Collaboration between university hospitals and local medical communities in Japan evaluated by a questionnaire among doctors

Background:   To provide quality medical service in a society with many elderly, university hospitals should clearly define their roles and contribute to the establishment of an integrated, comprehensive medical system.
Methods:   In this study, we conducted a questionnaire survey of doctors working at Kyoto University Hospital and at private practices in Kyoto about their attitude toward collaboration between the university hospital and private practices and asked their opinions on the role of university hospitals in the local medical community.
Results:   The survey showed that doctors both at the university hospital and in private practice regarded close collaboration as important, but also highlighted obstacles and problems that block collaboration.
Conclusion:   Overcoming these problems and constructing collaboration models will be a key for university hospitals to fully contribute to establishing a quality medical system.     

Paradigmenwechsel in der universitären Medizin?

1. The intended fusion of the university hospitals Marburg and Giessen in the state of Hessia is "a marriage under pressure with uncalculated risk" (Spiegel 2005). In the present political and financial situation it hardly appears to be avoidable. From the point of the view of the faculty of medicine in Marburg it is difficult to understand, that the profits of this well guided university hospital with a positive yearly budget should go to the neighboring university hospital which still had a fair amount of deficit spending in the last years.2. Both medical faculties suffer from a very low budget from the state of Hessia for research and teaching. Giessen much more than Marburg, have a substantial need for investments in buildings and infrastructure. Both institutions have a similar need for investments in costly medical apparatuses. This is a problem, which many university hospitals face nowadays.3. The intended privatisation of one or both university hospitals will need sound answers to several fundamental questions and problems:a) A privatisation potentially endangers the freedom of research and teaching garanteed by the German constitution. A private company will undoubtedly influence by active or missing additional support the direction of research in the respective academic institution. An example is the priorisation of clinical in contrast to basic research.b) With the privatisation practical absurdities in the separation of research and teaching on one side and hospital care on the other will become obvious with respect to the status of the academic employees, the obligatory taxation (16%) when a transfer of labor from one institution to the other is taken into account. The use of rooms for seminars, lectures and bedside with a double function for both teaching, research and hospital care has to be clarified with a convincing solution in everyday practice.c) The potential additional acquisition of patients, which has been advocated by the Hessian state government, may be unrealistic, when the 4th biggest university hospital in Germany will be created by the merger. University hospitals recrute the patients for high end medicine beyond their region because of the specialized academic competence and advanced technical possibilities. Additional recruitment of patients for routine hospital can hardly be expected.d) A private management will have to consider primarily the "shareholder value", even when investing in infrastructure and buildings, as it can be expected for one partner. On the longterm this will not be possible without a substantial reduction of employees in both institutions. There are, however, also substantial efforts of some private hospital chains in clinical research, e. g. by Helios in Berlin and Rh?n Gmbh at the Leipzig Heart Center.e) There is a yet underestimated but very substantial risk because of the taxation for the private owner when academic staff is transferred from the university to hospital care in their dual function as academic teachers and doctors. This risk also applies for the university if the transfer should come from hospital to the university. These costs would add to the financial burden, which has to be carried in addition to the DRGs.     

Medical activity of the French internal medicine departments in 2000-2001 from the DRG system

PURPOSE: Medical activity of the French Internal Medicine Departments has been described until now only by limited declarative surveys. The aim of this study was to describe this activity using the French DRG system. METHODS: A postal survey was conducted using the list of the French Society of Internal Medicine. The same questionnaire was posted to 212 departments (university, public and private hospitals) to collect the 2000 or 2001 data from the DRG system. RESULTS: 192,197 reports were analysed. One hundred and eighty four groups were listed on a theoretical number of 313 medical groups. The first 10 groups concerned common general diseases (pneumonia, anaemia, heart failure, diabetes, stroke.). The main difference between university and non-university hospitals concerned the management of systemic diseases, which was more frequently quoted in university hospitals. Benign and malignant haematological diseases and oncology were frequently quoted in both types of hospitals. CONCLUSION: This study allows for the first time in France to have an objective survey of the medical activity of Internal Medicine Departments. It confirms that these departments have a central role in the hospital management of current diseases but also of haematological diseases and cancer. University departments are more specifically implicated in the management of systemic diseases.     

