The timing of career decisions in internal medicine

The creation of new residencies in primary care internal medicine is aimed at increasing the number of individuals entering careers as general internists. This strategy assumes that final career decisions are made prior to application for residency training. A survey of all graduates of internal medicine residencies at the University of California, San Diego, during 1969-1979 resulted in 155 respondents (an 86 percent response rate) and revealed that only 30 percent had no change in career plans regarding general versus subspecialty practice since medical school and 41 percent had made final decisions during residency training. Inpatient care experiences, peer interactions, and faculty role models were the training factors which most influenced final career choice. The goal of increasing the number of general internists may be better served by strengthening the role of generalist faculty members in traditional internal medicine residencies rather than creating new programs which force trainees to make premature career choices.     

Mental health education in three primary care specialties

The authors used a questionnaire to examine the characteristics of the mental health components of residency training in traditional internal medicine, primary care internal medicine, and family practice. Traditional internal medicine programs relied almost exclusively on the consultation method and inpatient facilities, offered little formal instruction, used the psychiatrist as the primary teacher, and spent considerably less per resident for mental health training than the other programs. Psychologists and social workers as a group were the primary mental health teachers in family medicine residencies. Traditional internal medicine programs emphasized psychophysiological reactions and simple pharmacotherapy, while primary care internal medicine and family practice programs concentrated on life cycle issues, psychosocial awareness, and simple psychosocial management techniques. None of the three types of residencies focused on complex psychiatric disorders or management techniques. The three specialties differed significantly (F = 13, p = .0001) in the total amount of time on average the resident spent in formal mental health instruction. The need for evaluation of the outcome of training is also discussed.     

Gender differences in practice characteristics of graduates of family medicine residencies

A survey of 310 graduates of eight university-affiliated family medicine residencies in the northwestern United States conducted in 1985 revealed several significant differences between male and female graduates. The female graduates were significantly (p less than .05) more likely than male graduates to practice in urban settings, taking salaried positions, and work in nonprivate practice. With regard to practice content the women spent significantly (p less than .01) more time in the office setting, worked fewer hours per week in direct patient care, and reported doing fewer complex procedures in their practice than did the men. The women were more satisfied than the men with their income but equally satisfied as the men with their professional and personal lives. There were no significant gender differences with regard to concerns about liability and hospital privileges. The women felt significantly (p less than .05) less well prepared in several subject areas, especially surgical areas; hierarchical multiple-regression analysis showed that this difference persisted when analysis controlled for community size and practice setting. Possible explanations and implications are proposed.     

Family medicine research. Status at the end of the first decade

In a national survey of family medicine university units and residencies, 549 MD and 135 PhD faculty pursuing family medicine research were identified. Resources available for research were assessed, as were practice data system characteristics. The practice base nationally of programs pursuing research included 2.6 million patients from 1 million families, making 5.1 million visits per year. Common major impediments to research reported by programs included lack of faculty time (78%), lack of funding for faculty (61%) or staff, equipment and supplies (48%), and lack of research skill (45%) and role models (43%). The annual amount of all research grants received for calendar year 1979 was $3.4 million, of which $2.6 million was from federal government sources. This represented 0.06% of the federal health research effort. Continued development of family medicine research will require increased funding support both for research and research training.     

美国新毕业家庭医生寻找产科相关工作的体验

背景　足够的产科家庭医生对于确保患者获取必需的产科服务至关重要。然而,既往研究表明执业范围包含产科的家庭医生数量正在逐年减少,如今从事新生儿接生工作的家庭医生不到10%。目的　旨在探究希望将产科纳入其执业范围的新毕业家庭医生如何发现和选择工作,并进一步了解当前就业形势对家庭医生的执业范围,特别是产科、新生儿接生方面的影响。方法　于2017年进行问卷调查和定性访谈的混合方法研究。对美国家庭医生进行电子问卷调查并在目的性子抽样后对这些医生进行深度半结构化电话访谈。问卷调查总结了家庭医生未从事产科工作的原因,为进一步明确选择从事产科工作的家庭医生的具体情况,采用基于群体的沉浸式方法来转译定性访谈的结果。本研究向2 098例毕业于2014-2016年并希望从事新生儿接生工作的美国家庭医学专业实习医生发送调查问卷,回复1 016份,回复率48.43%,其中56例接受了电话访谈。结果　问卷调查结果显示,未能找到工作范围包含产科的工作是希望从事产科工作的家庭医学毕业生未从事该工作的主要原因。定性访谈结果显示,家庭医生通常通过人脉关系或人才招聘的途径找到产科相关工作,并根据地理位置偏好、家庭义务及生活方式要求等个人考虑因素做出选择。同时,求职过程和择业决策也受到工作结构、执业特点及缺乏产科相工作经验等因素的限制。结论　虽然个人意向决定大部分医学生的工作选择,但其选择仍受到多种不可控因素限制,特别是家庭医学工作提供产科相关工作的能力。美国毕业医学生从医院实习生到执业医师的转变同时影响着毕业生的求职选择和医疗机构患者寻求医疗服务的质量。因此,了解就业情况对家庭医生就业范围的影响方式,有助于进一步明确如何协助家庭医生在其希望从事的范围内工作并对其进行相应协助,从而确保每一个家庭可以获得更好的医疗服务。     

