贵州省"5+3"模式订单定向医学毕业生的离职意愿及影响因素研究

背景 我国基层全科医生的离职意愿较高，调查其离职意愿并分析影响因素，可以为减少基层卫生人才流失提供思路。目前，完成"5+3"模式（5年临床医学本科教育+3年住院医师规范化培训）培养的订单定向医学毕业生逐步履约进入基层工作，而针对该部分全科医生离职意向的研究相对较少。 目的 调查贵州省"5+3"模式订单定向医学毕业生回归基层工作后的离职意愿及影响因素，为完善吸引卫生人才留任、建设基层全科医生队伍相关政策提供依据。 方法 以贵州省截至2020年底已完成"5+3"模式培养并履约到基层医疗卫生机构工作的2015—2017级订单定向医学毕业生为研究对象。于2021-01-20至2021-02-10对其开展电子问卷调查，内容包括毕业生的一般情况、职业满意度、离职意愿、服务期满后职业方向。共回收问卷347份，其中有效问卷311份，问卷有效回收率为89.6%。采用单因素分析及多元逐步线性回归分析全科医生离职意愿的影响因素。 结果 贵州省"5+3"订单定向医学毕业生的整体离职意愿得分为（3.98±0.98）分，具有离职倾向者229例（73.6%）。不同性别、单位地理位置、每日工作量者的离职意愿得分比较，差异有统计学意义（P<0.05）。多元逐步线性回归分析显示，单位负责人对待下属的方式、在工作中获得的成就感、对当前收入满意程度、家人对工作的支持程度、当地激励政策执行程度是"5+3"订单定向医学毕业生离职意愿的影响因素（P<0.05）。服务期满后，计划留任原基层医疗卫生机构者12例（3.9%），计划去其他基层医疗卫生机构者21例（6.7%），计划离开基层去上级医院工作者196例（63.0%），计划攻读全日制硕士学位者60例（19.3%）。 结论 贵州省"5+3"模式订单定向医学毕业生的离职意愿较高，预计服务期满后基层全科人才流失较多，需从提高收入、重视全科医生心理需求、优化全科医生培养与使用、发展基层医疗卫生机构、加强全科宣传等方面着手改善。     

Real-World Palbociclib Use in HR+/HER2− Advanced Breast Cancer in Canada: The IRIS Study

Background: Palbociclib is a selective cyclin-dependent kinase (CDK) 4/6 inhibitor used in combination with aromatase inhibitors or fulvestrant for patients with hormone receptor-positive (HR+) human epidermal growth factor receptor 2 (HER2)-negative advanced/metastatic breast cancer (ABC/MBC). Palbociclib was the first CDK 4/6 inhibitor approved for HR+/HER2− ABC/MBC treatment in Canada in combination with letrozole (P+L) as an initial endocrine-based therapy (approved March 2016), or with fulvestrant (P+F) following disease progression after prior endocrine therapy (approved May 2017). The Ibrance Real World Insights (IRIS) study ({"type":"clinical-trial","attrs":{"text":"NCT03159195","term_id":"NCT03159195"}}NCT03159195) collected real-world outcomes data for palbociclib-treated patients in several countries, including Canada. Methods: This retrospective chart review included women with HR+/HER2− ABC/MBC receiving P+L or P+F in Canada. Physicians reviewed medical records for up to 14 patients, abstracting demographic and clinical characteristics, treatment patterns, and clinical outcomes. Progression-free rates (PFRs) and survival rates (SRs) at 6, 12, 18, and 24 months were estimated via Kaplan–Meier analysis. Results: Thirty-three physicians examined medical records for 247 patients (P+L, n = 214; P+F, n = 33). Median follow-up was 8.8 months for P+L and 7.0 months for P+F. Most patients were initiated on palbociclib 125 mg/d (P+L, 90.2%; P+F, 84.8%). Doses were reduced in 16.6% of P+L and 14.3% of P+F patients initiating palbociclib at 125 mg/d. The PFR for P+L was 90.3% at 12 months and 78.2% at 18 months; corresponding SRs were 95.6% and 93.0%. For P+F, 6-month PFR was 91.0%; 12-month SR was 100.0%. Conclusions: Dose reduction rates were low and PFR and SR were high in this Canadian real-world assessment of P+L and P+F treatments, suggesting that palbociclib combinations are well tolerated and effective.     

