Specialty choice and understanding of primary care among Japanese medical students

To assess specialty choice and understanding of primary care among Japanese medical students, all students from seven Japanese medical schools (three public and four private) were surveyed, using a written questionnaire. A total of 3377 students provided data for the study. Of the students surveyed, 89.8% wanted to become clinicians, and 79.3% wanted to have general clinical ability. About half of the respondents, 54.9%, replied that they had some, or great, interest in primary care, but it was found that their understanding of primary care was inadequate. Almost half (56.3%) of the students answered that they had some idea of what a general practitioner did. This proportion was nearly the same through all years of medical school. While 1245 (36.9%) students (most of them in the fifth or sixth year) replied that they had received some clinical training while working in hospitals, only 203 (6.0%) students had worked in private clinics (the sites where most primary care is still provided), and 129 (3.8%) students had experience in providing home visits and home care. An even greater number, 64.3%, replied that they had inadequate information about the career options available to them. The study found that although many Japanese medical students want to obtain broad clinical competence, their understanding of primary care is insufficient. In order to increase the number of primary care providers the system of medical education in Japan must provide primary care doctors to act as role models, and must make available information about postgraduate primary care programmes. These programmes need to be increased, as do rewarding positions for programme graduates.     

The next phase of Title VII funding for training primary care physicians for America's health care needs

Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and ultimately to improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk.     

Environmental medicine: its introduction into a medical school primary care requirement

Summary. One hundred and twelve medical students participating in a required 6-week primary-care rotation completed a pretest of environmental medicine knowledge and attitudes at the start of the rotation and a similar posttest on the last day of the rotation. Control group students were to participate in the usual weekly didactic sessions of the clerkship. Intervention students were given a booklet describing environmental considerations in clinical medicine and introducing them to the concept of risk assessment, three computer-assisted instruction cases, and a problem-based learning (PBL) exercise involving role-play. Because voluntary compliance with evaluation forms was poor during year one, during the second year students in the intervention group were required to return evaluation forms in order to sit for the course final examination. Knowledge and attitudes of both intervention and control groups were compared at baseline and at the end of the rotation. Students in the intervention group also completed process evaluations of the intervention materials. Students in both intervention and control groups increased knowledge gains significantly during the second year of the intervention, while neither group improved during year 1. This may have been due to a ‘spill-over’ effect among primary-care teachers implementing the intervention. Students ranked both environmental and occupational medicine of least importance in their training compared with eight other aspects of medicine, and this ranking did not improve with intervention. The PBL exercise was well received by the students. Of 28 evaluations, 27 ranked the session in the highest 3 of a 5-part Likert scale for worthwhile content, and 24 would recommend the session to a friend. When asked to list the most important things learned, 23 mentioned learning to look for additional information, and 12 mentioned realizing that the doctor does not know everything (and should admit that).     

Attachment theory in health care: the influence of relationship style on medical students' specialty choice

INTRODUCTION: Converging sources suggest that patient-provider relationships in primary care are generally of greater intensity and duration than those in non-primary care specialties. In this study, we hypothesised that Year 2 medical students whose close relationships were characterised by security and flexibility would be more likely than students who were less comfortable in close relationships to plan to pursue primary over non-primary care postgraduate training. METHODS: We determined the relationship styles and demographic characteristics of 144 Year 2 medical students. We also gathered information regarding their predicted choices of postgraduate training, which were clustered into primary or non-primary care categories. We compared student choices with respect to their interpersonal relationship styles based on attachment theory. RESULTS: Prevalences of attachment styles were similar to those found in the general population, with 56% of students rating themselves as having a secure relationship style. Students with a secure style were more likely to choose primary care (61%) over non-primary care compared to those whose styles were characterised by self-reliance, support-seeking or caution (41% chose primary care). Compared to those with a secure relationship style, students with a cautious style [OR = 5.9 (1.9, 18.7)] and students with a self-reliant style [OR = 2.4 (0.96, 5.9)] were more likely to choose non-primary over primary care, after controlling for gender. CONCLUSIONS: Assessing relationship styles using attachment theory is a potentially useful way to understand and counsel medical students about specialty choice.     

Comparison of rural and non-rural students undertaking a voluntary rural placement in the early years of a medical course

OBJECTIVE: The experiences of rural and non-rural students undertaking a voluntary rural placement in the early years of a medical course were compared. METHOD: Eighty percent (28) of the rural and 70% (114) of the non-rural students completed a post-placement questionnaire. RESULT: The two groups did not differ on their overall rating of the placement, whether they felt welcome, adequacy of the time with doctors or their rating of the accommodation provided. However, 46% (13) of the rural students reported the placement had changed their feelings towards rural practice to the maximum/almost maximum extent compared with only 24% (27) of the non-rural students.     