临床医学专业学位研究生（住院医师）培养质量现状调查

目的了解临床医学硕士专业学位研究生（住院医师）培养质量的现状,分析存在的问题。方法采用整群抽样的方法,运用自制的凋查量表对95名2010级研究生进行问卷调查,对临床医学硕士专业学位研究生住院医师（研究生住院医师）培养过程（包括课程设置、实践教学、教学管理、导师指导、就读收获）进行评价,并与2010级临床医学硕士专业学位研究牛（号业学位研究生）的评价结果进行比较。结果调查结果显示：学生对导师指导评价得分最高为（4．51±0．56）分,课程设置的评价最低为（3．84±0．40）分,总体评价平均（4．45±0．50）分。研究生住院医师与专业学位研究生的评价得分比较差异有统计学意义（P〈0．05）。其中专业学位研究生对于课程设置的评价得分高于研究生住院医师评价得分;研究生住院医师对于临床轮转、临床技能培训与考核、论文导师指导等培养环节的评价得分于高于专业学位研究生。对研究生住院医师培养质量有显著影响的因素是导师指导和实践教学。结论学生对研究生住院医师的培养质量比较满意,其培养模式有利于提高学生的临床能力;但也仔在不足之处,临床实践教学和日常过程管理应得到导师和管理部门的重视。     

Residents' experiences in, and attitudes toward, the care of persons with AIDS in Canada, France, and the United States.

OBJECTIVE--To evaluate resident physicians' experiences in, and attitudes toward, the care of persons with the acquired immunodeficiency syndrome (AIDS) in Canada, France, and the United States. DESIGN--Cross-sectional survey, using a self-administered, mailed questionnaire to residents in 10 American states, three French regions, and all 10 Canadian provinces, with follow-up surveys of nonresponders in France and the United States. SUBJECTS--Systematic samples of residents in the last year of internal medicine or family medicine residencies prior to subspecialization or entry into medical practice. RESULTS--While the majority of residents had provided inpatient and outpatient care to persons with AIDS, most believed that their training in ambulatory care of persons with AIDS had been deficient. The rate of blood-contaminated needle-sticks from human immunodeficiency virus-infected patients ranged from 4% for internal medicine residents in Canada to 14% in the United States (P less than .05). The majority recognized an ethical obligation to treat AIDS, but 4% in France, 14% in Canada, and 23% in the United States indicated that they would not care for persons with AIDS if they had a choice (P less than .001). A substantial minority of US physicians reported that a patient of theirs had been refused care by a medical specialist (19%) or a surgeon (39%), but less than 10% of French physicians reported such refusals (P less than .001). CONCLUSION--Concerns about caring for AIDS patients were common and many physicians reported that patients were refused care. While most residents acknowledged an obligation to treat human immunodeficiency virus infection, many did not, and viewpoints varied considerably across the countries studied. The lower level of reluctance to treat AIDS patients in France and Canada makes it clear that the higher rate in the United States is far from optimal and needs to be addressed.     

