear deficit occurs at a period when weight increments follow those of Kasongo. Since in the studied population food intake and breastfeeding could not explain the growth dynamics in the 1st year of life, it is suggested that the explanation may lie in micro-nutrient deficiency and intra-uterine development.     

Structured patient education for out-patients with hypertension in general practice: a model project in Germany

In a model project, office-based physicians in two regions of Germany provided a structured treatment and teaching programme for out-patients with hypertension. The project was carried out in co-operation with the German Hypertension League and designed to evaluate the practicability and efficacy of the implementation in routine primary health care. A total of 111 primary health care practices in two German districts who had participated in a training course were interviewed. In 43 of these offices documented data of all patients who had received the standardised treatment and teaching were evaluated. The programme was well received by the physicians of which 81% rated the training course and 93% the teaching material as 'very good' or 'good'. A total of 466 patients were trained. Data collected on 272 patients (22 weeks after the intervention) demonstrated the efficacy of the programme at treatment level: reduction of body weight (2 kg, P < 0.001) and blood pressure (from systolic 158+/-18 to 148+/-17 mm Hg, P < 0.001; diastolic 91 +/-9 to 86+/-9, P < 0.001). Sixty-five per cent of patients learned for the first time how to perform blood pressure self-monitoring during the programme. The number of blood pressure readings by the patients' increased significantly from 1+/-3 measurements per week before, to 8+/-7 measurements per week after the programme (P < 0.001). The results of the study demonstrate the practicability and efficacy of the implementation of the programme for patients with hypertension into routine primary health care.     

Climbing the stairway to competency: Trainee perspectives on competency development.

Training programs have increasingly focused on development of competencies as a benchmark for trainee progress. While much writing on the subject of trainee competency has focused on programmatic implementation of competency-based training, considerably less attention has been paid to the experience of trainees in these programs. The current study sampled a cross-section of 641 graduate students enrolled in member doctoral programs of the Council of University Directors of Clinical Psychology. These students were divided into four groups based on stage of training and reported on their development of core competencies. Overall, students entered doctoral programs reporting high levels of adaptive trainee characteristics and felt competent in a range of areas by the time they applied for internship. Competencies in research, assessment, and intervention developed over the course of graduate training. Reported competency in research was higher for trainees endorsing a goal of a research career, while reported competency in empathy and therapeutic relationships was higher for trainees endorsing a goal of clinical practice. Findings are discussed in the context of implementing competency assessment that encompasses the ratings of trainees as well as supervisors and programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of prostacyclin on myocardial hemodynamics and metabolism after coronary artery bypass grafting

OBJECTIVE: To evaluate the impact on clinical behavior of a 3-day workshop designed to increase trainees' rates of smoking cessation counseling and reminders about Pap smears in routine consultations. DESIGN: Randomized control trial. SETTING: Accredited teaching practices of the Royal Australian College of General Practitioners' Training Program. SUBJECTS: Thirty-four trainees and 1,500 consecutive adult patients ages 16-65 years. METHOD: Trainees randomly allocated to the experimental group participated in a 3-day interactive workshop on disease prevention during their 13-week family medicine term. Audiotapes of consultations with adults conducted by trainees at the beginning and end of the rotation were analyzed blind to compare assessment of patients' smoking status and, for women, date of last Pap smear. A questionnaire mailed to each patient after the consultation also allowed identification of smokers and women overdue for a smear. Consultations with these patients at risk were analyzed for preventive counseling. Inter- and intrarater reliability was calculated for audiotape analysis. RESULTS: Preworkshop rates of questions about smoking were low, occurring in 22% of consultations. While trainees allocated to the experimental workshop were more likely to ask a routine question about smoking at the end of the term than those in the control group (P = 0.01), two-thirds of smokers remained undetected irrespective of trainee group and fewer than one in five were advised to stop smoking. Reminders about Pap smears did not change as a result of training and remained low in fewer than 20% of consultations. kappa values demonstrated high reliability of audiotape analysis. CONCLUSION: This direct measurement of clinical behavior revealed that low levels of preventive care provided by trainees are resistant to skills training without reinforcement in clinical practice. In view of the importance of prevention in routine consultations, we recommend continued evaluation of more intensive educational programs. Those withstanding rigorous evaluation could be considered for implementation in similar training contexts seeking to improve the frequency and quality of disease prevention in primary medical care.     

Changes in trainees' intention use and volunteer clients' evaluations of sessions during early skills training.