Lung cancer screening practices of primary care physicians: results from a national survey

PURPOSE

Although current practice guidelines do not recommend screening asymptomatic patients for lung cancer, physicians may still order lung cancer screening tests. No recent national survey of health care professionals has focused on lung cancer screening. In this study, we examined the lung cancer screening practices of US primary care physicians and characteristics of those who order lung cancer screening tests.

METHODS

We conducted a nationally representative survey of practicing primary care physicians in 2006–2007. Mailed questionnaires assessed the physicians’ knowledge of lung cancer screening guidelines, beliefs about the effectiveness of screening tests, and ordering of screening chest radiograph, low-dose spiral computed tomography, or sputum cytology in the past 12 months. Clinical vignettes were used to assess the physicians’ intentions to screen asymptomatic 50-year-old patients with varying smoking histories for lung cancer.

RESULTS

A total of 962 family physicians, general practitioners, and general internists completed questionnaires (cooperation rate = 76.8%). Overall, 38% had ordered no lung cancer screening tests; 55% had ordered chest radiograph, 22% low-dose spiral computed tomography, and less than 5% sputum cytology. In multivariate modeling, physicians were more likely to have ordered lung cancer screening tests if they believed that expert groups recommend lung cancer screening or that screening tests are effective; if they would recommend screening for asymptomatic patients, including patients without substantial smoking exposure; and if their patients had asked them about screening.

CONCLUSIONS

Primary care physicians in the United States frequently order lung cancer screening tests for asymptomatic patients, even though expert groups do not recommend it. Primary care physicians and patients need more information about lung cancer screening’s evidence base, guidelines, potential harms, and costs to avert inappropriate ordering.     

What anatomy shall we teach medical and dental students in a primary health care curriculum?

The opinions of 142 doctors on the relevance of anatomy to the diagnosis and management of common clinical problems in their current medical and dental practice were analysed. This was in a bid to determine the relevant anatomy course content for the new primary health care oriented medical and dental curriculum of the College of Medicine, University of Lagos. The respondents gave high scores to the relevance of anatomy knowledge to the management of acute abdomen (mean = 3.5), dislocated shoulder (3.3), Colles' fracture (3.2), palmar space abscess (3.2), obstructed labour (3.2), carcinoma of the breast (3.2), ectopic pregnancy (3.1), flail chest (3.1) and upper respiratory obstruction (3.0). They gave minimal scores to helminthiasis (mean = 1.5) common cold and anaemia (1.6), sickle cell disease (1.7), gastroenteritis (1.8), dental abscess (2.0), hypertension (2.2) and asthma (2.2). A basis for selecting relevant anatomy course content is deduced for an undergraduate curriculum in which the responsibilities and competence of the graduates is known. A nationwide extension of the study, especially amongst general practitioners and first-line doctors in rural areas, would be useful for identification of health problems that require little or no knowledge of anatomy and which can be safely managed by lower cadres of health personnel, traditional practitioners and members of the lay community.     

On a European collaboration to identify organizational models,potential shortcomings and improvement options in out-of-hours primary health care

Background: Out-of-hours care (OOHC) provision is an increasingly challenging aspect in the delivery of primary health care services. Although many European countries have implemented organizational models for out-of-hours primary care, which has been traditionally delivered by general practitioners, health care providers throughout Europe are still looking to resolve current challenges in OOHC. It is within this context that the European Research Network for Out-of-Hours Primary Health Care (EurOOHnet) was established in 2010 to investigate the provision of out-of-hours care across European countries, which have diverse political and health care systems. In this paper, we report on the EurOOHnet work related to OOHC organizational models, potential shortcomings and improvement options in out-of-hours primary health care.

Needs assessment: The EurOOHnet expert working party proposed that models for OOHC should be reviewed to evaluate the availability and accessibility of OOHC for patients while also seeking ways to make the delivery of care more satisfying for service providers.

Outcomes: To move towards resolution of OOHC challenges in primary care, as the first stage, the EurOOHnet expert working party identified the following key needs: clear and uniform definitions of the different OOHC models between different countries; adequate—ideally transnational—definitions of urgency levels and corresponding data; and educational programmes for nurses and doctors (e.g. in the use of a standardized triage system for OOHC). Finally, the need for a modern system of data transfer between different health care providers in regular care and providers in OOHC to prevent information loss was identified.     

