Specialty Status Research Articles

You are only as good as your data: Developing an electronic picc database

The elevation of vascular access to specialty status mandates an increased responsibility for the demonstration of clinical quality and evidence of effectiveness. Although patient outcomes have always been important, the need to capture, qualify, and quantify outcomes has become essential to survival in today's competitive healthcare environment. Data collection and interpretation are integral steps in the ongoing process of outcomes analysis. Standardization in the definition of outcome indicators is imperative for accurate analysis and trending of performances that represent best practice. This article demonstrates how the development of an electronic PICC database can assist the practitioner in providing the evidence for evidence-based practice.

Physician Recruitment into Geriatrics—Further Insight into the Black Box

Physician Recruitment into Geriatrics—Further Insight into the Black Box

Gender Impact on the Socioprofessional Identification of Women Dentists in Bulgaria

Women comprise 73 percent of all dentists in Bulgaria. Almost all of them started their careers as salaried, and now they are self-employed. The purpose of this study was to show how female dentists in Bulgaria met the challenges of the social and health reforms during the period of transition from totalitarian to democratic rule. A field sociological survey was carried out between October 1996 and June 1997, involving a sample of 842 dentists. The questionnaire was designed to give information on dental demography trends, pattern of participation and practice of female dentists, and their career development. The data were treated statistically using an SPSS package. Results show that for the period 1991-96 women dentists owned more than 50 percent of the newly opened private practices in Bulgaria. They were more interested in improving their qualifications and more successful in obtaining specialty status than male dentists. Dentists in Bulgaria by the late 1990 s, with no gender difference, tend to identify themselves as liberal practitioners within the pluralistic model of dental services delivery. The volume of services delivered and profile of women in professional practice and their social and professional mobility are highly competitive, despite the growing problems of maternity leave coverage and funding to re-enter the profession.

Is Rural Nursing a Specialty?

Like many other nurses who work in rural and remote areas, I never considered myself a specialist. That is until several years ago when I started to teach an undergraduate course in rural nursing. As I immersed myself in the little bit of rural literature that was available at the time, I recognized that I was becoming increasingly convinced that indeed rural nursing is a specialty. I remember feeling really pleased that finally someone somewhere understood that nursing in rural sites was not merely the poor relation of urban nursing, but something that required special knowledge and skill. From that time to the present, I have proudly pointed out this fact to students. In Canada, however, rural nursing is still struggling to become recognized as a distinct entity. This caused me to consider the obstacles that we still face on the road to specialty status.

Pain Relief and Palliative Care in Hong Kong

Palliative care started in Hong Kong in 1982. It gradually established an increasingly important role in cancer care. Hong Kong is fortunate because analgesic drugs and expertise from various disciplines and specialties in pain management are readily available. A holistic approach to pain management has been adopted; various dimensions of pain are assessed and managed, and outcomes evaluated. Despite efforts in public education, patient-related barriers to pain management still exist, and it is important that misconceptions of patients be corrected. To promote the quality of palliative care and pain management, efforts have been made to provide training of healthcare professionals, and on formation of professional societies for palliative care doctors and nurses. In Hong Kong, palliative medicine achieved medical specialty status in 1998, with a curriculum and a structured training program designed for doctors interested in this field. Efforts are underway to further improve palliative care and pain management in Hong Kong through the formation of consultative teams in general hospitals, enhanced liaison with nursing homes, and possibly by redefining the role of traditional Chinese medicine in pain management.

The impact of the introduction of a fast track clinic on ovarian cancer referral patterns.

The aim of this study is to review the referral patterns for ovarian cancer in the Grampian region of Scotland and assess the impact of a 'fast track' clinic on the patient journey. Population-based retrospective analysis of a gynaecological cancer database and patient case notes were used. After its inception, 13.5% of patients were referred through the fast track clinic and 83% were seen within 2 weeks. Thirty-six per cent of patients were admitted as emergencies, mainly surgical or medical. The median general practitioner-to-specialist time was 3 days (range 0-188 days). The median time to diagnosis prior to the fast track clinic was 23 days and 17.5 days after its introduction (P = 0.003). A population-based ovarian cancer referral pattern is presented. Median waiting times are short but do influence time to diagnosis as do referral through a non-cancer specialty and patient performance status. Rapid access through a gynae-oncology clinic has some impact but is underused.

