Wisconsin's Program Research Articles

64 COMPARING UROLOGY RESIDENT AND FACULTY PERCEPTIONS OF SURGICAL SKILLS, LEARNING NEEDS, AND GENERAL SURGERY ROTATIONS FOLLOWING THE GENERAL SURGERY INTERNSHIP

INTRODUCTION AND OBJECTIVES: Urology program’s quality is in part measured by the graduating residents’ operative experience and duty hours compliance. This emphasis creates conflict between attaining the maximum operative experiences while being duty hour complaint and providing appropriate operative, clinical, and didactic education. In July, 2009, the Residency Review Committee in Urology implemented a minimum standard for operative cases that acts as a metric of resident competence. We set out to evaluate how the prior operative percentiles and national averages compare to the new minimum case volume standards. METHODS: An operative time study was developed using the Medical College of Wisconsin program figures and the ACGME 2008 09 Urology National Resident Report to calculate task time for registered surgical procedures. The urologic cases during a 6 month period (Jan. ’08 June ’08), were recorded to establish operative time logs. The operative times were used to calculate the total surgical times for the new minimum standards and the prior national averages. These results were then compared. RESULTS: Analysis of surgical time demonstrated that based on the 2008 09 National Average data, the 10th, 30th and 50th percentiles resulted in time consumption of 4,181 hours, 4,991 hours, and 6,430 hours respectively. The surgical time consumed with the new minimum standards was 4,282 hours. Thus, the minimum standards fall between the 10th and 30th percentiles. CONCLUSIONS: The new ACGME minimum standards reflect a reasonable baseline of operative experience. By not concentrating on attaining high volume case logs, an increase in available resident time may allow for diversification of other aspects resident education.

Harvesting the Lessons of State Health Policy

Harvesting the Lessons of State Health Policy

A Review of Scientific Teaching

Review of: Scientific Teaching; 5th printing; Jo Handelsman, Sarah Miller, and Christine Pfund; (2007). Supported by the Howard Hughes Medical Institute Professor Program and The Wisconsin Program for Scientific Teaching. W.H. Freeman and Company, New York, in collaboration with the Roberts and Company Englewood, Colorado. 184 pages.

Implementing routine testing for severe combined immunodeficiency within Wisconsin's newborn screening program.

Severe combined immunodeficiency (SCID) is the result of genetic defects that impair normal T-cell development. SCID babies typically appear normal at birth, but acquire multiple life-threatening infections within a few months. Early diagnosis and treatment with a bone-marrow transplant markedly improves long-term outcomes. On January 1, 2008, the newborn screening (NBS) program in Wisconsin became the first in the world to routinely test all newborns for SCID. A realtime quantitative polymerase chain reaction assay measures T-cell receptor excision circles (TRECs), which are formed during the maturation of normal T-cells. A lack or very low number of TRECs is consistent with T-cell lymphopenia. The development and validation of the TREC assay and the results of the first year of screening have been published. This article describes the process used to add SCID to the NBS panel, the establishment of follow-up capacity, and the integration of SCID screening into routine NBS workflows. The development of this expanded NBS program is described so that other states might benefit from the processes used in Wisconsin.

The Synergy of Class Size Reduction and Classroom Quality

A contextual approach to understanding class size reduction includes attention to both educational inputs and processes. Based on our study of a class size reduction program in Wisconsin we explore the following question: How do class size reduction and classroom quality interact to produce learning opportunities in early elementary classrooms? To address this question, we analyze data from 3 years of fieldwork in 27 classrooms in 9 schools implementing a class size reduction reform. Data generation included multiple ethnographic observations and interviews with teachers and principals, administration of the Classroom Assessment Scoring System, document and artifact collection, and analyses of school‐level standardized test scores. We present multiple vignettes to illustrate that class size reduction provides opportunities that can be activated by organizing and implementing high‐quality classroom practices. We argue that high‐quality classrooms combined with class size reduction contexts create a synergy for learning.

Learn the Basics of Energy Efficiency

This article discusses a public‐private partnership program developed by the state of Wisconsin called Focus on Energy that offers energy information and services to utility customers throughout Wisconsin. A wide range of initiatives were integrated in the program that can be used by any utility to encourage energy efficiency and use of renewable energy, enhance the environment, and ensure a future energy supply. The specific program objective was to develop an assessment approach that provides utility owners with tools for improvement. The article discusses approach methodology, including the following components: review facilities and recommend improvements; describe appropriate modifications; estimate energy savings; estimate modification costs; calculate the payback in energy savings; help implement the project; and, identify opportunities. Challenges to attaining energy efficiency are presented, along with results of the Wisconsin program. The article provides an insert on maintaining energy control.