Schnittstelle universitäre Medizin und Patientenversorgung

The working profile of university hospitals includes medical education, research and implementation of medical innovations as well as large volume patient care. University hospitals offer inpatient, day care and outpatient care which are of essential value for many patients. Besides their primary role in treating rare and orphan diseases and complex cases, they increasingly support general patient care. There are different kinds of outpatient access and treatment options available. The funding of university hospitals and clinics is based on general university funding, income from third party funds for research, income from patient care and funding from the federal states for investments. In recent years these institutions have suffered more and more from economic deficits, a lack of investment and inadequate funding whereby high performance medicine cannot be sufficiently supported. Professors are developing into scientific managers and are frequently assessed by economic outcome and competitiveness. At the same time they are embedded in the structures of the university and are not in the position to make decisions on their own, in contrast to doctors in private practices. Therefore, processes, necessary investments and restructuring are significantly delayed. There is a need to develop strategies for long-term funding and providing university hospitals and clinics with the means to deliver the necessary services.     

Internet in der Rheumatologie

OBJECTIVE: On behalf of the "Systemic Inflammatory Rheumatic Diseases Network" comprehensive, nationwide horizontal and vertical cross-linking of research and care is to be developed for the first time. The quality of scientific work and patient care is to be increased in the medium term through this improved communication and co-operation. Our objective was to determine what hardware and software are avail- able to the physicians involved, with a view to the Internet being used as a basis for communication and documentation within the network. METHODS: A survey was carried out among 723 active members of the German Rheumatology Society (DGRh). Data on the hardware and software used and on Internet access were collected using a unilateral questionnaire. RESULTS: The response rate among the addressed rheumatologists was 55.3%, with 64.1% of members in private practice replying. Of those responding 85% have Internet access, with rheumatologists in private practice using the Internet significantly less frequently at work than those working at a hospital (42% vs 80%). The latter accordingly reported a higher proportion of medical Internet usage (69% vs 52%, p<0.001). The survey demonstrated that software for private practices and hospitals shows a very variable picture with a multiplicity of systems being used. CONCLUSION: Use of the Internet for communication in the "Systemic Inflammatory Rheumatic Diseases Network" is practicable in hospitals but clearly restricted in the private practice sector. The widely varying software used in hospitals and private practices underlines the need for standardized, comprehensive documentation systems to be developed. To ensure acceptance and broadly based application, they need to be integrated into the existing computer infrastructure. In this context, Internetbased applications offer new opportunities through the use of system-independent file formats.     

Knowledge of proprietary and generic drug names among hospital prescribers: time to mandate generic prescribing?

Although medical students are taught clinical pharmacology using generic drug names, prescribing in hospitals often uses brand names. As a result, junior doctors may be prescribing drugs without knowing their nature or mode of action. We carried out a knowledge survey of 81 medical students and doctors at a 650‐bed Australian teaching hospital to assess their knowledge of common drugs when given the brand name. We identified 20 commonly prescribed drugs and their brand names based on current hospital inpatients. No participant was able to provide the generic name, class or mode of action for all 20 drugs, with an average of 8.3 of 20 and 6.3 of the 10 most common drug names correctly identified. These data support calls to mandate prescribing using generic rather than brand names of drugs in hospitals.     

Nursing of tuberculosis patients--quality nursing to support patient's compliance to treatment

Tuberculosis control program in Japan focuses more on completion of treatment. The activities for patients to complete treatment are being actively done with collaboration between nurses of hospitals and public health nurses of the health centers. In 2000, Ministry of Health Welfare announced DOTS program version Japan. As a result, health centers of big cities implemented DOTS for homeless tuberculosis patients and hospitals DOT for in-patients. In 2003, the government demonstrated the scheme of DOTS strategy Expansion Program version Japan, which includes community DOTS types to be selected depend upon the risk of default with an individual patient. It is necessary to develop and utilize social and human resources in the community to expand surely supporting system for patient's compliance. Mutual understanding and collaboration of the relevant organizations become very important. In this symposium, four panels from hospital, clinic and public health center discuss on the current situation and challenge of supporting system and the assessment of treatment outcome. 1. DOTS implementation with collaboration on nursing activities between hospital and public health center in Kyoto Prefecture: Ikuyo HIROHATA (National Hospital Organization Minami Kyoto National Hospital). 2. From standpoint of clinical practice: Hidenori MASUYAMA (Japan Anti-Tuberculosis Association Shibuya Clinic). 3. The activities for case support based on DOTS Program in Wakayama Prefecture: Kimiko KAWASAKI (Tanabe Public Health Center, Wakayama Prefecture). 4. Assessment of supporting activities for patient's compliance: Tomoko TAKANO (Uki Public Health Center, Kumamoto Prefecture). Three speakers gave additional comments and advice on quality supporting and nursing activities for patient's compliance through good coordination between hospitals and publics health centers.     

