Graduate Physicians Research Articles

Caring in English: ESP for Nurses

This paper explores the issue of practitioner-patient communication in the English as a Foreign Language (EFL) context, when the healthcare worker’s first language is not that same as that of the patient. In the English as a Second Language (ESL) setting of countries such as the USA and the UK, this issue concerns international graduate students, physicians, and nurses, who need to acquire the technical language of Medical English for their professional qualifications, along with the psychosocial language of physician-patient relationships. In the EFL setting of countries such as Korea the situation is different, but the need for health staff to be able to communicate with English-speaking patients is increasing, in addition to the need to read professional publications printed in English. This paper suggests therefore that due to factors such as international mobility, globalization, and the spreading of English as a Lingua Franca (ELF), medical colleges and nursing colleges in EFL countries should go beyond the ‘conversation English’ paradigm and offer special Medical English programs for pre-service and in-service healthcare personnel. Furthermore, the curricula of these programs should take a humanistic, patient-centered, task-based approach, promoting and developing sensitive counseling skills in English, in addition to teaching the specific vocabulary and lexis of physician-patient interaction.

The Military Health System: A Community of Solutions for Medical Education, Health Care Delivery, and Public Health

Multiple strategies have been proposed to improve health care in the United States. These include the development of communities of solution (COSs), implementation of patient-centered medical homes (PCMHs), and lengthening family medicine residency training. There is scant literature on how to build and integrate these ideal models of care, and no literature about how to build a model of care integrating all 3 strategies is available. The Military Health System has adopted the PCMH model and will offer some 4-year family medicine residency positions starting in 2013. Lengthening residency training to 4 years represents an unprecedented opportunity to weave experiential COS instruction throughout a family physician's graduate medical education, providing future family physicians the skills needed to foster a COS in their future practice. This article describes our COS effort to synergize 3 aspects of modern military medicine: self-defined community populations, the transition to the PCMH model, and the initiation of the 4-year length of training pilot program in family medicine residency training. In this way we provide a starting point and general how-to guide that can be used to create a COS integrated with other current concepts in medicine.

Acupuncture and PTSD: ‘Come for the Needles, Stay for the Therapy’

Definitive exposure-based therapies may be indicated but are not feasible logistically and are often temporally difficult to deliver. As challenges to provide useful therapeutic strategies to deployed troops limit classical interventions, integrative medicine offers the hope of providing more choices and with those options, the sense of empowerment over one’s own recovery. Post-course surveys reveal that physician graduates of this program use their new skills as frequently for stress symptoms (anger, anxiety, insomnia, agitation, fear, concentration difficulties) as for “kit neck” and “kit back,” the persistent cervical and lumbar musculoskeletal problems caused by wearing heavy protective gear and carrying weapons. Medical acupuncture, or the use of thin needles placed in proximity of tiny neurovascular bundles, releases a cascade of neurotransmitters that affect pain modulation and facilitate better functioning.

U.S. Graduate Medical Education and Physician Specialty Choice

The United States is facing a critical physician shortage. It will only get worse as many more Americans gain insurance coverage under the Affordable Care Act and as additional millions enter the Medicare system. There is a serious concern that the pipeline for the production of the physician workforce is inadequate to meet future needs. It is imperative to continue to monitor the structure and size of this pipeline-the purpose of the research reported here. This descriptive analysis uses data derived from the National Graduate Medical Education Census, which includes reports on the entire population of residents in programs accredited by the Accreditation Council for Graduate Medical Education. Data for the years 2001 to 2010 are reported both on specialties which can be entered directly from medical school or with one preliminary year and on subspecialty residencies and fellowships, which require completion of an earlier residency program. Estimates of the number of new trainees who will practice primary care are provided. In 2010, there were 4,754 residents reported in preliminary programs, 89,142 residents in core specialty and combined specialty programs, and 20,007 in subspecialty and sub-subspecialty programs. Between 2001 and 2010, there was a 13.6% (13,655) increase in all residents. Since 2001, there has been a 6.3% (540) decrease in the number expected to enter primary care. Without a substantially accelerated growth in graduate medical education, the physician workforce will fall short of the nation's needs, and competition for available residency positions will radically increase.

