Additional Medical Training Research Articles

Évaluation des échanges professionnels entre médecins généralistes et psychiatres

ObjectivesThere is in France a higher prevalence of psychiatric disorders and higher than average psychotropic consumption in the general population. Considering these elements and the need to involve two complementary medical specialities to manage these disorders, general practice and psychiatry, the necessity for optimal professional exchanges is a major public health concern. In the French public health system, primary care is overseen by self-employed general practitioners. The French psychiatric public sector is said to be “sectorised”, i.e. organised in specific sectors. These sectors include in-patient care entities and out-patient services. The private sector in psychiatry is not sectorised and is mainly composed of self-employed psychiatrists and private clinics. A 2004 law designed to govern who is authorized to refer patients to specialists, stipulated that general practitioners were the only authorized referring doctors for primary care. In the meantime, the number of general practitioners being consulted for cases of depression has doubled between 2005 and 2010. Less than a quarter of these patients were referred to a psychiatrist. Our main objective is to assess the satisfaction with and the efficiency of exchanges between psychiatrists and general practitioners. We also endeavour to identify the main channels through which collaborative care involving these two specialists can be improved. Materials and methodsOur work is an observational, transverse, monocentric and descriptive study carried out using analogous feedback forms mailed by post from June to September 2016. The feedback forms were designed to be analysed both separately and comparatively. Two hundred and ninety nine self-employed general practitioners and 46 psychiatrists employed in the public sector returned the forms. The psychiatric private sector was excluded. All of these doctors worked within three specific geographical treatment zones: Saint-Étienne, Ondaine and Pays de Gier (350,000 inhabitants). The results were treated anonymously via Microsoft Excel® and IBM Corporation SPSS Statistics®. This study was approved by the ethics committee of the university hospital center (CHU) of Saint-Étienne. The doctors’ registers were retrieved via the databases of the Departmental Council of Doctors (CDOM) of the Loire and that of the CHU of Saint-Étienne. ResultsOne hundred and twenty four general practitioners and 30 psychiatrists responded to the feedback form completely. Response rates were 41.4 % for the family physicians and 65.2 % for the psychiatrists. Respectively, 57 % and 70 % knew the identity of their counterpart. A public sector psychiatrist saw 91.9 % of the patients also treated by general practitioners. Of the attending doctors, 79.8 % reported a one third or less return rate of follow-up information from the psychiatrist for the patients they treated together. Similarly, 76.7 % of the psychiatrists reported a return rate of one third or less. One hundred percent (p<0.05) of the general practitioners who did not know the psychiatrists were dissatisfied with their collaboration. Likewise, 98.9% (p<0.05) of the general practitioners who rarely or never received correspondence from the psychiatrists were dissatisfied. Respectively, 77.7% (p>0.05) and 69.5% (p>0.05) of the psychiatrists were dissatisfied. In favor of participating in a standard addressing and return letter process, were 53.4% of the psychiatrists. On the contrary, 64.9% of the general practitioners were against such a process. Willing to receive additional medical training in the psychiatric field were 74.5 % of the family physicians. One out of five psychiatrists considered it a high priority for general practitioners to receive additional training in the psychiatric field. Sharing hospitalisation and consultation reports, along with general practitioners continuous medical training, were considered to be the top priorities for any approach for improving communication. ConclusionsWe observed a high level of dissatisfaction among the participants as a result of the lack of communication. As mentioned above, the field of psychiatry is compartmentalised, psychiatrists are less available for general practitioners. General practitioners are not sufficiently trained but are willing to take more training to improve their practice in the psychiatric field. The results of this study show that first and foremost there is a need to systematise mailings, to simplify phone-based opinion sharing, and to increase the frequency of cross-field training among general practitioners. All of the above could improve exchanges and the management of patients suffering from psychiatric disorders.

