Attitudes and expectations of 1995 gastroenterology graduates about gastroenterology

OBJECTIVE: To learn more about current attitudes and expectations of recent (June 1995) graduates of gastroenterology fellowship programs, why they chose either a private practice or academic career, and what impact managed care or health care reform had in their decision. METHODS: Between April and June 1995, and 8-page, 35-question survey questionnaire was mailed to graduating fellows and returned for evaluation. RESULTS: Graduates believed managed care had an impact on job availability, but it was not a factor in their job choice. Forty percent of the respondents reported that finding a job was either difficult or very difficult. The majority of respondents (67%) are pursuing a career in private practice. Most private practice physicians (PP) trained in 2-yr programs whereas academic physicians (AC) trained for the most part in 3-yr programs. The principal criteria on which decisions regarding job selection were based were similar between the two groups: co-workers, geographic location, access to patient care, and ability to perform endoscopy. Respondents in PP and AC expected to work 50-70 h/wk, care for patients with similar diseases, and have ample time for family. They would choose GI again as a career and believed that there is a future in GI. Salary expectations varied markedly between the two groups, and AC physicians were more concerned about their future financial needs. Twenty percent of PP physicians and 71% of AC physicians plan to participate in clinical research. CONCLUSIONS: Recent graduates of gastroenterology fellowship programs continue to have high expectations of their future careers. Although some had difficulty finding a job and stated that, although managed care had an impact on the job market, it had not yet become a major factor in their job selection.     

Effective outcomes management in occupational and environmental health

In the final analysis, outcomes management is about changing behavior, specifically in the occupational and environmental health practitioner's communication process and practice patterns and in the workers' prevention and compliance behavior. Outcomes management is also about quantifying results, establishing occupational and environmental health performance benchmarks, developing a best practices model and asking even more questions. As health care embraces the use of outcomes in evaluating its effectiveness, similar developments can be anticipated in occupational and environmental health. While occupational and environmental health outcomes management is still in its infancy, nurses in the workplace are well positioned to "shape it" into a useful tool that meets the needs of all the various practice settings. As nurses in the workplace begin to evaluate, report, and benchmark results, measurement tools will be refined, data bases will grow and new, useful benchmarks will be established. Because occupational and environmental health programs usually operate as part of a larger business unit, nurses in the workplace are continually faced with the challenge of ensuring that corporate programs including workers' compensation, health and disability benefit programs, vaccination programs, injury prevention, and health promotion or wellness programs are delivered in an efficient and cost-effective manner and that the expected outcomes are achieved. Effective outcomes management programs are the vehicles to effective goal achievement.     

Treatment and referral guidelines in gastroenterology

Practice guidelines have become an integral part of clinical practice. There are inherent potential problems involving their source, methodology, and measurement of their impact. Physicians may understandably have reservations about embracing practice guidelines. Such guidelines, however, offer the opportunity to ensure continued quality while controlling cost and resource utilization.     

Quality assurance and outcomes in outpatient parenteral antibiotic therapy

The quality improvement process in outpatient parenteral antibiotic therapy (OPAT) is driven by outcome measurement. Collection and analysis of outcome data will be an essential component of an OPAT program. Data collected must be measurable, consistently defined and transformed through analysis into understandable results that can be used to improve care.     

Quality management in emergency medicine

Although the need for the implementation of a quality management concept for the German emergency medical system (EMS) has been discussed for more than 10 years, such a concept has not been realised on a broad scale. Standardised national data sheets were developed many years ago. They are used by many local agencies, but a data-gathering system on a state or national basis is still lacking. In times of reduced funds for health care expenditures, quality management could be a reliable way to ensure that the EMS provides safe services to the patient based on the current state of medical science in an efficient manner. Based on clear definitions, structure, process, and outcome quality can be analysed, and the results provide the basis for continuous quality-improvement strategies. As not all aspects of the system can be analysed continuously, one has to select areas of special importance. External and internal quality control are equally important. Quality control works on the basis that all EMS team members are motivated to perform on a professional level to ensure that each patient is treated adequately. It evaluates the system to create circumstances that enhance the achievement of this goal. Quality management is not only concerned with mishaps, because areas with documented good performance also provide important information.     