A Milestone in the Milestones Movement: the JGME Milestones Supplement

The definition of the current competencies as well as their optimal assessment has remained controversial.,14,15 The purpose of competency assessment will need to be clarified, beyond formative vs. summative. Multiple agendas derived from different stakeholders may need to give way to the few that directly impact the goal of producing high caliber, independent practitioners.16 Streamlining the various purposes for assessment will be an important issue for the embryonic milestones as well. The reality for most training programs is that the supply of time and money is decreasing. No matter how laudable the goals of valid, reliable, and national educational outcomes, their implementation must be feasible within this reality. Therefore cost-effectiveness will need to be considered in future assessment studies. We must ensure the competent performance of graduate physicians, in the right balance of specialties, at a reduced cost to the nation; the milestones project may well be measured by how well it contributes to these aims. Will milestones advance the field of assessment and mark a turning point in GME? We urge readers to continue to the national conversation that seeks answers to these questions.

The first physicians and hospitals in Kragujevac: The capital of the revived Serbia

After the modern Serbian state was restored under the leadership of Prince Milos, who chose Kragujevac to be the capital, doctors came from abroad, working mainly on military-medical affairs. The first graduate physician who stayed in Kragujevac was Constantinos Alexandridi, MD, and at the time Vito Romita, MD, and Bartolomeo Cunibert, MD, were active as well. The first Serbian doctor, a Serb from abroad who came to Serbia (1826), was Jovan Stejic, MD, and the first Serbian doctor who was born in Serbia, was Stevan Milosavljevic, MD. The organizers of military and civilian medical services at the time were Karel Pacek, MD, and Emmerich Lindenmayer, MD. The first institutions that had characteristics of hospitals ('špitalji') were established in Kragujevac and Pozarevac (1832), but due to the lack of personnel and resources, these institutions as well as others like them had unstable organization. The first military hospital was formed in 1836 on the left bank of Lepenica River, at the edge of the Prince's Palace complex. The first health and medical authorities were established in the structure of government and administration in 1838, and one of the first leaders of these institutions were Jovan Stejic, MD, and Carlo Beloni, MD. Nine district physicians were appointed on August 7th, 1839 and they served for a long time as the highest organs of preventive and curative medicine. Josif Pancic, MD, Ljubomir Radivojevic, MD, Mladen Jankovic, MD, and Filip Tajsic, MD, were among the most deserving for the foundation of the District Hospital in Kragujevac on November 20th, 1860, after many delays. The work of a doctor of that time was not particularly appreciated, their private work provided their primary source of income and medical progress in Kragujevac was mainly related to military health care until the ninth decade of the 19th century.

The “Brain Drain”: Factors influencing physician migration to Canada

Context: Higher income countries have an average physician density of 300 physicians per 100,000 people. In stark contrast, lower income countries have an average physician density of 17 physicians per 100,000 people. A major cause of this discrepancy is the migration of healthcare professionals from lower income to higher income countries, a phenomenon colloquially known as the “brain drain”. Objective: To explore factors that led International Medical Graduate (IMG) physicians to leave their home countries and migrate to Canada. Methods: An anonymous questionnaire with a mix of open- and close-ended questions was sent to 500 randomly selected IMG physicians practicing in Ontario, Canada. Results were analyzed using a mixed-method design utilizing both descriptive statistics and a thematic analysis approach. Results: 39 physicians met inclusion criteria and completed the survey. The majority were 50 years or older, and over 60% were male. The most common reason for emigration from their home country was the socioeconomic and/or political situation, and the most common reason for selecting Canada was family issues. Suggestions for how brain drain could be stemmed fell into three broad categories: 1) more accurate information about lack of opportunities in Canada, 2) more continuing medical education opportunities in home countries, and 3) address issues such as safety and quality of life in home countries. Conclusions: This survey provides insights into the reasons for emigration and immigration for international medical graduates. The results of this survey can assist stakeholders in working toward appropriate and acceptable solutions to the brain drain.

Physician scarcity in underdeveloped areas of Turkey: what do new graduate physicians think?