The effect of compulsory participation of medical students in problem-based learning

Problem-based learning (PBL) is an instructional method that has attracted many advocates since its introduction in medical education almost 20 years ago. PBL features the use of student-directed tutorials, medically relevant problems to set study objectives, and independent learning. Educators have worried that not all students will do well with this method. This study compared a group of students who had chosen to be in a PBL curriculum with a group who had not, as they undertook a curriculum that contained both PBL and lecture-based courses. Academic performance was virtually identical regardless of learning method. Students slightly favoured the courses that featured the method they had originally chosen, but a significantly larger proportion of students shifted their preference from the lecture to the problem-based approach than vice versa. Students' academic performance does not appear to suffer when they are involuntarily enrolled in a PBL curriculum and many come to prefer this type of curriculum.     

Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed‐effects specification to address selection, it is estimated that the switch to capitation leads to a short‐run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes‐related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.     

How adults' access to outpatient physician services relates to the local supply of primary care physicians in the rural southeast

OBJECTIVE: To examine how access to outpatient medical care varies with local primary care physician densities across primary care service areas (PCSAs) in the rural Southeast, for adults as a whole and separately for the elderly and poor. DATA SOURCES: Access data from a 2002 to 2003 telephone survey of 4,311 adults living in 298 PCSAs within 150 rural counties in eight Southeastern states were linked geographically with physician practice location data from the American Medical and American Osteopathic Associations and population data from the U.S. Census. STUDY DESIGN: In a cross-sectional study design, we used a series of logistic regression models to assess how 26 measures of various aspects of access to outpatient physician services varied for subjects arranged into five groups based on the population-per-physician ratios of the PCSAs where they lived. PRINCIPAL FINDINGS: Among adults as a whole, more individuals reported traveling over 30 minutes for outpatient care in PCSAs with more than 3,500 people per physician than in PCSAs with fewer than 1,500 people per physician (39.1 versus 18.5 percent, p<.001) and more reported travel difficulties. Otherwise, PCSA density of primary care physicians was unrelated to reported barriers to care, unrelated to people's satisfaction with care, and unrelated to indicators of people's use of services. Use rates of six recommended preventive health services varied in no consistent direction with physician densities. Among the elderly, only the proportion traveling over 30 minutes for care was greater in areas with lowest physician densities. Among subjects covered under Medicaid or uninsured, lower local physician densities were associated with longer travel time, difficulties with travel and reaching one's physician by phone, and two areas of dissatisfaction with care. CONCLUSIONS: For adults as a whole in the rural South and for the elderly there, low local primary care physician densities are associated with travel inconvenience but not convincingly with other aspects of access to outpatient care. Access for those insured under Medicaid and the uninsured, however, is in more ways sensitive to local physician densities.     

The feminization of the medical profession in Israel

Two factors have caused major changes in the gender composition of the Israeli medical profession in recent years: (i) a wave of immigration from the former USSR, which increased the doctor population by approximately 70% and which included a majority of women physicians, and (ii) the entry of more Israeli women into medical school. This report presents the current gender status of the Israeli medical profession, regarding students and physicians, and the choice of medical specialty and academic seniority, and compares gender differences in Israel with those in other countries.
Traditional patterns of specialization persist in Israel, with women still concentrated in primary care (family medicine, paediatrics and psychiatry). In addition, women still face obstacles in entering the more prestigious (mainly surgical) specialties. Whilst the number of women in academic medicine has increased over the last decade, women are still concentrated in the lowest echelons of academic medicine. However, the steady trend towards the feminization of medicine will inevitably lead to an increase of women in all areas of the medical profession. Because cross-cultural studies have repeatedly revealed that women doctors have a more humanistic and personalized approach to patient care, a higher ratio of women in the profession should have a qualitative effect in this direction, despite the bureaucratic and fiscal constraints incumbent upon practising doctors. As more women become role models for medical students, their approach will influence the education of the doctors of the future.     