217 Attitudes towards Physician-Assisted Dying among medical students in an Irish medical school

Abstract Background Physician-Assisted Dying (PAD) is a controversial topic, particularly among medical practitioners, While PAD is currently illegal in Ireland, it has been legalised in several European countries. It is likely PAD will become an increasingly contentious issue as current medical students progress through their training and over the course of their future careers. Methods This project comprised of a fully anonymised survey (using the platform Qualtrics), exploring Trinity College Dublin (TCD) medical students’ attitudes towards PAD. All TCD medical students, aged 18 and above, were invited to take part in the online survey. The survey included thirteen questions, addressing student: sex, age, stage of medical training, exposure to geriatric medicine rotations, opinions on training in relation to PAD, and overall attitude to PAD. A participation information leaflet containing a link &amp; QR code to the survey was distributed to students at lectures. An email inviting students to take part in the study was also circulated. Consent was implied by completion of the survey. Results 200 students completed the survey. 119/200 (59.5%) of students were in favour of PAD, 53/200 (26.5%) were unsure, and 28/200 (14%) were opposed to PAD. Only 42/200 (21.%) students felt that their medical training adequately prepared them for potential discussions with patients about PAD The majority of students (31/37) who had completed rotations in Gerontology also felt that they were not adequately prepared for such discussions. 173/200 students feel that additional medical training related to PAD is warranted. Conclusion The majority of TCD medical students, across all genders, year of training and age groups, were in favour of PAD. Most students feel that their medical training does not prepare them for potential discussions about PAD in the future. Those who had clinical rotations in Gerontology did not feel more prepared for future discussions regarding PAD, suggesting the need for more formal teaching on the subject.

233 The Use of High-Fidelity Simulation to Identify Potential Protocol Violations and Latent Risk Threats During Standardized Protocol Training in a Large, Multicenter Study

High-fidelity simulation (HF-SIM) has been used extensively in medical education and quality improvement; however, its role in protocol training for large clinical research trials is not well described. We sought to utilize HF-SIM for protocol training for a large multicenter clinical trial in order to standardize training and identify potential protocol violations (PPVs) or study-related latent risk threats (LRTs) prior to enrolling patients in the Hyperbaric Oxygen Brain Injury Treatment (HOBIT) Trial. LRTs are elements of the health care system that make patient care errors more likely. In addition to having over a dozen study sites, the enrollment and treatment protocols for the HOBIT trial are complex, including interdisciplinary critical care transfers between multiple units and patient care areas. This makes a standardized approach to protocol training critical to success. This was a feasibility study of the use of HF-SIM for standardized protocol training in a large, multicenter study. Prior to onboarding individual study sites, 4 HF-SIM patient care scenarios were developed and run in active patient care areas at the primary study site. The scenarios included: 1) a standard, uncomplicated enrollment process with patient transport through all clinical areas, 2) a ventilator circuit kinking during transport requiring troubleshooting, 3) a pneumothorax during HBO therapy requiring urgent decompression, and 4) a ventilator disconnection during HBO therapy, requiring emergent decompression. The scenarios were thought to represent conditions most likely to result in PPVs or LRTs. After each scenario, PPVs and LRTs discovered during the scenario were documented. The primary site’s HF-SIMs were video recorded as examples, and all other participating sites were required to watch the scenarios and reproduce 2 HF-SIM cases at their individual institutions, including one uncomplicated enrollment case and one complication case. Individual sites were required to submit a recorded video of their simulations and a tracking document that listed any PPVs or LRTs discovered, along with potential solutions, in order to determine site readiness for active enrollment of patients. The PPVs and LRTs discovered were coded by 2 independent raters. Items lacking initial agreement were discussed and subsequently agreed upon. Use of HF-SIM was feasible for protocol training at the initial 2 study sites, as both had in-house simulation centers. One center was forced to run a portion of their scenario in the simulation center instead of the ICU due to hospital census, but was able to run the remainder of their HF-SIMs in patient care areas. No other financial or logistical barriers were reported. Aggregate data from these sites reveals that 34 unique PPVs or LRTs were discovered. Themes included: need for additional medical training n=7 (20.6%), protocol clarifications n=4 (11.8%), equipment issues n=8 (23.5%), and systems issues n=15 (44.1%). Some issues were found in multiple care areas, but only included once in the analysis. HF-SIM can be used as part of a standardized protocol training program for clinical trials. The use of HF-SIM identified multiple training and process deficiencies prior to enrolling patients, and could lead to decreased protocol violations as well as decreased patient safety threats during the actual study period.

A Public Dilemma with Prescription Pill Abuse: Searching for a Solution to Fight the Epidemic and Treat the Addicted

The steady increase in prescription pill abuse satisfies the contention that addiction is no longer a private problem. Current systems are only temporarily masking the dilemma. New protocols at both the state and federal levels need to be implemented to tackle the problem at hand. Additional medical training on pain management and full disclosure to patients will also help reduce prescription pill abuse and result in many lives saved. Public awareness and a demand for change of the stigma of addiction is the only way this nation will succeed in fighting the epidemic and treating the disease of addiction.