International report: current state and development of health insurance and emergency medicine in Germany. the influence of health insurance laws on the practice of emergency medicine in a European country

Germany has a comprehensive health insurance system, with only 0.183% of the population being uninsured. Access to office-based medicine and to hospitals is easy and convenient. Due to enormous financial pressures, Germany is currently decreasing the number of beds in hospitals, introducing the Diagnosis Related Groups (DRG), and restricting accessibility to specialists. In contrast to Anglo-American countries, Germany follows the concept of bringing the physician to the patient in the prehospital setting, with Emergency Medical Services (EMS) physicians responding to all Advanced Life Support (ALS) calls. Despite a mature EMS system with sophisticated medical equipment and technology, both in the prehospital and hospital setting, logistical issues such as a single emergency telephone number or multidisciplinary Emergency Departments have yet to be established. Within the hospital, this “Franco-German model” considers Emergency Medicine a practice model that does not merit specialty status. Spending restrictions in the health care system, with less access to hospital beds and office-based physicians, will increase the demand for hospital-based emergency care when patients experience problems accessing the medical system. Currently, the German hospital system is unprepared to care for greater numbers of emergency patients. This may call for changes in the German health care system as well as the medical education system, with the introduction of hospital-based Emergency Medicine as its own specialty, similar to Anglo-American countries.

A syllabus for fellowship education in palliative medicine.

Recent years have seen significant growth in palliative medicine training programs and positions. There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.

A Review on Specialization in Pharmacy—Part II: A Commentary on Postgraduate Training and Pharmaceutical Care

Many opportunities exist for pharmacists who desire to expand their role in providing comprehensive pharmaceutical care services to patients and other health care providers, who they serve and collaborate with on a daily basis. Consequently, there is a strong trend within pharmacy to specialize in areas of professional interest. In many respects, pharmacy has turned toward the medical model in addressing its needs and providing a framework for specialization in practice. With respect to generalist and specialized practitioners and varying initiatives relative to the medical model, the concept of specialization in pharmacy has recently developed some interesting tangents when issues of certification, credentialing, disease-state management, and added qualifications enter the discussion. The previous installment in this 2-part article focused on specialization in pharmacy and offered a review of the current initiatives by which a pharmacist can achieve specialty status. In this concluding installment, discussion is offered that addresses pharmaceutical care and postgraduate training in pharmacy relative to future professional and societal expectations for pharmacy.

A Review on Specialization in Pharmacy—Part I

Many opportunities exist for pharmacists who desire to expand their role in providing comprehensive pharmaceutical care services to patients and other health care providers whom they serve and collaborate with on a daily basis. Consequently, there is a strong trend within pharmacy to specialize in areas of professional interest. In many respects, pharmacy has turned towards the medical model in addressing its needs and providing a framework for specialization in practice. With respect to generalist and specialized practitioners and varying initiatives relative to the medical model, the concept of specialization in pharmacy has recently developed some interesting tangents when issues of certification, credentialing, disease-state management, and added-qualifications enter the discussion. In this, the first of a 2-part series (Part II in the upcoming issue) focusing on specialization in pharmacy, a review of the current initiatives by which a pharmacist can achieve specialty status will be addressed.

Hospital prescribing errors: epidemiological assessment of predictors.

To demonstrate an epidemiological method to assess predictors of prescribing errors. A retrospective case-control study, comparing prescriptions with and without errors. Only prescriber and drug characteristics were associated with errors. Prescriber characteristics were medical specialty (e.g. orthopaedics: OR: 3.4, 95% CI 2.1, 5.4) and prescriber status (e.g. verbal orders transcribed by nursing staff: OR: 2.5, 95% CI 1.8, 3.6). Drug characteristics were dosage form (e.g. inhalation devices: OR: 4.1, 95% CI 2.6, 6.6), therapeutic area (e.g. gastrointestinal tract: OR: 1.7, 95% CI 1.2, 2.4) and continuation of preadmission treatment (Yes: OR: 1.7, 95% CI 1.3, 2.3). Other hospitals could use our epidemiological framework to identify their own error predictors. Our findings suggest a focus on specific prescribers, dosage forms and therapeutic areas. We also found that prescriptions originating from general practitioners involved errors and therefore, these should be checked when patients are hospitalized.