Volunteer clients (N = 96) evaluated sessions conducted by prepracticum trainees prior to and after the trainees received instruction in interpersonal–psychodynamic therapy. The relationship between changes in therapeutic style, measured by intension use, and changes in volunteer clients' session evaluations were examined with growth curve analyses. After training, trainees increased their focus on client emotions and on the therapeutic relationship and decreased their verbal activity. Increased session smoothness was related to decreases in trainee verbal activity and to increases in trainee flexibility. Increases in volunteer clients' perceptions of trainee expertness, attractiveness, and trustworthiness were related to trainees' increased focus on client emotions and increased focus on the therapeutic relationship and to decreases in confrontation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Academic faculty practices: issues for viability in competitive managed care markets

This study compares the perspectives of eighteen managed care executives and twenty-four faculty practice executives on critical policy issues related to the managed care marketplace. Market sites studied in 1994 included four major metropolitan areas: Minneapolis-St. Paul, Los Angeles, Philadelphia, and Atlanta. These markets were selected as being representative of communities with descending degrees of managed care involvement, but with significant market activity. Study participants from both managed care systems and faculty practices examined five policy issues: (1) the importance of including academic medical centers in current and future health care plans for marketing purposes; (2) the provision of clinical services that are unique to the academic medical center, that is, unavailable elsewhere in the community; (3) the degree of financial supplement that employers might pay for including an academic medical center; (4) future restructuring of organizations to sustain the educational mission of academic faculty within a viable delivery system; (5) satisfaction of managed care providers with graduates of academic medical centers, as measured by the clinical skills of graduate physicians. The study findings showed little support among managed care plans for paying supplements to include faculty practices in a health care network. Most study participants from managed care systems and academic faculty practices identified limited competencies that are unique to academic centers. Moreover, managed care organizations were only willing to undertake limited restructuring at best to include faculty practices within their networks. General concern about the preparation of resident physicians (especially those in primary care disciplines) for practice within contemporary managed care organizations existed among managed care informants. The results of the study indicate that as traditional funding sources for medical education are reduced, schools require greater integration with managed care plans to enable academic medical centers and their faculties to continue promoting clinical enterprise.     

Establishing a high-school-based training room clinic

Being a team physician can be a time-consuming commitment. The team physician is responsible for all aspects of the athlete's care and has the final say in all medical matters related to athletic participation. Primary care physicians are well suited to be team physicians. The training room is an outstanding way to increase physician availability to adolescents and underserved population. Setting up a training room must be planned in advance, including funding, supplies and liability. Most legal problems can be avoided with a contract and proper documentation. The school-based training room provides the physician with an excellent opportunity for community service and can be a very rewarding experience.     

Oxidative damage to the eye lens caused by cigarette smoke and fuel smoke condensates

The degree to which a reformed U.S. health care system relies on an adequate supply of primary care physicians will determine the urgency of change in the composition of the medical workforce. In many areas of the United States, the demand for primary care physicians, particularly in managed care settings, far exceeds the supply. In contrast, reports of reduced practice opportunities for medical and surgical subspecialists in the same settings are increasing. As opportunities for and incomes of primary care physicians are enhanced, some medical subspecialists may seek retraining in primary care. This article provides a context for understanding the development of physician retraining programs, examines precedents for retraining physicians, describes four possible pathways through which medical subspecialists might acquire primary care training, and emphasizes the importance of defining the scope of practice and necessary skills for providing primary care. Obstacles to retraining appear to be economic (Who will pay? Is the cost worth the benefit?) and jurisdictional (Who will define core competencies? Who will credential programs and trainees?). The current absence of demand for such retraining programs suggests either that marketplace-induced changes will not take place or that the notion of a primary care provider shortage and an oversupply of medical subspecialists is overstated. The inclusion of physician retraining programs in proposed health reform legislation suggests that policymakers are convinced that such programs offer one viable solution to the nation's medical workforce needs.     

基于VR技术的矿山冒顶片帮事故教学培训

为了提高非煤矿山冒顶片帮VR培训效率,基于Unity3D、3DMax和Visual Studio 2019软件开发了包括预培训、隐患岩块识别培训和灾害现场逃生培训3个模块的矿山冒顶片帮事故教学培训平台.该平台采用虚拟教练进行示范性教学,指导受训者识别、清理隐患岩块和完成灾害现场逃生,并将虚拟教练培训与传统UI文字培训的...     

Review of a general practice attachment for accident and emergency training

The changes occurring in the health care delivery system afford ideal opportunities for call centers to expand their essential functions. Two obvious and timely services that can be adapted to the call center are outcomes management and disease management. These services benefit from the central role that telephonic nurses can play in clinical assessment and data collection and analysis. Other new services, such as gate-keeping functions, may also be relevant to call centers. The information and technology specialization of expert clinicians who practice "sightless" nursing make call centers the new clinical epicenter in the service capabilities of health care networks.