Hygiene in endoscopy in the clinic and practice, 2003: Results of infection hygiene survey on endoscopy services in Frankfurt am Main by the public health service

Guidelines for reprocessing flexible endoscopes have been published in many countries. Compliance to the German guidelines, published in 2002 by the Commission on Hospital Hygiene and Infection Prevention on the Robert Koch Institute is mandatory in all endoscopic units, in hospitals as well as in private practices. Here, a survey of current reprocessing practices in an urban region in Germany is published, covering all hospitals and private practices in this region. MATERIAL AND METHODS: In summer 2003, all endoscopic units in Frankfurt/Main, Germany--15 hospitals and 23 private practices -- were visited by members of the public health service, using a checklist based on the recommendations of the German guideline. RESULTS: In these institutions, more than 70 000 endoscopic examinations per year are performed. 87 % (13 /15) of the hospitals and 43 % (10/23) of the practices, reported to conduct more than 1000 procedures per year. Great differences were found in hygienic quality comparing endoscopic units in hospitals and in private practices. In hospitals compliance with the guidelines was satisfactory. Main problems in the practices were: missing facilities for ultrasonic cleaning (74%) and sterilizing (43%), faults in reprocessing the bottle and tube for air/water-channel flushing (26%) which was filled in with water not sterilised (48%), storage of the endoscope with risk of recontamination (48%), missing routine-tests of the endoscopes after reprocessing (44%). Generally, hygienic conditions and procedures were worse in smaller units than in bigger ones. DISCUSSION: The data from Frankfurt hospitals are satisfactory. In private practices, however, especially in smaller ones, improvements are mandatory. Improvements should cover the quality of structure and process, i.e. specific education of the nurses, availability of ultrasonic cleaners and sterilizators and -- preferably -- automatic dishwashers, as well as implementation of a written protocol for hygiene in endoscopy, based on the German Guidelines.     

Collaboration between a local medical community and a university hospital

Here we report the current status and problems in collaboration between a local medical community and a university hospital. It is important for the university hospital to clearly define its role in the local medical community, collaborate with local medical and welfare institutes and establish a local medical and care network that supports patients and their families. For this purpose, the social service department is expected to play a role as a coordinator between the university hospital and the local medical community so that the patients can make the best use of medical and care resources.     

Health care market trends and the evolution of hospitalist use and roles

OBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists' services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002-2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3-4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals' and physicians' responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians' relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine's 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians' decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.     

A survey on Koreans’ preferred type of collaboration between conventional medical and traditional Korean medicine doctors

Although collaborative treatment by traditional Korean medicine doctors (KMDs) and medical doctors occurs, it is mainly done by referral. As no survey of the general public''s preference for the type of collaboration has ever been conducted, we aimed to investigate Koreans’ preferences for a collaborative treatment type.The responders were extracted by random digit dialing and then reextracted using the proportional quota sampling method by sex and age. From July to October 2017, telephone interviews were conducted and the participant responses regarding treatment history for spinal or joint diseases, experiences with collaborative treatment, and preferred type of collaborative treatment were recorded.Of the 1008 respondents, 44.64% reported a history of treatment for spinal or joint diseases at a medical institution. The concurrent collaborative treatment system, in which both KMDs and medical doctors are present in one location participating in the treatment concurrently, was the most preferred system among the respondents. Respondents who reported experience with traditional Korean medicine hospitals were more likely to prefer a one-stop treatment approach than those who did not have experience with traditional Korean medicine hospitals (adjusted odds ratio: 1.73; 95% confidence interval: 1.12–2.68). Respondents who were familiar with collaborative treatment but did not report any personal experience with it were more likely to prefer a one-stop treatment approach than those who were not familiar with collaborative treatment (adjusted odds ratio: 1.82; 95% confidence interval: 1.37–2.44).Koreans prefer a concurrent type of collaborative treatment system by KMDs and medical doctors. Therefore, efforts and support are needed to increase the application of the concurrent type of collaborative system.     