露天采场爆破质量管理

爆破是矿山生产的重要环节.文中介绍了蒙库铁矿露天采矿场在中深孔爆破的设计和施工中,为了提高爆破质量而进行的爆破技术、现场施工及器材管理工作.通过爆破质量管理制度的建立和实施,使露天采矿场爆破质量得到进一步的巩固和提高.     

1997 gastroenterology update--I

Artificial neural networks (ANNs) were used to measure the quality of care (Q) at two admission units in a state psychiatric hospital, each unit having two treatment teams, one led by a permanent (PM) staff physician, and one led by various locum tenens (LT) physicians. An LT physician's tour of duty (TOD) averaged approximately 30 days. Over nearly a 2 1/2-year period the four treatment teams received 744 admissions. Our previous research has reported measuring Q using percent accurate prediction of hospital length-of-stay (LOS), divided by a measure of severity of patient illness. We calculated Q for each treatment team's test set of patients using a trained ANN for each team. All the teams' test sets were run through each of the trained ANNs resulting in a set of four Q values for each ANN. We defined the standard deviation of Qs resulting from a single team's test set run through it own as well as the other three teams' ANNs as representative of the "diversity" of the patients in that test set. We defined the reciprocal of the standard deviation of the Qs resulting from each of the teams' test sets run through a single team's ANN as that team's "robustness." The product of "robustness" times "diversity" was defined as the value (V) of the treatment team. The V of the PM physician-led teams was 1.9 times that of the LT physician-led teams. We normalized V for patient entropy (uncertainty) with a metric called the "risk ratio" (RR), derived from Boltzmann's law. This resulted in the V/RR of one PM physician-led team as superior, despite treating patients with the highest risk. The LT physician-led teams, despite having fewer patients afflicted with the more problematic diagnosis of schizophrenia, were handicapped by not having preexisting therapeutic relationships with their patients, giving both LT teams low robustness. There was no statistically significant difference in patient LOS between the teams. Because the greatest change in team composition was due to LT physicians, we assumed that the differences in V/RR were due to the short (30-day) TOD and not to any skill deficits in the LT physicians. This article explores a new paradigm which compares the value of patient care in separate delivery systems despite differences in severity of illness, case-mix, and uncertainty associated with an imperfect therapeutic environment.     

Electronic documentation of images and findings in gastroenterology

Clinico-neuropathological findings recorded from one case of cerebral gliomatosis are reported in this paper. Immunocytochemical methods (GFAP, protein S-100) were used together with morphometric computer-assisted analysis for more effective investigation of certain cytopathological features such as the relationship between cerebral gliomatosis and low-graded astrocytoma. Immunohistochemically, most of the proliferating cells were positive to GFAP and/or to protein S-100, which was in fair agreement with publications elsewhere in the literature. However, varying amounts of spindle-shaped cells remained unstained. The nature of such cells is unclear. The morphometric study showed the majority of cellular parameters of cerebral gliomatosis to be comparable to cellular parameters recordable from "peripheral" regions of a series of low-grade astrocytomas.     

A strategy for osteoporosis in gastroenterology

Osteoporotic fractures are a major public health problem. Gastroenterologists see many patients at risk of osteoporosis, particularly those with coeliac disease and inflammatory bowel disease. In this paper, the extent of the problem is reviewed and a strategy of investigation and treatment is recommended.     

Highlights of the year in gastroenterology

The past 12 months have been a period of steady progress in the field of gastroenterology. Helicobacter pylori continues to dominate many areas of clinical research and the indications for eradication are increasing. A potent, topically-acting corticosteroid for Crohn's disease, and new hope and potential treatments for IBS sufferers are other developments.     

Teaching gastroenterology in a private outpatient clinic

In this essay I review how I have taught clinical gastroenterology to residents and fellows and medical students for the past 40 years in an academic private outpatient clinic. Private patients can serve as "teaching patients," even in an ambulatory setting, and even in a managed care environment that encourages productivity.     