From the "what" to the "how": Teaching integrative medicine-related skills to medical students during COVID-19

ObjectiveTo examine the impact of an integrative medicine (IM) course on self-perceived IM-related communication and research skills.MethodsA 3-day mandatory "hybrid" (online and in-person) IM course was held within COVID-19 restrictions for 161 pre-clerkship medical students, with workshops facilitated by mentor healthcare professionals (IM and non-IM) and student-directed tasks. Self-perceived levels of 6 IM-related skills were scored (from 1 to 5) for history-taking; communicating with patients with "alternative" health-beliefs; referral to IM consultations; assessing risks/benefits; and working with non-medical IM practitioners.Results137 students (85.1%) completed pre-/post-course questionnaires, with overall scores improving from pre-course (1.98 ± 0.92) to post-course (3.31 ± 0.63; p < 0.0001), for the entire group and student subgroups (with vs. without prior IM experience). Multivariate analysis found no association between age, gender, primary language or prior experience with IM and improvement in skill scores.ConclusionsThe IM course increased self-perceived skill levels, reflecting the course curriculum and workshops. Further research needs to explore the application of these skills during clinical training.Practice implicationsTeaching medical students about IM in a course comprising communication and research skills was shown to be feasible and effective. The application of IM-related skills needs to be evaluated during the clinical clerkship.     

河南省非订单定向全科住院医师规范化培训结业学员的就业状况及影响因素研究

背景 全科医生数量和质量是人力资源管理的两个重要维度，其中，医生数量的新增、保持和流失，是全科人力动态规划、管理和评价的重要考量，也是全科住院医师规范化培训（简称全科住培）的绩效指标。探讨全科住培学员的就业状况及影响因素，可以为今后住培政策和激励机制的制定提供参考，但目前针对非订单定向全科住培学员的相关研究较为缺乏。 目的 了解河南省非订单定向全科住培学员的就业状况，分析学员结业后未从事全科医学相关工作的原因，从而为完善培训管理和人力资源激励机制提供参考。 方法 于2021年8月，采用分层随机整群抽样法，在河南省选取2014—2017年入培且已结业的非订单定向全科住培学员326例进行问卷调查。问卷由课题组自行设计，主要内容为学员的基本信息、全科住培情况、目前工作情况及结业后从事与未从事全科医学相关工作的原因。问卷通过"问卷星"平台发放，由学员自行填写。 结果 共发放问卷326份，回收有效问卷271份（83.1%）。结业后，从事全科医学相关工作者77例（28.4%），从事非全科医学相关工作者194例（71.6%）。多因素Logistic回归分析结果显示，年龄、文化程度、生源类型、全科住培基地所在区域是学员结业后是否从事全科医学相关工作的影响因素（P<0.05）。与结业后未从事全科医学相关工作的学员相比，结业后从事全科医学相关工作学员注册为全科医学专业的比例更高〔70.1%（54/77）比32.0%（62/194），P<0.05〕，在乡镇卫生院/社区卫生服务中心执业的比例更高〔49.4%（38/77）比6.2%（12/194），P<0.05）〕。194例未从事全科医学相关工作的学员中，从事内科学工作者78例（40.2%），从事急诊及危重症医学工作者33例（17.0%），从事外科学工作者17例（8.8%）。不选择从事全科医学相关工作的前3位原因分别为：单位安排〔34.5%（67/194）〕，所在单位没有全科医学科〔29.9%（58/194）〕，薪酬低〔26.8%（52/194）〕。 结论 非订单定向全科住培学员选择从事全科医学相关工作的比例较低，年龄、文化程度、生源类型及基地所在区域是影响因素。建议加大全科医学理念宣传，加快综合医院全科医学科建设，提高全科医生薪酬待遇，以此增加全科医生的职业吸引力。     

Economic Status and Mortality in Patients with Alzheimer's Disease in Japan: The Longevity Improvement and Fair Evidence Study

ObjectivesAs more countries are implementing measures to address Alzheimer’s disease (AD), it is essential to update the available knowledge on the relationship between economic status and mortality in patients with AD. This study examined the influence of economic status on mortality in Japanese individuals with AD using a medical claims dataset.DesignThis was a retrospective cohort study.Setting and ParticipantsMedical claims data from April 2014 to March 2019 were obtained from 13 local cities participating in the Longevity Improvement and Fair Evidence study. The inclusion criteria were patients aged 65 years and older who were newly diagnosed with AD during the study period.MethodsThe outcome was death during the follow-up period. We assessed economic status by household income (middle to high income and low income); data were obtained from the use of the Medical Expenditure Ceiling Application and Standard Copayment Reduction Card (fee reduction card) when receiving an AD diagnosis, as an indicator of low-income status. We performed multivariate Cox proportional hazards analyses to examine the relationship between economic status and mortality; the model was adjusted for age, sex, the Charlson comorbidity index, and antidementia drug use.ResultsWe identified 39,081 newly diagnosed patients with AD from the Longevity Improvement and Fair Evidence study database (mean age, 83.6 years; female, 67.1%). Of these, 3189 individuals were identified as having a low-income status. After adjusting for possible confounders, low-income status was associated with mortality (hazard ratio, 1.95; 95% confidence interval, 1.84–2.07).Conclusions and ImplicationsLow-income status was associated with substantially poorer prognoses in new AD cases, indicating a need for a thorough examination of medical and nursing care services utilized by low-income individuals with AD and to explore improvement strategies.     