A sufficient and balanced distribution of physicians plays a key role in access to high quality healthcare services. However, this issue presents serious problems globally. Turkey is currently experiencing physician shortages, with insufficient numbers of physicians in its rural and underdeveloped areas. The objectives of this study were to identify the views of new graduate physicians, prior to employment, on working in underdeveloped areas, in order to discover factors impacting their desire to work in these areas, and to show the actual geographic distribution of physicians in Turkey. This provides the basis for discussing future policies. This study was conducted in Turkey from September to November 2009. All physicians (N=4753) who graduated in 2009 were included in the study via online questionnaires. The response rate was 78%. Variables potentially related to physicians' decisions to work in underdeveloped areas were analyzed using the χ(2) test. To discover the imbalance in geographic distribution of physicians, data collected by the Turkish Ministry of Health (MoH) were re-analyzed. Physician density was calculated for the six zones determined by the MoH according to socioeconomic development. Of the physicians who participated, 52.5% were male and 13.5% expressed a desire to work in underdeveloped areas. Male physicians were more likely to work in underdeveloped areas (17.5% and 9.1%, respectively; p<0.05). There was a significant relationship between desire to work in underdeveloped areas, regions of longest stay and birthplace (p<0.05). Physicians who had lived for a significant period in areas with a high number of underdeveloped cities (Southeastern and Eastern Turkey) and those who were born in underdeveloped cities were more likely to wish to work in these areas. The most influential factor for working in these areas was higher salaries. Physicians who have particular socioeconomic backgrounds such as rural origin and lower background-family income are more likely to have be motivated to work in underdeveloped areas. They are also more likely to accept work in these areas if financial and non-financial opportunities are provided. The findings of this study provide guidance for those revising health workforce policies.

State of psychiatry in Denmark

Danish psychiatry has gone through profound changes over the past two to three decades, reducing inpatient-based treatment and increasing outpatient treatment markedly. The number of patients treated has almost doubled, and the diagnostic profile has broadened, now including a substantial number of common mental disorders, in particular depression and anxiety. Furthermore, ‘new’ diagnostic groups are represented in the treatment statistics with steeply increasing incidences, e.g. attention deficit hyperactivity disorder (ADHD) and eating disorders, especially in the outpatient part of the statistics. Over the same 30 years, the number of available beds has been reduced by 60–70%; however, as the length of stay of inpatients has been reduced markedly, the departments are still able to treat a high number of patients. The financial budgeting of psychiatry is not increasing equivalently to the somatic specialities, handicapping development in psychiatry. Action has been taken to increase research activity in psychiatry. This is facilitated by an increasing interest among medical students and young graduate physicians attracted by the neuropsychiatric paradigm, rapidly implemented in Danish psychiatry.

Physician Assistant Program Characteristics and Faculty Credentials on Physician Assistant National Certifying Exam Pass Rates

Determination of the ideal terminal degree for physician assistants (PAs) and academic preparedness of PA educators have received much attention in recent years. This investigation, completed in 2009, sought to describe the current state of PA training programs, specifically regarding Carnegie classification, percent conferring master's degrees, number of full-time faculty, percent of faculty--both principal and other full-time faculty--with doctoral degrees, student-to-faculty ratio, and first-time graduate Physician Assistant National Certifying Exam (PANCE) pass rates. A secondary aim was to determine if any of these variables predict PANCE pass rates. This study combined existing data obtained from multiple Internet resources including PA program websites and the PAEA Faculty Directory to determine the number of faculty, faculty credentials, number of students, and PANCE reports. Faculty members were categorized by highest degree attained. Linear regression was used to examine whether any of the programmatic variables were significant predictors of PANCE pass rates. Two of four predictors were significant--whether the program conferred a master's degree (Beta = 0.54, t = 7.25, P = .001) and student-to-faculty ratio (Beta = -0.21, t = 2.63, P = .01). Mean number of full-time faculty per training program was eight (SD = 4, range = 2-36). The mean percent of full-time faculty members with doctorates per training program was 17.6% (SD = 17.7%, range = 0-80%). These results, if replicated, suggest that if a program is seeking to increase its student performance on the PANCE, it may be more helpful to focus resources on improving student-to-faculty ratio, regardless of whether or not the faculty are doctoral level.