Clinical applications of nuclear medicine in gastroenterology

This study describes the antibiotic resistance of 1961 staphylococcal strains that were isolated at the University Hospital of Vienna from July to December 1991. Staphylococcus aureus (SA) represented 43.2%; coagulase-negative (CNS) staphylococci 56.8%, three quarters of which were Staphylococcus epidermidis. Excepting netilmicin, the proportion of resistant strains to all antibiotics was higher with CNS than SA. Methicillin resistance (M(r)) was found in 11.8% of SA and 30.3% of CNS. Borderline oxacillin resistance (BOR) was noted in 7.4% of SA and 32.5% of CNS. It is important to note that severe or generalized infections due to M(r) staphylococci should be treated with glycopeptide antibiotics such as vancomycin or teicoplanin from the very beginning, whereas chemotherapy of those with BOR strains may also be carried out with beta lactamase-stable beta lactam antibiotics. Comparing the results of this study with those of the first half of 1991, the respective proportion of M(r) staphylococci was significantly lower than 23.6% for SA and 47.6% for CNS recorded then. As compared with the foregoing period, however, these strains demonstrated increased resistance frequencies to gentamicin (from 81.3 to 90%), amikacin (from 35.4 to 69%), netilmicin (35.4 to 55%), and ciprofloxacin (56.2 to 64%). This is taken as an indication for the epidemic spread of a clone of resistant strains.     

Quality assurance and risk management in gynecology and obstetrics]

The predominance of medical experts in hearings on so-called professional malpractice has frequently been bemoaned, but is indispensable since lawyers lack the necessary knowledge and requisite expertise. Court decisions are therefore essentially dependent on the quality of expert medical opinions, which in turn are dependent on the professional competence of the expert and on whether the expert is aware of the judicial demands made of him, i.e. whether the expert correctly understands his status and function within the scope of the civil or criminal proceedings. For example,the fact that court practice allows for differing standards (i.e. that medical standards can vary within limits) is important for the expert's appraisal, as is also knowing to what extent he is bound by the assignment and which requirements apply for proving causality (i.e. of an error leading up to damage) in civil and criminal proceedings. Strict objectivity, comprehensible language, restriction to one's own special field, preparation of the report within a reasonable time, intellectual integrity, no dealing with legal issues, ex ante assessment of the case and personal responsibility for the opinion are other important precepts that must be adhered to in order to avoid a miscarriage of justice. Quality control as exercised by specialised experts is therefore of vital significance.     

Quality management and the clinical microbiology laboratory

Quality management in today's health care environment requires a fresh approach. Laboratories that have traditionally directed their efforts toward meeting the needs of physicians must now also satisfy the needs of society, the greater public health, and the agency's administrators. Technical advances must today be considered in the context of patient care cost-effectiveness or final outcomes. Examples of strategies for improving quality in the laboratory, such as seeking input from all individuals involved in interpreting or using laboratory test results, forming multidisciplinary committees for development of critical pathways, issuing surveys for assessing the level of satisfaction of the laboratory's customers, and providing visual feedback of the results of activities, are described.     

Effects of stress management on clinical outcomes in rheumatoid arthritis

An intriguing feature of early zygote development in Chlamydomonas reinhardtii is the active elimination of chloroplast DNA from the mating-type minus parent due presumably to the action of a zygote-specific nuclease. Meiotic progeny thus inherit chloroplast DNA almost exclusively from the mating-type plus parent. The plus-linked nuclear mutation mat3 prevents this selective destruction of minus chloroplast DNA and generates progeny that display a biparental inheritance pattern. Here we show that the mat3 mutation creates additional phenotypes not previously described: the cells are much smaller than wild type and they possess substantially reduced amounts of both mitochondrial and chloroplast DNA. We propose that the primary defect of the mat3 mutation is a disruption of cell-size control and that the inhibition of the uniparental transmission of chloroplast genomes is a secondary consequence of the reduced amount of chloroplast DNA in the mat3 parent.