Training in a primary care internal medicine residency program. The first ten years

We surveyed all 49 graduates of the University of California, San Francisco, residency program in primary care internal medicine to determine whether they chose careers as general internists and whether training in ambulatory care at the expense of hospital-based medicine is adequate preparation for general internal medicine practice. Graduates rated adequacy of training and relevance to their current clinical practice of 87 content and skill areas on five-point Likert scales. Of the 44 respondents, 39 (89%) chose careers as general internists and five (11%) as subspecialty internists. Training in nine of 11 internal medicine disciplines (eg, cardiology) was rated as highly adequate, and the areas as highly relevant. For ten of 15 non-internal medicine areas (eg, ear, nose, and throat), mean relevance scores significantly exceeded adequacy scores, suggesting training underemphasis. Mean relevance scores also significantly exceeded adequacy scores for seven of 11 basic knowledge/skill areas (eg, patient interviewing) and 13 of 14 areas related to clinical practice (eg, quality assurance). We conclude that the vast majority of graduates of the University of California, San Francisco, primary care residency program became general internists and that, rather than feeling deficient in training in hospital-based medicine, graduates reported unmet needs for ambulatory-care experiences and skills related to general internal medicine practice.     

A proposal for a combined family practice--internal medicine residency

Both family practice and internal medicine currently train graduates for primary care. A single, four-year program is proposed that combines the strengths of family practice and internal medicine, incorporates community needs into the curriculum, and addresses the physician's changed role in a revolutionized health care provision system. Specific training recommendations and the societal and professional advantages of such a program are detailed.     

Pediatric manpower in Canada: a cross-country survey.

Health care costs and government cutbacks in Canadian training posts have caused concerns about physician manpower. To determine the present pediatric manpower situation a cross-country survey was undertaken of all pediatricians and their practice patterns. Of the 2060 recipients of a questionnaire 5% were found to not be pediatricians. Of the remaining 1960, 69% returned a completed questionnaire. Overall, 70% of the pediatricians were men, although among those less than 35 years of age 49% were women. Across Canada 37% of the pediatricians practised primary care, 25% secondary care and 38% tertiary care. There were wide regional differences in practice patterns, with large numbers of primary care pediatricians in Winnipeg, Toronto, Ottawa and the province of Quebec; few pediatricians in the Maritimes and the remainder of western Canada practised primary care. Non-Canadian graduates accounted for 33% of the pediatricians and represented a considerable proportion of tertiary care pediatricians. Cutbacks in numbers of pediatric training positions and restrictions on immigration of foreign pediatricians may lead to unexpected deficiencies in the availability of some types of pediatric practitioners, especially those in tertiary care.     

Canadian departments of pediatrics and family medicine: in need of family therapy?

Whether and how much the departments of pediatrics in Canadian medical schools collaborate with the family medicine departments in training for child care were the focus of a survey conducted in 1983-84. Responses to a questionnaire sent to department heads indicated that in general the most supportive relationships existed in the western provinces, with progressively more problems uncovered from west to east. The responses concerning the roles of pediatricians and family physicians paralleled this trend, with the western view being that pediatricians are consultants and not competitors for primary care. Many respondents supported the expansion of family medicine, particularly into ambulatory and behavioural areas. The data provide some cause for concern about the future health care of children, as the forecasted oversupply of physicians is likely to encourage competition rather than consultation between the two groups. Also, many Canadian pediatricians accept the US model of pediatrics, which includes primary care, although in Canada the ratio of family physicians to pediatricians is six times that in the United States, and Canadian specialists are concentrated in urban centres. This means that family physicians will continue to provide most of the child care in Canada and need adequate training. They also need to develop cooperative, supportive relationships with specialists in child health care to enhance appropriate referral patterns.     

Academic family medicine in Canada.

Fifty years ago family practice in Canada had no academic presence. Stimulated by a number of general practitioners and with the support of the Canadian Medical Association, the College of General Practitioners of Canada (CGPC) was founded in 1954. In 1962, conferences on education for general practice attended by the Association of Canadian Medical Colleges and the CGPC led to pilot postgraduate residencies in family practice supported by Department of National Health and Welfare. The first certification examination was held in 1969 and, by 1974, all Canadian medical schools had a family medicine residency program. Today departments of family medicine contribute substantially to undergraduate education in all 16 schools. In Canada, the medical profession, governments and the medical schools have demonstrated the importance they place on appropriate education for family physicians.     