Effectively Training the Hospice and Palliative Medicine Physician Workforce for Improved End-of-Life Health Care in the United States

The widening gap between the demand for palliative care services and the supply of trained palliative care professionals has resulted in considerable end-of-life distress for patients. Without formal training in palliative medicine and end-of-life symptom management, physicians in the United States are less equipped to competently address seriously ill and dying patients' medical, emotional, and spiritual needs. Recent attempts within graduate medical education training deliberately seek to prepare a critical mass of physicians as the new hospice and palliative medicine workforce in the United States. In addition, healthcare reform proposals may re-define the National Health Service Corps (NHSC) post-graduate training over the next five years and the Hospice Medicare Benefit altogether. Healthcare policy options include steady changes at multiple levels of medical training -namely, medical school curriculum mandates, requiring all graduate physician residency training to foster patient-centered communication skills and discussions about advanced directives, and instituting palliative medicine proficiency Continuing Medical Education (CME) requirements for all states' medical licensing boards. Attracting qualified physicians to serve patients at the end of life, innovative medical school loan repayment programs and scholarships will also foster excellence in the field of hospice and palliative medicine. Correcting our current paucity of formal training in palliative medicine better utilizes hospice and restores patients' dignity at the end of life.

Nature and nurture in the family physician's choice of practice location

An understanding of the contextual, professional, and personal factors that affect choice of practice location for physicians is needed to support successful strategies in addressing geographic maldistribution of physicians. This study compared two categories of predictors of family practice location in non-metropolitan areas among undergraduate medical students: individual characteristics (nature), and the rural program component of their training program (nurture). The study aimed to identify factors that predict the location of practice 2 years post-residency training and determine the predictive value of combining nature and nurture variables using administrative data from two undergraduate medical education programs. Databases were developed from available administrative sources for a retrospective analysis of two undergraduate medical education programs in Canada: Université de Sherbrooke (UdeS) and University of British Columbia (UBC). Both schools have a strong mandate to evaluate the impact of their programs on physician distribution. The dependent variable was location of practice 2 years after completing postgraduate training in family medicine. Independent variables included individual and program characteristics. Separate analyses were conducted for each program using multiple logistic regression. The nature and nurture variables considered in the models explained only 21% to 27% of the variance in the eventual location of practice of family physician graduates. For UdeS, having an address in a rural/small-town environment at application to medical school (OR=2.61, 95% CI: 1.24-6.06) and for UBC, location of high school in a rural/small town (OR=4.03, 95% CI: 1.05-15.41), both increased the chances of practicing in a non-metropolitan area. For UdeS the nurture variable (ie length of clerkship in a non-metropolitan area) was the most significant predictor (OR=1.14, 95% CI: 1.067-1.22). For both medical schools, adding a single nurture variable to the model using only nature variables significantly increased the amount of variation accounted for in predicting location of practice in non-metropolitan areas. Aspects of graduates' rural background increase the chances of practicing in a non-metropolitan area. A third-year clerkship experience in a rural area may increase the chances of non-metropolitan practice. Although the total variation predicted by both nature and nurture variables in this study was small, adding a nurture variable significantly improves the prediction of individuals who will practice in a non-metropolitan area. The fact that total variation predicted was small is likely to be due to the limitations of the administrative databases used. Different strategies are being implemented in each university to improve the quality of existing administrative databases, as well as to collect relevant data about intent-to-practice, training characteristics, and the attitudes, beliefs and backgrounds of students.