Specialty recognition is here

The attainment of specialty status for pharmaceutical medicine with its own Certificate of Completion of Specialist Training (CCST), which is expected literally within the next few days, will be a major step in the evolution of the professional standing of those who have chosen to pursue a career in either the pharmaceutical industry or the regulatory authorities. Whilst at the moment this is for the UK, it is planned to take this forward to EU wide. In order to obtain a CCST it will be necessary for candidates to enrol on a programme of Higher Medical Training (HMT), which involves demonstrating a level of competence in seven modules of work that make up the curriculum. Obtaining the Diploma of Pharmaceutical Medicine is part of the process and it is assumed that most people will sit this about two years after joining the industry. At least three of the modules must be completed within the person’s place of work and it may be that, for some individuals, all of them can be completed this way. However, it is recognized that companies vary in size and structure and there is a wide diversity of jobs within pharmaceutical medicine. Thus, the Faculty of Pharmaceutical Medicine is arranging for a series of taught modules to be available so that people who cannot complete their training in the work place have an alternative route to obtaining all the necessary training for a CCST. These courses will be provided by a variety of organizations, such as the Medicines Control Agency, some pharmaceutical companies and some universities, and the Faculty will put in place a quality control process that ensures that the standards are maintained. The achievement of a CCST is a major step in anyone’s career development and it is important that those embarking on a career in pharmaceutical medicine have the same professional status as other medical disciplines. Getting this far is the result of a huge amount of work by a large number of people, but the two whom I would like to recognize for their skilful manipulations through the tortuous path that we trod are Professor David London and Professor Peter Stonier. It is to be hoped that future generations of patients and pharmaceutical physicians will acknowledge the service that they have done. INTERNATIONAL JOURNAL OF PHARMACEUTICAL MEDICINE 2002, 16:111 & 111

A policy of introducing a new contract and funding system of general practice in Estonia.

The socialist bloc of post-war Europe was obliged to follow the Soviet example with a hierarchical, centrally controlled health care system based on polyclinics and other facilities providing extensive specialist services at the first level of contact. All the countries of Central and Eastern Europe have now expressed their wish to totally change their health care systems. Changes in these countries include: the introduction of market economy mechanisms in health care, an increased focus on population health needs in guiding health care systems, and the possibility of introducing a more general type of care at primary level. Patient expectations of access, choice and convenience are factors in shaping new models of health care delivery. Appropriate timing is the key determinant of the success of reforms. In Estonia the beginning of the 1990s was the time when several interest groups in society supported changes in the health care system. The first step after regaining independence was the reintroduction of a Bismarck-type insurance system. In the late 1990s the primary care reforms have changed the initial plans and elements of a National Health Service were introduced, especially general practitioners' lists, capitation payment and gate-keeping principles. The family medicine reform in Estonia has two main objectives: introduction of general practice as a specialty into Estonian health care and changing the remuneration system of primary care doctors. The specific tasks are: to provide practising primary care doctors with opportunities for retraining to gain the specialty status of a general practitioner, to create a list system for the population to register with a primary care doctor, to introduce a partial gate-keeping system and to give the status of the independent contractor to primary care doctors.

Something special: forensic psychiatric nursing

In this paper the claims that forensic psychiatric nursing has achieved the status of a specialist area of nursing are refuted. An examination of the literature demonstrates that specialist knowledge and skills have not been documented. It is suggested that three requirements are necessary if forensic psychiatric nurses wish to achieve specialty status. Forensic nurses have to consolidate their role in the containment and care of patients, they have to return to the nurse–patient relationship as the foundation of psychiatric nursing practice, then, within that relationship, nurses must expand their practice to include dealing with offence issues.

Something special: forensic psychiatric nursing.