重庆市首届农村订单定向医学生基层工作情况及对策建议

背景　国家发展改革委等5部门于2010年启动实施农村订单定向医学生免费培养工作，截至目前已为中西部乡镇卫生院培养了近5.7万名订单定向生，从规模上实现了为中西部每家乡镇卫生院培养1名从事全科医疗本科医学生的“全覆盖”。订单定向医学生在基层的工作和生活现况，以及基层医疗卫生单位对订单定向生的评价，是值得进一步关注的问题。目的　了解重庆市2010级首届订单定向生在基层的工作和生活情况，进而为订单定向生的培养与使用提供建议。方法　于2019年8-12月，以重庆市2010级完成5年本科医学教育、3年住院医师规范化培训并履约到基层工作的首批订单定向生为调查对象（n=160），采用研究组自行设计的调查表，调查其工作单位情况、薪酬待遇、服务期满后的工作计划、生活状况及面临的困难、对基层工作满意度等。另分别对重庆市永川区、南岸区、梁平区、黔江区订单定向生所在区（县）卫生健康委相关管理人员、签约乡镇卫生院的院负责人和中层管理人员共38人开展焦点小组访谈，主要访谈其对首届农村订单定向医学生的评价、影响订单定向生“扎根基层”的因素及培养建议等。结果　最终回收有效调查表121份（75.6%）。工作方面：43例（35.5%）订单定向生所在工作单位已设立全科医学科/全科诊室；16例（13.2%）在工作单位从事全科岗位；98例（81.0%）月收入<6 000元；97例（80.2%）已通过中级职称考试，但其中的90例（92.8%）尚未被聘为主治医师；81例（66.9%）近一年未参加过继续医学教育培训/学术会议；对于服务期满后的工作计划，66例（54.6%）表示不清楚，5例（4.1%）计划继续留在基层工作。生活方面：21例（17.4%）订单定向生表示单位提供免费周转房，93例（76.9%）认为单位不能为其解决部分实际困难。对基层工作的满意度方面：86例（71.1%）订单定向生对个人收入不满意，57例（47.1%）对工作岗位和承担任务不满意，24例（19.9%）对个人工作业绩不满意，22例（18.2%）对单位领导重视程度不满意。访谈结果显示：订单定向生在基层工作单位展现出较强的学习能力，综合素质较高，但收入欠佳；受多种因素影响，订单定向生长期服务基层的意愿不强；建议高校和住院医师规范化培训单位加强对订单定向生思想方面的引领，同时加强订单定向生与签约单位的沟通。结论　首届订单定向生在乡镇卫生院的工作满意度不高，基层单位对订单定向生重视程度不足，订单定向生培养模式和签约单位的需求“脱节”。教育培训单位应该进一步完善订单定向生培养模式，相关政府部门须全面落实薪酬及职称晋升等相关待遇，使订单定向生能够“下得去、用得上、留得住”。     

Women in medicine: practice patterns and attitudes.

Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada's health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.     

Career and practice profiles of Alberta medical graduates (1973-85) practising in Alberta.

This collaborative study examined the career choices and practice locations of the 940 (58%) of the Alberta medical students graduating between 1973 and 1985 who remained in Alberta. Of the 686 practising graduates slightly less than two-thirds were in family/general practice; the remainder were in a specialty. More women (76%) than men (60%) had chosen family/general medicine. The women graduates spent about 10 hours less a week on patient care than their male colleagues. Personal and professional factors were cited most often as determinants of practice location. Approximately 20% of the practising graduates chose to locate in small towns or rural areas. Accessibility to consultants and opportunities for continuing medical education were reported as vital prerequisites for more physicians to move to smaller Alberta centres. These findings provide a starting point for studies designed to determine how Alberta medical school graduates are contributing to patient care within the province.     

Neonatal resuscitation in Canadian hospitals.

A survey of Canadian hospitals providing obstetric care was undertaken to assess preparation, protocols, training and staff availability for neonatal resuscitation. Of the 721 hospitals contacted 577 (80%) responded. The reported availability of written guidelines for resuscitation varied greatly, depending on hospital size and proximity to a tertiary care centre. Many hospitals, especially those with 300 births or fewer annually, reported that they depend on family physicians or nurses to start and to continue neonatal resuscitation. Approximately one third of the hospitals had written guidelines for summoning personnel for additional help, and one third used a list of maternal or fetal indications for the presence of a physician specifically for the care of the infant at birth. Of 200 hospitals 138 (69%) had to summon additional medical help from outside the institution, 60% at all times. A neonatal resuscitation team in which members' roles were defined was established in 22% of the hospitals. Few hospitals held rehearsals for resuscitation. Nurses were permitted to perform intubation in 21 hospitals (4%), 7 of them in Alberta. National professional bodies should develop guidelines for training and skill maintenance, and hospitals should develop protocols for maintaining equipment and for neonatal resuscitation team activities, including regular practice. Training should be improved in family practice and obstetrics programs, and consideration should be given to training senior obstetric nurses and respiratory therapists in intubation of neonates.     