Georgetown University School of Medicine

Georgetown University School of Medicine

Columbia University College of Physicians and Surgeons

Columbia University College of Physicians and Surgeons

Reform in medical education

There is a worldwide concern about the existing curricula of Medical Education (ME) and its effectiveness in producing capable graduates. The current wonder is about the outcome of medical schools conducting their educational programs based on such curricula and whether they are competent enough to meet today's health problems and disease control. Knowledge, skills and attitude of the graduates compose the extent of their competence as physicians are the elements to be considered in the development of medical curriculum. Despite the fact that these essential elements of education are well realized by most academicians for almost a century, today the numbers of institutions that have incorporated these elements in their curriculum development are not very many. The majority of medical schools worldwide still lack a well defined Reform in their medical education curricula that can cover the abovementioned domains of effective medical education. Quite number of national, regional and international congregations emphasiz(ing)ed a serious action to be taken on the issue of Reform in ME. According to the currently available theories in education and effective learning the outcome of the educational process should posse two essential characteristics namely: and LIFE LONG knowledge. The Quality Assurance (QA) of the learning process demands planners and designers of Educational Programs (EPs) to mastery the knowledge of education and to be more familiar with the elements that make the learners firmly informed, skilled enough and confident to make the right decisions. Learner centered EPs provide the opportunity for paced thinking strategies that help the learner to develop thinking skills hence better conceptualization of the learning issue(s). Innovative approaches in ME like Organ Based (OB) or Clinical Presentation (CP) curricula are among methods utilized in the Reform practice. These new approaches rely heavily on the Horizontal and Vertical integration of basic and clinical contents of the EP. Add to these issues the emphasis on the Social Accountability of medical schools and the way this is translated into practical and cognitive contexts. The latter will add to the quality of the graduate physicians as major players in the society's health status and promotion. It should be emphasized that reform in ME is a necessity today yet the same time a task that demands heavy efforts. An outcome based ME program and curriculum requires the gathering of large number of staff in both basic medical and clinical sciences who should be well informed in the theories of effective learning and education in order to compose a curriculum that can produce physicians who are well equipped with medical knowledge and at the same time have promotional impact on individual and society's health.

Money for nothing?

One of the stages of medical training is the residency programme. Hosting institutions often claim compensation for the training provided. How much should this compensation be? According to our results, given the benefits arising from having residents among the house staff, no transfer (either tuition fee or subsidy) should be set to compensate the hosting institution for providing medical training. This paper quantifies the net costs of medical training, defined as the training costs over and above the wage paid. We jointly consider two effects. On the one hand, residents take extra time and resources from both the hosting institution and the supervisor. On the other hand, residents can be regarded as a less expensive substitute to nurses and/or graduate physicians, in the production of health care, both in primary care centres and hospitals. The net effect can be either positive or negative. We use the fact that residents, in Portugal, are centrally allocated to National Health Service hospitals to treat them as a fixed exogenous production factor. The data used comes from Portuguese hospitals and primary care centres. Cost function estimates point to a small negative marginal impact of residents on hospitals' (-0.02%) and primary care centres' (-0.9%) costs. Nonetheless, there is a positive relation between size and cost to the very large hospitals and primary care centres. Our approach to estimation of residents' costs controls for other teaching activities hospitals might have (namely undergraduate Medical Schools). Overall, the net costs of medical training appear to be quite small.

Protecting an Endangered Species: Training Physicians to Conduct Clinical Research

The Program in Clinical Effectiveness (PCE) at Harvard School of Public Health is a postgraduate program emphasizing clinical research. The authors sought to evaluate the research careers of physician graduates and to determine correlates of National Institutes of Health (NIH) grant funding. In 2006, all 1,489 graduates from 1986-2005 were sent a 48-item survey that collected information on demographics, program experience, chosen career path, grant awards, and research pursued postprogram. Reported NIH grants were verified on the NIH Computer Retrieval of Information on Scientific Projects Web site. Cox proportional hazard regression was used to determine participant and program features associated with NIH grant funding. Overall, 994 of the 1,365 located graduates (73%) responded to the survey. Graduates pursued research in the following areas: 437 respondents (44%) pursued clinical trials, 537 (54%) pursued epidemiology, and 408 (41%) pursued health services research. A total of 156 respondents (24%) were principal investigators on an NIH grant. Correlates of receiving NIH grant funding included age less than 40 years at time of program enrollment (hazard ratio [HR] 1.87, CI 1.03, 3.41), generalist status (HR 1.57, CI 1.14, 2.16), and publishing research begun as course projects (HR 1.65, CI 1.19, 2.31). Gender, academic status at enrollment, ethnicity, tuition sponsorship, and earning an advanced degree were not associated with receipt of NIH grant funding. Physicians who enrolled in the PCE at an early age and generalist physicians were particularly successful in establishing careers as clinician-investigators. Programs such as the PCE can help to sustain the workforce of physician-investigators.