The importance of the examination of, education on, and infection control of tuberculosis in medical school hospitals in Japan

Since the incidence of tuberculosis (TB) has markedly decreased over the last half-century, dedicated TB hospitals in Japan have been reducing the beds or have been merging with other hospitals. In accordance with this situation, less than 30% of medical school hospitals (MSHs) have facilities for infectious TB patients. In the meantime, and contrary to the previous trend, elderly TB patients or those who have serious underlying diseases have been increasing. MSHs have therefore not only to take care of these patients, but at the same time they have to reform their TB education system in addition to upgrading TB infection control. To elucidate the current problem regarding TB in MSHs, the survey in the current study was performed for 80 MSHs in Japan in January 2002. Two sets of questionnaires were prepared and delivered to doctors in these hospitals. One set mainly asked about the status of TB examination and education, and was aimed at doctors in the division of respiratory diseases of the department of internal medicine (Rs); and the other mainly asked about the status of TB infection control and was aimed at doctors in the divisions of infectious diseases, or whoever in charge of hospital infection control (Is). Response rates from Rs and Is were 75.0% (60/80) and 65.0% (52/80), respectively. Seventy-three point three percent (44/60) of Rs and 73.1% (38/52) of Is were working in hospitals without TB beds. Because of the current incidence of TB, the number of TB patients they examined in a year was small (35/60 of hospitals examined less than 20 TB patients in a year). Although there were some experienced doctors on TB in each hospital, most MSHs had only a small number of experienced nurses. Nevertheless, 89.3% of doctors in MSHs (a total of 100/112 Rs and Is) believed that they required TB rooms exclusively for TB patients who have some underlying diseases, and for TB education. Regarding the role of MSHs for TB patients care, the majority of doctors (70.5% of Rs and 68.4% of Is) considered MSHs should be able to offer treatment to TB patients with underlying complications. As to the educational aspect, most medical schools (MSs) devoted little time to lectures on TB (the median was 1 to 1.5 hour); on the other hand, some MSs (31.8%: 14/44 of MSHs without TB rooms) included a clinical practices in TB hospitals for TB education, although its term was short. Regarding TB infection control issues, most of the MSHs had active infection control committees in their hospitals and TB was thought to be one of the most important targets for these committees. About 40% (20/51) of these hospitals over the past few years had experienced nosocomial TB infection due in part to the so called "Doctor's delay". As one of the strategies to prevent nosocomial TB infection, special education sessions, not only for staff and residents but also students, were therefore performed in 60.8% (31/51) of MSHs. As to the evaluation of the tuberculin skin test (TST) status of medical students, the two-step TST was performed in 47.1% (24/51) of MSs (as most Japanese underwent their BCG vaccination in their childhood) and 54.9% (28/51) of MSs had a BCG revaccination policy for TST negative students. Although steps toward reforms in TB issues in MSHs were slow, some minor progress had been made as compared with previous surveys performed by us and others. Even though the numbers of TB patients examined in MSHs have been smaller than before, MHSs still have to take care of some TB patients with some complications. A great deal of effort still needs to be expended to establish efficient and effective TB education and infection control systems. Even though many ideas have been put forward to improve the current situation, one of the most successful answers is to set up small number of special rooms, not only for TB patients but also for other airborne infectious diseases, in all MHSs. The other clue is to establish an intimate collaboration between MSHs and TB hospitals with regard to clinical TB education not only for medical students but also for medical staff.     

Hospital experience and mortality in patients with systemic lupus erythematosus: which patients benefit most from treatment at highly experienced hospitals?