In this paper the claims that forensic psychiatric nursing has achieved the status of a specialist area of nursing are refuted. An examination of the literature demonstrates that specialist knowledge and skills have not been documented. It is suggested that three requirements are necessary if forensic psychiatric nurses wish to achieve specialty status. Forensic nurses have to consolidate their role in the containment and care of patients, they have to return to the nurse-patient relationship as the foundation of psychiatric nursing practice, then, within that relationship, nurses must expand their practice to include dealing with offence issues.

Managed care, time pressure, and physician job satisfaction: results from the physician worklife study.

To assess the association between HMO practice, time pressure, and physician job satisfaction. National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one's career and one's specialty. Linear regression-modeled satisfaction (on 1-5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. "HMO physicians" (9% of total) were those in group or staff model HMOs with > 50% of patients capitated or in managed care. Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P <.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P <.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P <.05) and from job, career, and specialty satisfaction (P <.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P <.05 after Bonferroni's correction). HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians' satisfaction with staff, community, resources, and the duration of new patient visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.

Conceptual frameworks. Putting the nursing focus into core curricula.

The growing movement toward specialty certification in nursing has resulted in an increased demand for continuing education that supports specific areas of specialty practice and certification status. In examining a number of the specialty practice core curricula documents, it is evident that there is a tendency to organize nursing content using the medical model as a framework. A method by which core curricula for specialty practice are organized and developed from a distinctly nursing perspective is needed. The authors suggest that conceptual frameworks, developed by nurses who are expert in a specific clinical practice area, are a practical method for the development of such curricula.

Female medical leadership: cross sectional study Editorial by Showalter

Objective: To assess the relation between male and female medical leadership.Design: Cross sectional study on predictive factors for female medical leadership with data on sex, age, specialty, and occupational status...

Gender Differences in the Process of Occupational Integration of Immigrant Physicians in Israel

The immigration of more than 13,000 physicians,over half of whom were women, from the former SovietUnion to Israel during the first half of the 1990's,provided an opportunity to investigate genderdifferences in the occupational integration of a largegroup of professionals. The present paper presentsfindings from a three-stage cohort study of 333 formerSoviet physicians covering their first five years in Israel, and from in-depth interviews withtwenty-three immigrant physicians. After two andone-half years in Israel (Stage 2), male respondentswere more likely to be working in their profession thanfemale respondents, who were more likely to beunemployed. After five years (Stage 3), men and womenwere equally likely to be working as physicians, but themen were significantly more likely to be in residency programs to attain specialty status, while thewomen were more likely to be working as generalpractitioners. The narratives suggest that genderdifferences in professional behavior were intricatelyrelated to traditional gender-related family normswhich persisted throughout the Communist era. Thetendency for some of the women to delay resuming theircareer in Israel is seen as adaptive in the context of migration, because it provides continuity ofself-identity and family norms. Furthermore, women whochose to work as general practitioners saw this work asa continuation of their work in the USSR. After five years in Israel, there were no genderdifferences in work satisfaction, self-esteem, mood andgeneral adaptation to life in Israel.

Academic dental public health diplomates: their distribution and recommendations concerning the predoctoral dental public health faculty.

The purpose of this study was to assess the representation of academically based diplomates of the American Board of Dental Public Health (ABDPH) and to identify their perceptions on the training of dental public health predoctoral faculty. Data were collected by a mailed, self-administered, 13-item questionnaire. The population was the 48 diplomates of the ABDPH as of March 1997 associated with academic institutions. Twenty of the 55 US dental schools had a diplomate of the ABDPH with a mean of 1.8 diplomates per school with a diplomate. An average of 4.5 full-time faculty members per school were associated with teaching dental public health. A master's degree in public health (MPH) was the most frequently suggested educational requirement for dental public health faculty. Continuing education courses were training needs perceived for dental public health faculty. The lack of time, money, and incentives, along with perceived rigidity of requirements for board certification, were reported as major barriers for faculty becoming dental public health board certified. Numerous challenges confront the development of a strong dental public health presence in US dental schools. These challenges include, among others, insufficient numbers of academic dental public health specialists and insufficient motivations to encourage promising candidates to pursue specialty status.