Barriers and facilitating factors in the professional careers of international medical graduates

Social and cultural diversity are increasingly important characteristics of the medical professional workforce. Every year, substantial numbers of international medical graduates (IMGs) seek jobs outside the countries in which they were educated. This article concerns IMGs who enter the Netherlands as refugees or as spouses of Dutch citizens. As their non-European medical qualifications are not considered equivalent to the Dutch qualifications, they are required to undertake additional medical training. Because little is known about their professional careers, we set out to identify the barriers that confront and the facilitating factors that support IMGs before, during and after their supplementary medical training. We invited 58 IMGs who had successfully completed their additional medical training requirements in Maastricht, the Netherlands (1996-2007) to participate in in-depth interviews. They were identified by the university's Institute of Medical Education and from its alumni database. Thirty-two IMGs participated and reported a range of issues affecting their attempts to practise medicine in the Netherlands. Reported barriers included difficulties in accessing information on complementary medical education and lack of (financial) support. Perseverance was reported to be essential. Financial and social support were also reported as facilitating factors. Lack of command of the Dutch language and age were seen as barriers to securing employment and entrance to specialisation. The barriers identified have major implications for IMGs wishing to practise medicine in the Netherlands. Better support to overcome the difficulties inherent in migration and career change will result in better trained and acculturated doctors who will be more motivated to contribute to society.

The clinical skills assessment for international medical graduates in The Netherlands

Aim: A need was felt to improve the quality of admission and licensing procedures for international medical graduates in The Netherlands.Method: A clinical skills assessment was designed as part of a new procedure to realize a high-stakes, fair, transparent, and a time-limited path of admission for international medical graduates to the Dutch health care system. Additionally, it should provide a well-founded advice about length and content of additional medical training, should this be indicated by the outcome of the assessment.Results: The clinical skills assessment procedure was developed as a Dutch variant of the “Step 2 Clinical Skills examination” of the Educational Commission for Foreign Medical Graduates (ECFMG) in collaboration with the United States National Board of Medical Examiners, which has a well-documented validity and reliability. The experience with the new procedure is yet limited, but enough to warrant a report.Discussion: Worldwide, a number of countries have developed such high-stake assessment procedures, but they show little uniformity and transparency. By describing the design and development of our procedure, we do not pretend to set a standard, but we hope to contribute to more fair, accurate and uniform approaches for doctors moving from one country to another.

Exhibit Essay Review: "Faux Reality" Show? The Body Worlds Phenomenon and Its Reinvention of Anatomical Spectacle

Exhibit Essay Review: "Faux Reality" Show? The Body Worlds Phenomenon and Its Reinvention of Anatomical Spectacle Reviewed by J. T. H. Connor It is safe, arms-length, faux reality, very much like the plastinated corpses. . . . We call it art or "history"—anything but reality. Thomas Lynch, essayist, poet, and funeral director1 The human body and its history have become "fashionable to the point of ubiquity."2 Undoubtedly, the boldest example of this "body trend" is the oeuvre of Gunther von Hagens, who is neither a historian nor a scholar of the humanities but a medical doctor-cum-artist. Born in 1945 near Posen as Gunther Liebchen, [End Page 848] von Hagens (the name originates from his first wife) began medical studies in 1965 at Friedrich-Schiller University in Jena; a decade later he obtained his license after additional medical training at the University of Lübeck. Using an anatomical preservation process that he patented in 1977 while at the University of Heidelberg, he has turned the human body into a form of medical technology/material culture and/or art. The process is referred to as "plastination," with the resultant silicone-impregnated preserved specimens called "plastinates." Von Hagens has laboratory operations located in Kyrgyzstan and Dalian, China, but his Institute for Plastination (an organization apparently at arm's length from his exhibition business) is based in Heidelberg.3 Earlier representations of the human body produced in print, wax, stone, or papier maché were "only" artistic depictions, no matter how lifelike. Precursors to von Hagens's more realistic work, perhaps, are the prepared tableaux and "wet" specimens of Frederik Ruysch (1638–1731) and his student Bernhard Siegfried Albinus (1697–1770): these Dutch anatomists posed fetal skeletons and severed babies' limbs to create, in the words of Rosamond Purcell and Stephen Jay Gould, an "alien aesthetic."4 Similarly, the specimens of Honoré Fragonard (1732–99) included an anatomized rider with horse, and a dancing baby.5 But the preparations of von Hagens fuse real flesh and bones, art, and high technology into a hybrid form that in many ways transcends the work of his predecessors. His labors have produced a seemingly unending stream of fully anatomized, posed "action" figures, including a chess player, a basketball player, a pole vaulter, a gymnast, an archer, a hurdler, a figure skater, and a teacher.6 [End Page 849] Von Hagens's traveling exhibit, entitled Body Worlds or Körperwelten,7 is probably the first "blockbuster" exhibition that the non-art-museum world is likely to encounter. Since its opening in 1995, twenty million people in Asia, continental Europe, the United Kingdom, and, most recently, the United States and Canada have paid admission fees to view this biomedical spectacle. Yet von Hagens's declarations that his specimens are science and not art have confounded some commentators as well as triggering a flood of criticism that is both engaged and emotional; so, too, have his comments that he wishes to breach societal taboos through his works and their exhibition. He certainly achieved this last goal when he recently extended his activities in London by augmenting his displays with a public dissection performed and televised in the boiler house of London's Old Truman Brewery. Such an act, announced his promotional literature (which also featured the frontispiece from Vesalius's De Fabrica), was "last performed" in 1830; it gave rise to another flood of popular and professional commentary (and lots of publicity). The descriptors, epithets, and sobriquets that have been applied to von Hagens by the public and popular media—such as "Frankenstein," "Josef Mengele," and the "Disney of Death"—indicate their unease.8 Body Worlds has also attracted the attention and ire of many others, including professional medical organizations that take exception to the public display of, and apparent disrespect for, human remains. In short, von Hagens has brought cadavers from behind closed stainless steel doors and put...