OBJECTIVE: To determine if hospitalization at a hospital experienced in the treatment of systemic lupus erythematosus (SLE), compared to hospitalization at a less experienced hospital, is associated with decreased in-hospital mortality in all subsets of patients with SLE, or if the decrease in mortality is greater for patients with particular demographic characteristics, manifestations of SLE, or reasons for hospitalization. METHODS: Data on in-hospital mortality were available for 9989 patients with SLE hospitalized in acute care hospitals in California from 1991 to 1994. Differences in in-hospital mortality between patients hospitalized at highly experienced hospitals (those hospitals with more than 50 urgent or emergent hospitalizations of patients with SLE per year) and those hospitalized at less experienced hospitals were compared in patient subgroups defined by age, sex, ethnicity, type of medical insurance, the presence of common SLE manifestations, and each of the 10 most common principal reasons for hospitalization. RESULTS: In univariate analyses, in-hospital mortality was lower among those hospitalized at a highly experienced hospital for women, blacks, and Hispanics, and those with public medical insurance or no insurance. The risk of in-hospital mortality was similar between highly experienced and less experienced hospitals for men, whites, and those with private insurance. Patients with nephritis also had lower risks of in-hospital mortality if they were hospitalized at highly experienced hospitals, but this risk did not differ in subgroups with other SLE manifestations or subgroups with different principal reasons for hospitalization. In multivariate analyses, only the interaction between medical insurance and hospitalization at a highly experienced hospital was significant. Results were similar in the subgroup of patients with an emergency hospitalization (n = 2,372), but more consistent benefits of hospitalization at a highly experienced hospital were found across subgroups of patients with an emergency hospitalization due to SLE (n = 405). CONCLUSION: Risks of in-hospital mortality for patients with SLE were similar between highly experienced hospitals and less experienced hospitals for patients with private medical insurance, but patients without private insurance had much lower risks of mortality if hospitalized at highly experienced hospitals. The benefit of hospitalization at highly experienced hospitals was more consistent across subgroups of patients with a hospitalization due to SLE, suggesting that differences specifically in the treatment of SLE, rather than differences in the general quality of medical care, account for the lower mortality among patients with SLE hospitalized at highly experienced hospitals.     

Measuring the efficiency of dental departments in medical centers: a nonparametric analysis approach

Data envelopment analysis (DEA), a cross-sectional study design based on secondary data analysis, was used to evaluate the relative operational efficiency of 16 dental departments in medical centers in Taiwan in 1999. The results indicated that 68.7% of all dental departments in medical centers had poor performance in terms of overall efficiency and scale efficiency. All relatively efficient dental departments were in private medical centers. Half of these dental departments were unable to fully utilize available medical resources. 75.0% of public medical centers did not take full advantage of medical resources at their disposal. In the returns to scale, 56.3% of dental departments in medical centers exhibited increasing returns to scale, due to the insufficient scale influencing overall hospital operational efficiency. Public medical centers accounted for 77.8% of the institutions affected. The scale of dental departments in private medical centers was more appropriate than those in public medical centers. In the sensitivity analysis, the numbers of residents, interns, and published papers were used to assess teaching and research. Greater emphasis on teaching and research in medical centers has a large effect on the relative inefficiency of hospital operation. Dental departments in private medical centers had a higher mean overall efficiency score than those in public medical centers, and the overall efficiency of dental departments in non-university hospitals was greater than those in university hospitals. There was no information to evaluate the long-term efficiency of each dental department in all hospitals. A different combination of input and output variables, using common multipliers for efficiency value measurements in DEA, may help establish different pioneering dental departments in hospitals.     

Hospital infection control: old problem – evolving challenges

Hospital infection prevention and control (IPC) is often regarded by doctors as mundane and unnecessarily rigid, but the continued occurrence of preventable healthcare‐associated infections, increasing antimicrobial resistance (to which hospitals are major contributors) and rare, but potentially devastating hospital outbreaks of emerging infectious diseases, suggest that IPC must be taken seriously. Healthcare professionals often fail to comply with effective, evidence‐based IPC practices and there is ample evidence that doctors, generally, do so less consistently than nurses. However, doctors' practices are highly variable, apparently because of a perceived entitlement to clinical autonomy. In practice, most doctors observe safe IPC practices, most of the time. However, some are ignorant or dismissive of IPC policies and some respond angrily, when reminded. Among a small proportion of senior consultants, negative attitudes to IPC are perceived by their peers to correlate with a more general failure to meet their public hospital commitments, apparently because of conflicting demands, including private practice. The fact that breaches of IPC practice have significant, although often hidden, consequences indicates a need for continued improvement based on new strategies that might include: better surveillance, to identify and inform doctors of the true burdens of healthcare‐associated infections; professional self‐reflection on falsely dichotomous claims of medical professionalism namely: clinical autonomy versus regard for patient welfare by complying with ‘rules’ designed to protect them; and review of the consequences of recent changes in healthcare delivery, including proliferation of multiple, part‐time consultant contracts at the expense of public hospital culture and status.     

Administrative procedures in cases of medical errors: the jurisdiction of the hospitalist

The administrative jurisdiction is, with the exception of free practice within hospitals, that which judges whether actions of hospital doctors are at fault, and evaluates the harm done to the plaintiff. After a reminder of the fundamentals of medical liability as regards the administration, a short update on private practice in hospital, and the notion of fault being separate from the hospital function, the author analyses the important elements such as the concept of the preliminary decision and the status of the expert, and then a number of characteristic elements of this type of procedure, stressing in particular the absolute necessity of a perfectly kept hospital medical record.     