Sex-specific differences in chromosome-dependent regulation of vascular reactivity in female consomic rat strains from a SS × BN cross

High-throughput studies in the Medical College of Wisconsin Program for Genomic Applications (Physgen) were designed to link chromosomes with physiological function in consomic strains derived from a cross between Dahl salt-sensitive SS/JrHsdMcwi (SS) and Brown Norway normotensive BN/NHsdMcwi (BN) rats. The specific goal of the vascular protocol was to characterize the responses of aortic rings from these strains to vasoconstrictor and vasodilator stimuli (phenylephrine, acetylcholine, sodium nitroprusside, and bath hypoxia) to identify chromosomes that either increase or decrease vascular reactivity to these vasoactive stimuli. Because previous studies demonstrated sex-specific quantitative trait loci (QTLs) related to regulation of cardiovascular phenotypes in an F2 cross between the parental strains, males and females of each consomic strain were included in all experiments. As there were significant sex-specific differences in aortic sensitivity to vasoconstrictor and vasodilator stimuli compared with the parental SS strain, we report the results of the females separately from the males. There were also sex-specific differences in aortic ring sensitivity to these vasoactive stimuli in consomic strains that were fed a high-salt diet (4% NaCl) for 3 wk to evaluate salt-induced changes in vascular reactivity. Differences in genetic architecture could contribute to sex-specific differences in the development and expression of cardiovascular diseases via differential regulation and expression of genes. Our findings are the first to link physiological traits with specific chromosomes in female SS rats and support the idea that sex is an important environmental variable that plays a role in the expression and regulation of genes.

Learning the Hard Way

Learning the Hard Way

Moving from Medieval Apprenticeships to Reflective Practice

Moving from Medieval Apprenticeships to Reflective Practice

Virtual Schools: An Ethical Option

An odyssey of civil rights in education has been taking place in America over the last 16 years. Theschool choice issue has heated up in the last decade and a half, traversing the years from 1990, withthe first urban school choice program in Wisconsin, to 2006, with a suit filed against Los AngelesUnified Schools for lack of cooperation in informing parents of educational options available. The coreargument is that parents, not government, should have the primary responsibility and economic powerto determine where and how their children should be educated. This is a basic ethical, philosophical,and human rights concern, and is an essential American freedom.

Landowner Satisfaction with the Wetlands Reserve Program in Wisconsin

We evaluated ecological monitoring data and landowner perceptions to the federally funded Wetlands Reserve Program (WRP) in a three-county region in Wisconsin. We surveyed landowner satisfaction, involvement, participation, and use of the WRP restoration sites. We found that landowners are satisfied with the overall program (mean, 3.6 +/- 0.2 [SE], on a scale of 1-5, with 5 being completely satisfied). WRP restorations significantly increased the area of wetland within the sites surveyed, the increase was primarily of fresh meadow (736.32 ha after restoration). Satisfaction is related to landowner participation during restoration and to the economic incentives provided by the WRP, Landowner satisfaction and the number of plant communities after restoration are unrelated to each other or to restoration and easement costs per hectare. Survey participants recommended some changes to the WRP, including a reduction in the tax rate of land enrolled in the WRP, approval for permanent deer stands, and increased communication with WRP officials during the restoration. Monitoring information collected for WRP restoration sites does not allow assessment of whether WRP sites are functionally equivalent to natural sites. We suggest that the WRP require a more rigorous monitoring program, including guidelines for invasive species control. Managers should also encourage collaborations with external researchers and consider restorations within an experimental framework.

Concept Mapping in Pulmonary Physiology Using Pathfinder Scaling

This three-part article begins with a brief presentation of a framework that describes different approaches to conduct and report research on expert knowledge. The framework contrasts direct vs. indirect approaches and provides examples of each. Second, the article gives a detailed description of the methods and results of three concept mapping studies in pulmonary physiology that employ Pathfinder scaling, an indirect approach. The studies derive concepts maps for a variety of faculty experts individually and in groups. Two of the studies focus on changes in students' concept maps of the pulmonary physiology concepts as a result of instruction. Changes are gauged in terms of the degree to which students' concept maps approximate instructors' concept maps due to educational interventions. An index of student-instructor concept map similarity is also correlated with student performance on final examinations. The article concludes by articulating several "next steps" in the Feinberg Northwestern and Wisconsin program of health sciences education research on concept mapping using Pathfinder scaling.