Medical Decision-Making by Psychiatry Residents

Several conspiring factors have resulted in an increase in the level of medical burden in psychiatric patients. Psychiatry residents require increasing levels of medical sophistication. To assess the medical decision-making of psychiatry residents, the authors examined the outcome in subjects initially seen in the emergency psychiatric service and referred to the medical emergency department for medical evaluation and treatment. Psychiatry residents completed a survey sheet for every patient referred for medical evaluation from the emergency psychiatric service. The survey collected information on demographics, the level of subjective concern, and the anticipated level of medical intervention. Twenty-seven medical referrals were made in the 6-week study period. Complete data were available for 23 (85.2%) subjects. Psychiatry residents accurately predicted the medical intervention 43.5% of the time. They overestimated the intervention 26.1% of the time and underestimated the intervention 30.4% of the time. Psychiatry residents' medical decision-making can be improved. Additional research is required to determine whether additional medical training is needed or whether our findings are a consequence of the variability in how different physicians address medical problems.

Best Practices: Psychiatrists and Primary Caring: What Are Our Boundaries of Responsibility?

Best Practices: Psychiatrists and Primary Caring: What Are Our Boundaries of Responsibility?

Law Enforcement Agencies and Out-of-Hospital Emergency Care

Study objective: We sought to assess the involvement of law enforcement agencies in out-of-hospital emergency medical care and their attitudes toward expanded roles in emergency medical services (EMS) systems. Methods: We mailed a 20-question survey to 800 police chiefs and sheriffs randomly selected from a list of all law enforcement agencies in the United States. The questions focused on the characteristics of each law enforcement agency, its current level of involvement in providing out-of-hospital emergency medical care, and the characteristics of its associated community and local EMS system. The survey concluded with four statements to assess officer attitudes toward an expanded role in EMS-related activities. We used the χ 2 or Fisher exact test to analyze differences in proportions. The α-error rate was set at .05. Results: Seventeen surveys were returned as undeliverable. Of the remaining 783 surveys, we received 602 responses (77%). Five hundred forty-nine (70.1%) of the respondents were the primary law enforcement agencies in their communities; they make up the final sample. The median number of officers per agency was 12 (range, 1 to 2,623), and the median population served was 6,936 (range, 150 to 1,500,000). Responses indicated that 442 (80.7%) agencies responded to one or more specific types of medical emergencies and 263 (50.3%) provided some level of patient care. Law enforcement officers frequently arrived at the scene of medical emergencies before EMS personnel (81.5%), with a roll-time interval of less than 8 minutes (87.2%). Only 14 agencies (2.6%) used automatic external defibrillators. Fifty-three percent agreed with the statement that EMS-related activities would interfere with their law enforcement duties. However, more than 60% of respondents agreed that law enforcement agencies should be involved in providing emergency medical services for life-threatening emergencies, that their officers would be willing to undertake extra medical training, and that EMS-related activities would improve their public images. Conclusion: Many law enforcement agencies are involved to some extent in providing out-of-hospital emergency medical care, and most of the agencies we surveyed would support additional medical training and new or expanded roles for themselves in EMS systems. Alonso-Serra HM, Delbridge TR, Auble TE, Mosesso VN, Davis EA: Law enforcement agencies and out-of-hospital emergency care. Ann Emerg Med April 1997; 29:497-503.]