The impact of neighborhoods and friendships on interracial anxiety among medical students and residents: A report from the medical student CHANGES study

Objective

To examine the experience of interracial anxiety among health professionals and how it may affect the quality of their interactions with patients from racially marginalized populations. We explored the influence of prior interracial exposure—specifically through childhood neighborhoods, college student bodies, and friend groups—on interracial anxiety among medical students and residents. We also examined whether levels of interracial anxiety change from medical school through residency.

Data Source

Web-based longitudinal survey data from the Medical Student Cognitive Habits and Growth Evaluation Study.

Study Design

We used a retrospective longitudinal design with four observations for each trainee. The study population consisted of non-Black US medical trainees surveyed in their 1st and 4th years of medical school and 2nd and 3rd years of residency. Mixed effects longitudinal models were used to assess predictors of interracial anxiety and assess changes in interracial anxiety scores over time.

Principal Findings

In total, 3155 non-Black medical trainees were followed for 7 years. Seventy-eight percent grew up in predominantly White neighborhoods. Living in predominantly White neighborhoods and having less racially diverse friends were associated with higher levels of interracial anxiety among medical trainees. Trainees' interracial anxiety scores did not substantially change over time; interracial anxiety was highest in the 1st year of medical school, lowest in the 4th year, and increased slightly during residency.

Conclusions

Neighborhood and friend group composition had independent effects on interracial anxiety, indicating that premedical racial socialization may affect medical trainees' preparedness to interact effectively with diverse patient populations. Additionally, the lack of substantial change in interracial anxiety throughout medical training suggests the importance of providing curricular tools and structure (e.g., instituting interracial cooperative learning activities) to foster the development of healthy interracial relationships.     

Constructing queer mother‐knowledge and negotiating medical authority in online lesbian pregnancy journals

Medical interactions around reproduction are increasingly extending beyond the physician's office and onto the Internet, where negotiation with medical authority occurs in complex and dynamic ways. Recently, scholars have noted the Internet's potential for creating spaces where women can dialogue with and reconstruct medical authority, yet this growing body of work is overwhelming heteronormative. This paper thus interrogates how lesbian women use the Internet to challenge, deploy, and rework medical authority around reproduction while navigating the transition to parenthood. I draw from 17 online journals authored by lesbian couples during the conception, pregnancy, and birth of their first child, each spanning between 18 months and 2 years, in order to understand how the transition process unfolds over time. I argue that lesbian couples engage with medical authority when seeking affirmation and normalisation yet discard and publicly reject the heteronormative assumptions that accompany reproductive medicine. Further, they chart a new process that I term ‘constructing queer mother‐knowledge’, in which they critique and balance knowledges from institutionalised medicine, their own bodies, and their queer communities. With this new concept, I complicate understandings of lesbian mothers‐to‐be and their interactions with medical authority as they build subversive families.     

Emergency department patient payer status after implementation of the Affordable Care Act: A nationwide analysis using NHAMCS data

ObjectiveTo evaluate changes in insurance status among emergency department (ED) patients presenting in the two years immediately before and after full implementation of the Affordable Care Act (ACA).MethodsWe evaluated National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department public use data for 2012–2015, categorizing patients as having any insurance (private; Medicare; Medicaid; workers' compensation) or no insurance. We compared the pre- and post-ACA frequency of insurance coverage—overall and within the older (≥65), working-age (18–64) and pediatric (<18) subpopulations—using unadjusted odds ratios with 95% confidence intervals. We also conducted a difference-in-differences analysis comparing the change in insurance coverage among working-age patients with that observed for older Medicare-eligible patients, while controlling for sex, race and underlying temporal trends.ResultsOverall, the proportion of ED patients with any insurance did not significantly change from 2012 to 2013 to 2014–2015 (74.2% vs 77.7%) but the proportion of working-age adult patients with at least one form of insurance increased significantly, from 66.0% to 71.8% (OR 1.31, CI: 1.13–1.52). The difference-in-differences analysis confirmed the change in insurance coverage among working-age adults was greater than that seen in the reference population of Medicare-eligible adults (AOR 1.70, CI: 1.29–2.23). The increase was almost entirely attributable to increased Medicaid coverage.ConclusionIn the first two years following full implementation of the ACA, there was a significant increase in the proportion of working-age adult ED patients who had at least one form of health insurance. The increase appeared primarily associated with expansion of Medicaid.