Newborn screening for cystic fibrosis: ensuring more good than harm

Newborn screening for cystic fibrosis: ensuring more good than harm

Co-Benefits from Carbon Sequestration in Forests: Evaluating Reductions in Agricultural Externalities from an Afforestation Policy in Wisconsin

<i>Besides climate change mitigation, policies encouraging the conversion of agricultural land to forest may generate additional environmental benefits. We estimate the reductions in agricultural externalities (soil erosion, nitrogen, and atrazine pollution) from an afforestation program in Wisconsin. Existing benefits estimates are used to quantify the value of reduced soil erosion and some benefits from enhanced wildlife habitat. These values are the same order of magnitude as the costs of the carbon sequestration policy, indicating that the co-benefits of forest carbon sinks are an important factor for countries to consider in designing a portfolio of climate mitigation strategies.</i> (JEL Q23)

Managed long-term care: limits and lessons.

In the mid-1990s, states began to reduce their reliance on commercial health plans in the primary and acute care markets. At the same time, however, many states are for the first time encouraging these plans to participate in long-term care programs. The evidence suggests, however, that commercial health plans will not provide a quick cure to the long-term care system. At the same time, several states have managed long-term care initiatives that do not rely on commercial health plans but that do an excellent job of case management and that also seem to be among the national leaders in offering home and community-based services. Oregon provides one example, but so does the traditional managed long-term care system in Arizona and the Community Options Program in Wisconsin. The current efforts in Arizona and Wisconsin to abandon these models and to embrace competition may therefore be a mistake.

Optimizing Adherence to Pharmaceutical Care Plans

With increasing drug prices in the past decade, affordability and medication adherence are a growing concern for near-poor older adults, especially for those who are not receiving Low-Income Subsidy in Medicare Part D. SeniorCare is a pharmaceutical assistance program in Wisconsin for near-poor older adults, providing comprehensive prescription coverage with flat copayments.To evaluate five-year trends in financial hardship and medication adherence and to examine factors associated with these outcomes in SeniorCare members.SeniorCare program enrollment and pharmacy claims data from 2014 to 2018 were used. The study population was near-poor older adults in SeniorCare with annual family income ≤200% of the federal poverty level. Financial burden was assessed using the proportion of total annual out-of-pocket costs to total annual income. Medication adherence was assessed by adapting the measures endorsed by the Pharmacy Quality Alliance and National Quality Forum. Descriptive statistics and independent t-tests were used to evaluate the trends, and multivariate logistic regressions were conducted to examine factors associated with financial burden and medication adherence.From 2014 to 2018, mean annual out-of-pocket costs per member declined by 3.7% (p < 0.001) for all drugs, while those for specialty drugs increased by 31.2% (p < 0.05). Around 3.3% spent more than 5% of their income for prescription drugs in 2014, which decreased to 2.4% in 2018 (p < 0.001). The proportions of adherent patients increased from 78.1% to 81.2% (p < 0.001) for diabetes medications (excluding insulins), from 77.3% to 79.5% (p < 0.001) for statins, and from 79.8% to 80.8% (p < 0.05) for RASA. Members subject to a $500 annual deductible were more likely to experience high financial burden (adjusted odds ratio (AOR) = 1.677, p < 0.001) and less likely to be adherent to diabetes medications (AOR = 0.484, p < 0.001).The near-poor older adults enrolled in Wisconsin SeniorCare program had low financial burden and good medication adherence within the program.

