Students sitting medical finals--ready to be house officers?

An initial survey of students approaching qualification and the preregistration house officer year revealed anxiety about competence in several important clinical skills. A questionnaire study was then undertaken to assess, first, the extent to which students had attained the skills required for the preregistration year and, second, the amount of training in these skills provided during the preregistration year. 122 medical students taking their final examinations were asked about training and practice in eight core clinical skills, and 84 graduates from the same school, approaching the end of their preregistration year, were asked about postgraduate training in these skills. The response rate of each group was 100%. Of the eight skills studied, most had been performed few times by the students at qualification. Less than half the current preregistration house officers could recall training being given in any of the skills studied. There were no significant differences in house-officer training between teaching hospitals and district general hospitals. Regarding needlestick injuries, nearly two-thirds of preregistration house officers were unable to recall any training at either undergraduate or postgraduate level. These results suggest that training in clinical skills can be improved. Training is already changing with use of clinical skills laboratories and logbooks. We also recommend mandatory needlestick training both in undergraduate programmes and in induction courses for preregistration house officers.     

Do junior house officers routinely test visual acuity and perform ophthalmoscopy?

Our objective was to assess junior house officer (JHO) practice of visual acuity testing and ophthalmoscopy in clerking patients. DESIGN: Cross-sectional questionnaire-based study using a standardised structured interview technique. SETTING: A Scottish university teaching hospital employing 65 JHOs. PARTICIPANTS: All medical and surgical JHOs from this hospital were interviewed over a three month period. MAIN OUTCOME MEASURES: Questionnaire-based data on the subjective responses studying current practice of visual acuity testing, and direct ophthalmoscopy with and without topical mydriatics. RESULTS: 18.5% and 4.6% of participants perform daily ophthalmoscopy and visual acuity testing respectively. Most do not routinely use the Snellen chart (80.0%) or topical mydriatics during ophthalmoscopy (75.4%). JHOs claimed these were not easily available in the wards. CONCLUSIONS: The majority of JHOs fail to test visual acuity or perform ophthalmoscopy in clerking patients. This study highlights the poor availability of Snellen charts, functioning ophthalmoscopes, and topical mydriatics in the wards. This warrants further investigation.     

Does a new undergraduate curriculum based on Tomorrow's Doctors prepare house officers better for their first post? A qualitative study of the views of pre‐registration house officers using critical incidents

INTRODUCTION: In 1994 Manchester University introduced an integrated undergraduate medical course using problem-based learning (PBL) throughout. The study reported here explored whether there were any differences between the new course graduates (NCGs) and the traditional course graduates (TCGs) in the types of scenarios they recalled as 'critical incidents', or challenging cases, while working as pre-registration house officers (PRHOs). The focus is on differences rather than causal links. METHOD: We used semistructured interviews to generate our data. Twenty-four traditional course graduates and 23 new course graduates were interviewed approximately 3 months after starting their first PRHO placement. RESULTS: We identified 4 types of critical incidents relating to: clinical practice; limitations of competence; emotional involvement; and communication. Traditional course graduates reported difficulties in making patient management decisions, whereas the NCGs were better at dealing with uncertainty, knowing their limits and asserting their rights for support. Communication difficulties and coping with emotional involvement were common across both groups of graduates and hence remain problems in relation to being prepared for the role of a PRHO. CONCLUSIONS: Graduates of the new, integrated curriculum seemed to be much better at dealing with uncertainty, knowing their personal limits and asserting their rights for support when they felt these limits had been reached. Communication difficulties and emotional involvement remain major factors in the transition from student to PRHO.     

Which physicians and practices are using electronic medical records?

Greater use of electronic medical records (EMRs) has the potential to improve the quality of medical care and has become a goal of the U.S. administration. According to the National Ambulatory Medical Care Survey, only an average of 17.6 percent of physicians reported use of EMRs in their office-based practices. The adoption rate did not increase from 2001 through 2003. Practices with more physicians and those owned by health maintenance organizations (HMOs) were significantly more likely to use this technology, but use varied little by the characteristics of individual physicians, the practice's scope of services, or the practice's sources of revenue.     

Physician assistants in occupational medicine: how do they compare to occupational physicians?

BACKGROUND: Physician assistants (PAs) have been present in occupational and environmental medicine (OEM) in the USA since 1971, yet remarkably little is known about their activity. METHODS: An administrative study of PA activities was undertaken and compared with the activities of physicians in the same occupational medicine setting. Patients were not triaged to either provider and all resources of care were recorded for the visit. An episode of care approach was used for the analysis. RESULTS: The characteristics of patients seen by each provider were similar in age, gender ratio and severity of injury. Physicians saw a mean of 2.9 patients/h and PAs 2.5, but PAs worked more hours and saw more patients per year than physicians. The average charge per patient visit and total charge for an episode of care were similar. Differences between PAs and physicians were seen in the areas of 'limited duty' duration given to patients and on average PAs prescribed 15 days and physicians 17 days. PAs referred a patient 19.7% of the time, while physicians referred 17.4%. Most of the referrals were to physical therapy. The salary of a physician, based on an hourly rate, was approximately twice as much as a PA. CONCLUSION: The use of PAs in OEM may represent a cost-effective advantage from an administrative standpoint. Clearly, more research is necessary in determining the role and utilization of PAs in OEM and how they may improve the delivery of physician services.     

When do older patients change primary care physicians?

BACKGROUND: Concerns have been raised about changes in the health care system that may disrupt continuity of care and thereby reduce the quality of that care. The purpose of this study was to look at the reasons that older patients give for changing primary care physicians (PCPs) and to look at relationships between the duration of the PCP-patient relationship and the perceived quality of primary care received. METHODS: We analyzed data collected during the first 2 years of a longitudinal study of primary care patients 65 years of age and older. Variables included sociodemographic characteristics, duration of relationship with current PCP, reasons for leaving last PCP, estimated numbers of visits to PCP, other clinics, and emergency departments, and admissions to hospitals and nursing homes in the last year, self-rated health, 2 measures of health-related quality of life, and the Components of Primary Care Index (CPCI). RESULTS: 799 patients of 23 PCPs were enrolled in year 1 of the longitudinal study, and 579 were re-evaluated in year 2. The mean and median PCP-patient relationship durations were 10.27 and 8 years, respectively. Duration of the PCP-patient relationship was associated with greater patient age, income, level of education, and frequency of visits to the PCP. Longer relationship duration was also associated with higher scores on all 8 CPCI subscales. The distribution of reasons for changing PCP was associated with duration of relationship; those with a longer relationship were more likely to change involuntarily. Insurance-related reasons for changing PCP were more common in those who had changed more recently. One hundred and fourteen (14%) changed PCP during the first year of the study. Three CPCI subscale scores predicted PCP change, accumulated knowledge, communication, and family orientation. Eighty-seven percent changed involuntarily, 44% for insurance-related reasons and 40% because their doctors had moved, retired, or died. CONCLUSIONS: Older patients, particularly those who are older and have more education and income, tend to stay with their PCPs until they are forced to change. The longer they stay in the relationship, the better they feel about the quality of the primary services they receive. Changes in the health care system may have increased the number of patients forced to change PCP.     

PURLs: Time to try this warfarin alternative?

Dabigatran appears to be as effective as warfarin in preventing stroke and thromboembolism in patients with atrial fibrillation--and is easier to use.