Significance of selective proximal vagotomy (spV) in the treatment of gastroduodenal ulcer in a district hospital of an occupational health service

In a small district hospital of the Factory Public Health the selective proximal vagotomy was introduced in conformity with the indicated standard operation technique in patients with gastroduodenal ulcer. This operation technique was based on the literature publications and on the own experiences within the methodical instructions in university hospitals. The importance of the selective proximal vagotomy (spV) was checked by means of 110 surgical operations, above, all for the reincorporation of the miners into the work procedure. Simultaneous the value of a continually dispensary care of the patients who underwent gastric operation was emphasized. The possibilities of the preoperative and postoperative diagnostic in a small district hospital were pointed out; at this a good cooperation and interdisciplinary collaboration with greater hospitals guarantees optimum investigation programmes. The regular medical supervision of operated patients is at the same time followed by a control of quality of the own performed work.     

Patients’ use of the internet for medical information

OBJECTIVES: To determine the percentage of patients enrolled in a primary care practice who use the Internet for health information, to describe the types of information sought, to evaluate patients' perceptions of the quality of this information, and to determine if patients who use the Internet for health information discuss this with their doctors. DESIGN: Self-administered mailed survey. SETTING: Patients from a primary care internal medicine private practice. PARTICIPANTS: Randomly selected patients ( N=1,000) were mailed a confidential survey between December 1999 and March 2000. The response rate was 56.2%. MEASUREMENTS AND MAIN RESULTS: Of the 512 patients who returned the survey, 53.5% (274) stated that they used the Internet for medical information. Those using the Internet for medical information were more educated ( P <.001) and had higher incomes ( P <.001). Respondents used the Internet for information on a broad range of medical topics. Sixty percent felt that the information on the Internet was the "same as" or "better than" information from their doctors. Of those using the Internet for health information, 59% did not discuss this information with their doctor. Neither gender, education level, nor age less than 60 years was associated with patients sharing their Web searches with their physicians. However, patients who discussed this information with their doctors rated the quality of information higher than those who did not share this information with their providers. CONCLUSIONS: Primary care providers should recognize that patients are using the World Wide Web as a source of medical and health information and should be prepared to offer suggestions for Web-based health resources and to assist patients in evaluating the quality of medical information available on the Internet.     

Jordan's government wrestles with health care and its economy

This paper presents the problems encountered by the government concerning health services provision during an economic crisis in Jordan. Despite an ample of new building houses, a great number of Jordanian families had difficulties in acquiring affordable housing since many are affected by high unemployment. The difficulty for Jordan is that economic development has been heavily influenced by factors outside the control of the government. The effect on the medical practitioner had been particularly severe. Private medical practitioners rarely receive more than two patients a day, thus few doctors have taken advantage of the high costs of private treatment in Jordanian hospitals and specialize in the export of patients to Iraq where costs are very low. The demand for private medicine is high because government hospitals are overcrowded, lack of modern treatment facilities, and are generally held in low esteem. As a result, Jordan's Ministry of Health had taken measures to guarantee competent services for the people through collaboration with the Jordan University Hospital. Also, the government is taking the necessary precautions on the upsurge of unemployment by regulating with the Labor Ministry, trade union leaders, and business representatives.     

Educating physicians and treating patients in the ambulatory setting. Where are we going and how will we know when we arrive?

We evaluated 15 group practices in general internal medicine in university hospitals with regard to access to and quality of care, patients' satisfaction with that care, and quality of residency education provided. We used these data to speculate about potential changes in ambulatory care programs in university teaching hospitals. All 15 practices participated for 4 years. One third of their patient population had no medical insurance. Practice patients had twice as many chronic illnesses as did the general population, and two fifths of patients stayed at least 2 years in the practice. Few faculty members spent more than 14 hours weekly in the practices, and housestaff worked an average of 4 hours per week. Patient waiting times did not meet ideal standards, but patient satisfaction was higher than in a general population. Compliance with quality of care criteria was not exceptional; for example, 10% of eligible patients received an annual influenza vaccination. Housestaff assigned a relatively low ranking to their educational experience in the practices. We recommend the institution of additional experimental programs in ambulatory care and housestaff education to improve the quality of care in the ambulatory setting.