146 The Master Gardener Program in Wisconsin

The Master Gardener Program in the state of Wisconsin is growing rapidly and has been in existence since the late 1970s. There are several aspects of our program(s) that make us unique. First, we are one of the very few states to service all counties within the state, not just our heavily metropolitan areas. Second, we have two major program types along with some unique county programming. We have the basic Master Gardener Program, which covers the major aspects of horticulture—this gives the learner 36 h of training with an expectation of 36 h of volunteer work in return. We now offer the general program in districts (extension has six clusters of counties in Wisconsin)—such that the counties within a district (usually around 16) will have the chance to offer the course at least once every 3 years. That is because the general course is offered once a week (3 h in the evening) for 12 weeks; and thus the basic course is offer spring and fall. If some of the counties within a particular district do not choose to participate, then other counties around the state can take part. Most of the 12 programs are high quality 2-h video productions followed by a 1-h ETN program, which is like a big conference call—everyone has an interactive session with the specialist who developed the video. The specialized program is a series of four 36-h (six 6-h days) training over a 4-year period, which covers flowers, fruit, vegetables, and turf, along with trees and shrubs. This program is offered in our four largest metropolitan areas and is still done all by live lecture. Finally, we require update training for our MGs if they want to continue to be members in good standing (wallet-size cards are issued). This involves 10 h of specified educational opportunities and 10 volunteer hours per year. We also have a day-long educational conference each spring as well as cooperating with Iowa and Minnesota to offer a 2-1/2 day workshop on the alternating years of the international conference. This is hands-on training, held usually the end of June, and rotates among the three states. We now have a stong MG association which has nonprofit status and is an integral partner with us here at the university. Not only do MGs receive members in good standing cards annually, they also receive certificates for 150, 250, 500, 750, and 1000 h of service as well as a 10-year certificate.

Towards a Comprehensive Therapy for Schizophrenia

Back to table of contents Previous article Next article Letter to the EditorFull AccessTowards a Comprehensive Therapy for SchizophreniaMark R. Munetz, M.D.Mark R. MunetzSearch for more papers by this author, M.D.Published Online:1 Apr 1998https://doi.org/10.1176/ps.49.4.540AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Towards a Comprehensive Therapy of Schizophrenia presents the written versions of papers from the Fourth International Schizophrenia Symposium held in Bern, Switzerland, in September 1993. As such it has all the strengths and weaknesses of a somewhat dated, multiauthor work. On the strengths side are its array of internationally prominent contributors from Switzerland, Germany, and the United States and its broad biopsychosocial focus. It reviews psychosocial treatment approaches to schizophrenia that are apparently well known in German-speaking countries but are likely to be less familiar to the English-reading audience of this edition. On the weaknesses side is a marked variability in the readability and depth of the different sections and specific chapters.After an introductory section that includes two chapters relating chaos theory to schizophrenia, the subsequent four sections each focus on a different aspect of intervention related to a stress-vulnerability-coping-competence model for schizophrenia. Sections address biologic vulnerability, cognitive vulnerability, stressors and social supports, and coping strategies aimed at relapse prevention.The most successful chapters are those that summarize the state of knowledge in a particular area and then raise, and begin to answer, the key research questions remaining to be addressed. Chapters by Green and associates on cognitive remediation, Bellack on social skills training, and Test and associates on Wisconsin's Program of Assertive Community Treatment all do so quite successfully. Chapters that are less successful describe more narrow areas of research and are either too obscure for the general reader or too limited in scope to be helpful as a state-of-the-art review. Most disappointing along these lines are the two chapters in the biologic-vulnerability section that focus on experience with risperidone.The final two chapters of the book remind the reader of the humanity of people with schizophrenia. The chapter by John Strauss entitled “Processes of Healing and the Nature of Schizophrenia” is a moving reminder to us all that we are working in a human science. As we move toward a model that emphasizes recovery from serious mental illness, Strauss helps us understand how such improvement may come about. Having spent extensive time with patients who have substantially improved, Strauss notes first that all of these patients talk about, in essence, a “reintegration of the self,” a “sense of finding who one is,” and in some way resolving conflicting goals and values. Second, he observes the importance of relationships in the recovery process. He points out the disturbing reality that patients “testify to how crucial—and how rare—it is to find someone, especially a doctor, who took me seriously.”Although this is not a book I found easy to read from cover to cover, Strauss' chapter, along with several excellent overviews of effective, complementary psychosocial interventions for schizophrenia, does make it a worthwhile reference for the researcher or clinician interested in a comprehensive approach to the treatment of schizophrenia.Dr. Munetz is chief clinical officer for the Summit County (Ohio) Alcohol, Drug Addiction, and Mental Health Services Board in Cuyahoga Falls and associate professor of psychiatry at the Northeastern Ohio Universities College of Medicine.edited by Hans D. Brenner, Wolfgang Böker, and Ruth Genner; Seattle, Hogrefe & Huber Publishers, 1997, 283 pages, $49 FiguresReferencesCited byDetailsCited ByNone Volume 49Issue 4 April 1998Pages 540-540 Metrics History Published online 1 April 1998 Published in print 1 April 1998

Do Physician Executives Make a Difference?

