A national survey of flexible sigmoidoscopy training in primary care graduate and postgraduate education programs

OBJECTIVES: Expanding the pool of primary care endoscopists to perform flexible sigmoidoscopy (FS) has been advocated as a strategy for building colorectal cancer screening capacity. The principal aim of this study was to evaluate the availability and structure of FS training among internal medicine (IM), family practice (FP), physician assistant (PA), and nurse practitioner (NP) training programs. METHODS: A postal survey of all accredited IM (n = 445), FP (n = 471), PA (n = 118), and NP (n = 149) training programs nationwide was conducted. The primary outcome was the proportion of programs offering or mandating FS training; and secondary outcomes, if applicable, were the number of participating trainees, the number of required procedures, the availability of instruction in endoscopic biopsy technique, mentors, and barriers. RESULTS: The overall response rate was 63%. Most IM (89%) and FP (99%) programs offered FS training versus only 12% of PA and 0% of NP programs. Family practice programs were more likely to offer training (p < 0.0001), require training (p < 0.0001), and teach biopsy techniques (p < 0.0001); Internal medicine programs were more likely to have minimum requirements (p < 0.0001) and required >/= 25 procedures per trainee (p < 0.0001). Physician assistant programs were less structured and often lacked minimum requirements. CONCLUSIONS: Flexible sigmoidoscopy training is widely available among FP and IM programs but more restricted or nonexistent among PA and NP programs. The lack of minimum standards for ensuring competency highlights the need for a standardized credentialing process.     

Financing long-term care. The growing dilemma

The financing of long-term care is one of the largest and most vexing health care problems facing our society. The problem will be further exacerbated when the rate of growth in the number of persons needing long-term care is further accelerated by the graying of those in the "baby boom" generation. The current financing mechanism, which relies almost entirely on concurrent funding through either a means tested welfare program (Medicaid) or self-pay, is inequitable and inadequate even for our present needs. Despite the magnitude of the problem, only recently has sufficient attention been focused on finding alternatives to the current means of financing long-term care. The search for a solution has been hampered by multiple, and sometimes conflicting, policy and political considerations. After reviewing the demographic and social roots of our current dilemma and listing the major alternatives for financing long-term care, a series of basic principles and definitions are reviewed. These elements are meant to serve as guidelines to compare and evaluate the growing number of proposals which seek to create a more effective and equitable system for financing long-term care. Future articles in this section will detail some of the more promising approaches to the dilemma of financing long-term care.     

Incorporating palliative care into primary care education

Summary  The confluence of enhanced attention to primary care and palliative care education presents educators with an opportunity to improve both (as well as patient care) through integrated teaching. Improvements in palliative care education will have benefits for dying patients and their families, but will also extend to the care of many other primary care patients, including geriatric patients and those with chronic illnesses, who make up a large proportion of the adult primary care population. In addition, caring for the dying, and teaching others to carry out this task, can be an important vehicle for personal and professional growth and development for both students and their teachers. Developed for the National Consensus Conference on Medical Education for Care Near the End of Life, Washington, D.C., May 16–17, 1998. Support for the National Consensus Conference on Medical Education was provided by the Project on Death in America of the Open Society Institute and by the Robert Wood Johnson Foundation (grant 029360). Helpful editorial suggestions were provided by J. Andrew Billings, MD, and David Barnard, PhD.     

Supporting primary care medical education

A number of fundamental issues must be considered in preparing the education system to produce more primary care physicians. Governmental controls and redirection of resources will force significant changes in the structuring of approaches to both undergraduate and graduate education in primary care. Particularly challenging will be restructuring and funding medical student programs in primary care, given a nearly certain requirement that more than 50% of medical school graduates enter primary care disciplines. Institutions will need to make strategic resource allocations to compete for the funding once the allocation process begins. Educational institutions will also face a cultural adaptation to primary care as an educational priority. This paper presents a model to study costs and funding for residency programs as they move from the traditional inpatient orientation to an outpatient focus. The authors suggest that for medical student education, the development of large academic health care systems may make funding primary care education more feasible.     

Supporting primary care medical education

A number of fundamental issues must be considered in preparing the education system to produce more primary care physicians. Governmental controls and redirection of resources will force significant changes in the structuring of approaches to both undergraduate and graduate education in primary care. Particularly challenging will be restructuring and funding medical student programs in primary care, given a nearly certain requirement that more than 50% of medical school graduates enter primary care disciplines. Institutions will need to make strategic resource allocations to compete for the funding once the allocation process begins. Educational institutions will also face a cultural adaptation to primary care as an educational priority. This paper presents a model to study costs and funding for residency programs as they move from the traditional inpatient orientation to an outpatient focus. The authors suggest that for medical student education, the development of large academic health care systems may make funding primary care education more feasible.     

The effect of primary care training on patient satisfaction ratings

This study examines the association between type of internal medicine training and satisfaction ratings among 509 patients who visited the clinic of an urban teaching hospital over a 3-month period in 1994. When controlling for patient, health-system, and other resident factors, primary care training was significantly associated with higher satisfaction ratings (cumulative odds ratio 1.53; 95% confidence interval 1.04, 2.25; p = .031) than categorical training. Using satisfaction ratings to rank the residents without adjusting for patient and health-system factors would have correctly classified only 27% of the residents in the lowest quartile. These findings have implications for both the education and potential employment of internists.     