Reducing unmet needs: a prevocational medical training program in public health medicine and primary health care in remote Australia

OBJECTIVES: To describe the development and implementation of a prevocational medical training program in public health medicine and primary health care in remote Australia and to evaluate the program's adherence to adult learning principles. METHODS: Reports, funding applications and other relevant material relating to the program were reviewed to document learning objectives, and teaching and program implementation strategies. RESULTS: The 24-week program employs two prevocational medical practitioners each year and comprises four weeks at Fremantle Hospital's sexual health clinic followed by 20 weeks in the Kimberley. Curriculum objectives include clinical and public health aspects of sexually transmitted infection management, immunisation, clinical audit and quality improvement, primary health care in remote Aboriginal communities, oral and written presentation skills and working as part of an interdisciplinary team. Teaching strategies used were in accordance with adult learning principles. CONCLUSIONS: Prevocational medical training in public health medicine and primary health care in remote Australia is achievable and reduces current gaps in prevocational medical education.     

Views of junior doctors on the specialist registrar (SpR) training scheme: qualitative study of UK medical graduates

OBJECTIVE: To report junior doctors' views on specialist registrar (SpR) training. DESIGN: In 1999, as part of ongoing studies of doctors' careers, we surveyed all doctors who had qualified from UK medical schools in 1993. Structured questions about recipients' careers were accompanied by a form inviting free text comments. Comments about the SpR scheme were extracted for analysis. RESULTS: Doctors commented that there were insufficient national training numbers (NTNs) for those who wanted them, and that more than the minimum entry requirements seemed necessary for shortlisting. Strengthening curricula vitae through research and published work could prolong the duration of training and did not guarantee success. Specialist registrar training was considered by some respondents to be narrow and inflexible, with service work taking priority over training needs. As a result, some respondents feared they would not be competent to practise as consultants. There was a perceived shortage of consultant vacancies and 6 months was considered insufficient time for obtaining a suitable post. DISCUSSION: It is inevitable that doctors may not necessarily be able to pursue their initially chosen career paths. Trainers need to provide realistic advice about career opportunities. Provision of information about NTN availability and formal career counselling could help to prevent delays in career progression. The shortened and more structured programme of training has reduced its flexibility in some doctors' experience. Improvements in educational content will need greater input from consultants, which may require an increase in consultant posts. Time will tell whether concerns about competence to practise as consultants and consultant post availability will be justified.     

Psychiatry as compared to other career choices: a survey of medical students in Hong Kong

A questionnaire was administered to two groups of medical students, one preclinical and the other clinical, to assess their career choices, opinions of six specialties (including internal medicine, general practice, obstetrics and gynaecology, paediatrics and psychiatry as well as surgery) and anxieties about psychiatry. It was found that both groups of students conceptualized clinicians according to stereotypes which were modified but not abated by clinical exposure. Although the clinical students compared to preclinical students attributed more positive personality traits to psychiatrists, students interested in taking up careers in psychiatry were few in both groups. Compared to the preclinical class, clinical students were less worried about disturbed patients and emotional involvement with patients, but were more concerned about their deficiency in knowledge and skills relevant to psychiatry.     

Gender in medicine: the views of first and fifth year medical students

This study of first and fifth year medical students found a general recognition among male and female students that gender affects future career choices and the ability to reach career goals. Females were seen as being disadvantaged both in terms of career choice and their ability to achieve career goals. These views are less abstract and more based upon the reality of personal experiences in clinical attachments among fifth year students. While both male and female students describe negative experiences of clinical training, female students were more likely to suffer discrimination because of their gender in certain specialties, such as surgery, and to be dissuaded from pursuing a career in that specialty. Despite the general awareness of the effects of gender in medicine this did not appear to have an effect upon personal career choice. However, some female students were considering career choices at an early stage in their career based on accommodating their future desire to have a family life. Over half of all male and female fifth year students reported that having time for their family was an important consideration in choosing a career.     

Refugees and medical student training: results of a programme in primary care

CONTEXT: Medical schools have responded to the increasing diversity of the population of the USA by incorporating cultural competency training into their curricula. This paper presents results from pre- and post-programme surveys of medical students who participated in a training programme that included evening clinical sessions for refugee patients and related educational workshops. METHODS: A self-assessment survey was administered at the beginning and end of the academic year to measure the cultural awareness of participating medical students. RESULTS: Over the 3 years of the programme, over 133 students participated and 95 (73%) completed pre- and post-programme surveys. Participants rated themselves significantly higher in all 3 domains of the cultural awareness survey after completion of the programme. CONCLUSIONS: The opportunity for medical students to work with refugees in the provision of health care presents many opportunities for students, including lessons in communication, and scope to learn about other cultures and practise basic health care skills. An important issue to consider is the power differential between those working in medicine and patients who are refugees. To avoid reinforcing stereotypes, medical programmes and medical school curricula can incorporate efforts to promote reflection on provider attitudes, beliefs and biases.     

Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.