The role of the physician executive was effectively and accurately highlighted in 1989 at a symposium sponsored by the Association of University Programs in Health Administration (1989), and the article by Barbara LeTourneau and Wesley Curry offers a timely, important update on this issue. I fully agree with most of what they have written-including their basic thesis that the field is growing both quantitatively and qualitatively, and that this growth will potentially add value to the performance of the healthcare system in the United States. Let me instead comment on several aspects where I draw different, perhaps sharper, conclusions. The Definition of the Profession There is evidence that the numbers and types of physician executives are increasing, but what exactly qualifies one as a physician executive? Membership in the American College of Executives is one indication, and its growth rate is impressive, but membership is open to whomever chooses to join. In the Physician Characteristics and Distribution in the United States, the American Medical Association listed 15,684 physicians in 1994 whose primary professional activity was in management, 2.53 percent of all active physicians. The percentage, which was 3.9 percent in 1970, declined from 2.8 percent in 1980 to 2.6 percent ten years later. Many more physicians indicate administration as a secondary or temporary activity, as shown in Table 1 (Kindig 1991). Based on this data, it was estimated that there were 27,635 full-time equivalent physician executives in 1986, an increase of 38% since 1977, mainly in younger age groups; these figures clearly need to be updated to reflect current trends and practices. Is the Executive's Role Unique? The authors seem unclear on this point, using this term several times, but they also indicate that others in the health management team can do many of the tasks as well. Certainly, we can all think of nonphysicians-managers or other clinicians-who excel at different components of the management role. I prefer to think in terms of comparative advantage: In a differentiated management team, the physician executive brings an important specialized expertise to the management table, as do others in, say, finance and marketing. I like Paul Ellwood's idea that medical management is a clinical science, based on such core competencies as information systems, decision theory, social psychology of organized care, and health promotion and disease prevention (Ellwood 1989). Add to these the competencies of managing other physicians and ethics, and an important role, full of potential, begins to emerge. Is Clinical Experience Required? To this question I clearly answer yes, because much of the physician executive's comparative advantage comes from clinical experience-not primarily for the respect of physician peers, as the authors suggest-but mainly the deep and experiential understanding of the care process, of the physician-patient relationship, of physician values and culture, of the hidden subtleties of ethics, and of the difficulty of the quality/cost trade-off at the individual patient level. This is why the American Board of Medical Management requires clinical board certification and substantial clinical experience in order to sit for the board exam, and why the Administrative Medicine Program in Wisconsin has adopted a similar standard for admission. The comparative advantage disappears if the physician executive has only-or has nevercompleted residency training, even if that manager has an MBA. For this reason I have reservations about the authors' suggestion for management training for students and residents. Some understanding of health economics, health outcomes and quality, and trends in managed care is certainly vital for those still in training, but more indepth managerial training should wait for this second career in management after an initial one in clinical practice. …

RURAL NONPOINT SOURCE POLLUTION CONTROL IN WISCONSIN: THE LIMITS OF A VOLUNTARY PROGRAM?1

ABSTRACT: This paper examines the relationship between best‐management practices, institutional needs, and improved water quality within the watersheds of Wisconsin's program for controlling rural nonpoint source pollution. The first section describes the federal requirements for state nonpoint source programs and the legislative and management methods the state of Wisconsin uses to put those requirements into practice. The emphasis of the paper, described in the second section, is the institutional difficulty in evaluating the success of a large, integrated water quality program. Measurements which are investigated include (1) watershed water quality before and after implementation of BMPs; (2) program participation as measured by eligible vs. participating landowners, BMPs considered necessary vs. BMPs implemented, or dollars allocated to the NPS program vs. dollars expended; and (3) institutional goal coordination and management effectiveness. It is found that, despite the size and sophistication of Wisconsin's NPS program, there is little if any improvement in ambient water quality in these watersheds, probably because of a general lack of adequate participation in this voluntary program.