Addressing the primary care physician shortage in an evolving medical workforce

BackgroundPrimary care physicians have been shown to play an important role in the general health of the communities in which they serve. In spite of their importance, however, there has been a decrease in the number of physicians interested in pursuing primary care fields, while the proportion of specialists continues to increase. The prediction of an overall physician shortage only augments this issue in the US, where this uneven distribution is particularly evident. As such, serious effort to increase the number of practicing primary care physicians is both necessary and beneficial for meeting this country's health care needs.DiscussionThere are several factors at play which contribute to the decrease in the number of practicing physicians in primary specialties. Lifestyle concerns, such as schedule and income, as well as the lack of prestige associated with this field seem to be among the most prevalent reasons cited for the diminishing interest. Multifaceted concerns such as these, however, are difficult to adequately invalidate; doing so would not only require a great deal research, but also a good deal of time – a resource which is in short supply given the current physician shortage being faced. Thus, a more immediate solution may lie in the increased recruitment and continued support of those individuals who are already associated with primary care service. This is particularly relevant given the Association of American Medical College's goal of increasing medical school enrollment by 15% over the next 10 years.Several groups have been shown to be large contributors to primary care in the US. Here, we focus on three such groups: minority students, International Medical Graduates (IMGs) and Osteopathic Physicians (DOs). Although these groups are highly diverse individually, they all share the distinction of being underutilized in regard to the current primary care shortages faced. Thus, through more fully accentuating these resources, some of the problems being faced by this nation's healthcare industry may be ameliorated.SummaryTo improve our nation's heath and healthcare, it is our opinion in this commentary that we must determine a comprehensive approach to increase the number of practicing physicians in primary care which may include minority and underserved medical student recruitment, and acceptance of international medical graduates and osteopathic physicians. Although overtime some of the more underlying causes of primary care under-representation must be addressed, these previous options may offer more immediate aid, while recognizing and augmenting populations who already contribute greatly to our nation's medical system.

The illusion of minority status

It is common to think in terms of ‘minority’ admissions when considering displaced Natives (First Nations peoples) or populations who capture lower percentages of total physicians when compared with their percentage of the population. In America, the African American, rural, Hispanic, and lower income origin physicians are all ‘underrepresented’. Each group captures less than 10% of total physician graduates. The use of the terms ‘minority’ or ‘diverse’ should be recognized as a construct of those shaping workforce studies. It is a perception and a series of observations, typically from past tradition or based on majority status.

The Net Costs of Medical Training

One of the stages of medical training is the internship, where doctors-to-be (interns) face the real world of medical practice for the first time, under the supervision of a graduated physician. According to the career choice, the internship takes place at a provider of primary or secondary care. Hosting institutions often claim compensation for the training provided. The goal of this study is to identify the impact of the presence of the interns on the costs of providing care by the hosting institutions. We contribute by jointly considering several important effects. On the one hand, interns are a fixed exogenous factor on the beginning of their learning curve, taking extra time and resources from both the hosting institution and the supervisor. On the other hand, interns can be regarded as a less expensive substitute to nurses and/or graduate physicians, in the production of health care, both in primary care centres and hospitals. Therefore, interns are a specific input that hosting institutions take into account when organizing health care delivery. The net effect can be either positive or negative. The data used comes from Portuguese primary care centres and hospitals. Regression analysis was used to estimate their impact on the cost structure. The results point out to a negligible impact of the interns in the total cost structure of primary care hosting institutions. In the case of hospitals, the presence of interns represents an extra cost to the institution, above the yearly wage. Furthermore, there is a positive relation between dimension and cost to the hospital. Therefore, net training costs (defined as the costs incurred by the hosting institution above the wage paid) seem to be largely compensated by the activity performed by interns, and training compensations, over and above the interns salary should be relatively minor.