国外农村基层医师医学培养项目实施现状、成效及评价的系统综述

背景　2010年我国农村订单定向医学生免费培养工作启动，旨在为农村地区培养具备本科学历的全科医生，缓解农村地区基层医师匮乏的现状。本研究通过系统综述了解国外类似项目的实施现状、成效及评价，为我国农村订单定向医学生培养工作评价和改善提供理论参考。目的　了解国外农村基层医师医学培养项目实施现状、成效及评价指标方法等。方法　2019年2-7月，采用系统综述的方法，以“医学教育”“医学教育+医学本科生”“医学院校教育”“医学生”“住院医师规范化培训”“医学专业+人力资源”“农村地区”“农村基层医疗服务”“医师执业地点”“农村基层医师”“农村基层医师培养”“农村医学实习”“农村临床见习”为检索词，检索Ovid MEDLINE、PubMed、Cochrane及Google Scholar主要英文数据库，获取2000-01-01至2019-01-01发表的关于全球农村基层医师院校教育及住院医师培训等项目的实施现状、成效及评价的英文文献。结果　最终纳入53篇文献，分别来自美国、加拿大、澳大利亚、日本、泰国及南非6个国家，包括20个院校教育项目和6个住院医师培训项目。文献显示各国农村基层医师培养项目均具有指向性招生策略、面向农村卫生和全科医学的临床课程体系、以农村执业的家庭医生为临床导师及农村地区临床实践基地等要素；培养项目学生选择家庭医学为执业专业、农村地区执业率和长期农村保留率均明显高于非培养项目学生，两者国家医疗执照考试成绩和通过率无明显差异。长期农村地区临床实践培训、招生策略倾斜农村成长背景学生及农村执业的家庭医生导师是影响项目最终效果的关键因素。结论　医学教育是解决农村基层医师匮乏的有效途径。国外农村基层医师培养项目的招生策略、临床课程体系设置、导师指导及评价可为我国农村订单定向医学生培养工作提供有益参考。     

The Class of 1989 and physician supply in Canada

BACKGROUND: "The Class of 1989" is a study of 1722 people who were awarded an MD degree by a Canadian university in 1989. This paper reports on migration, specialty choices and patterns of post-MD training in order to assess the contribution of the graduating cohort to the physician workforce of Canada. METHODS: A longitudinal study was conducted over 7 years after graduation to trace the current location, the post-MD training history and the professional activity of the graduating cohort. Several medical professional and educational associations in Canada and the United States provided year-by-year information on field and location of post-MD training, certification achieved, whether in practice and location of practice through to spring 1996. Information from all sources was linked to a list of 1989 medical school graduates. RESULTS: From entry to medical school through to 7 years after graduation the cohort was diminished by about 16%. The main reason for loss was migration to other countries: 193 graduates (11.2%) were outside Canada in 1995-96. Internal migration was extensive also; for example, by 1995-96 relatively few of the graduates were located in Newfoundland or Saskatchewan. Of the 1516 graduates active in Canada in 1995-96, 878 (57.9%) were in general practice/family medicine, and only 638 (42.1%) were practising or training in a specialty. INTERPRETATION: The "yield" of the Class of 1989 for Canada's physician workforce is insufficient to meet annual physician inflows from Canadian sources to serve population growth and to replace retiring or emigrating physicians. As output from Canada's medical schools drops even further, the gap between requirements and supply will grow even wider.     

南京医科大学七年制临床医学专业人才培养效果评价

通过对毕业生及其培养或用人单位的问卷调查,本文分析了南京医科大学七年制临床医学专业人才培养的成效,以及江苏省医疗卫生事业发展对高层次医学人才的需求.结果 显示,临床实践能力和科研创新能力是医疗卫生事业发展所需要的高层次医学人才的重要能力;在三级甲等医院工作,具有硕士/博士学位、在专业技术岗位的被调查者更加看重医学生的科研创新能力;而在"1年通识教育、4年医学专业教育(含1年临床课程及见习、1年临床通科实习)、2年二级学科轮转"模式下培养的七年制临床医学专业毕业生的临床实践能力较强,但是科研创新能力不足,且学业负担偏重.因此,应当加强对七年制临床医学专业学生科研创新能力的培养和临床实践能力的通科训练.