Utilizing education infrastructure for primary health care

Sahar Matha Secondary School and Ghoretar Health Post serve approximately 30,000 people living in scattered communities over the steep foothills of the Himalaya in East Nepal. A pilot health education and sanitation project was implemented with the objectives of giving the secondary school students the knowledge and skills necessary for building domestic pit latrines in their villages. It was hoped that the students could be motivated to create enough awareness of the need for domestic pit latrines so that latrines would continue to be built after the pilot phase of the project. At the end of the 4 week building period there were 150 completed domestic pit latrines and 45 pits or partially complete latrines. Seeing pit latrine in Ghoretar at the school and health post had not been enough to motivate people to build their own domestic pit latrine. It seemed that people could understand the convenience of privacy in an area where there was no jungle cover, but did not appreciate the hygiene reasons for using pit latrines. It is now planned to extend the project into the 19 schools which feed the 2ndarty school, with the 2ndary school boy and girl scouts taking the health messages to the primary schools. Particular attention will be given to the teaching of modes disease transmission. So that the villagers can use their latrines hygienically.     

Continuing education in rheumatoid arthritis for the primary care physician.

An educational program in rheumatoid arthritis was developed for primary care practitioners. This program is community based and utilizes physicians, identified by their peers as being influential, for the dissemination of information. A marked change in knowledge has been noted in those completing the program, but further followup is needed to determine if a change in the care of patients with rheumatoid arthritis will also result.     

Residency training in primary care internal medicine. Report of an operational program.

The Primary Care Program at the Massachusetts General Hospital is designed to develop competence in the full range of problems encountered by general internists delivering primary care. House staff spend 3 years in the program, which starts with internship, includes a senior residency, and fulfills the requirements for board eligibility in internal medicine. Half of the training is provided in outpatient care settings. House staff assume responsibility for organization and operation of an ambulatory medical unit. In addition, there is supervised instruction in office gynecology, orthopedics, ear, nose and throat, dermatology, and psychiatry. Close integration with the traditional inpatient-oriented training program is maintained to ensure commensurate growth and competence in management of acute, life-threatening disease.     

Direct care workers' recommendations for training and continuing education

Training of direct care workers (DCWs) varies depending upon the setting in which they work and the state in which they are trained. Evidence points to the importance of adequate training as critical to DCW job satisfaction and reduction in turnover. Several approaches have been taken to enhance the training of DCWs with the objective that as job satisfaction increases, the quality of care provided to consumers will also be enhanced. Based on a sample of 644 DCWs across the nursing home, assisted living, and home health settings, we share DCWs' perceptions and recommendations for better training and continuing education.     

Gerontological education in Japan--geriatric education and training.

There are 13 academic geriatric departments among 80 medical schools in Japan as of November 1991. The first independent department was established in 1962 at Tokyo University. The undergraduate education program includes lectures in geriatrics (20 hours/year in 11/12 medical schools), bedside teaching at geriatric ward (6/12 medical schools, 66 hours on average per year). The theme of lectures are diverse and incorporate all the three major fields in gerontology: biology of aging, clinical geriatrics and socio-economical aspects of aging society. The postgraduate geriatric education is carried out mainly at university setting and most of the medical schools (83%) accept graduate students who are trained at independent geriatric ward (92%) as well as at outpatient clinics. In 1989, Japan Geriatrics Society started a new certification system by which 687 MDs have been temporarily certified in geriatrics. The first examination will be given by the society in 1992 and the eligibility to sit in the examination requires three years geriatrics fellowship after certification in medicine or general surgery. The curriculum proposed by the society shares many items of training in common with those found in north American and in Europe. Some points of suggestions and recommendations were presented for future improvement in the education of gerontology in Japan.     

Doctoral clinical geropsychology training in a primary care setting

Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica, to clinical psychology doctoral students within a large urban professional psychology program. In an innovative effort to provide the most disadvantaged elderly with comprehensive mental health treatment and maximize trainee exposure to an interdisciplinary treatment model, the program also pairs selected doctoral psychology trainees with medical residents to optimize integrated mental health service delivery for primary care elderly. The program has the following core objectives: (1) Infuse the mental health and aging knowledge base into the regular graduate curriculum; (2) Provide interdisciplinary training in geropsychological diagnostic and consultative services within an urban primary care setting; (3) Provide interdisciplinary training in the practice of psychological and neuropsychological evaluation of elderly; (4) Provide training in geropsychological psychotherapeutic intervention, including individual, couples/family, and brief/psycho-educational therapies with outpatient older adults. These objectives are achieved by pooling the resources of a graduate school of psychology, a local public hospital, and an academic medical center to achieve educational and clinical service goals.     

The irritable bowel syndrome. A continuing dilemma

This article deals with the dilemmas in the definition, diagnostic work-up, and treatment of patients with the irritable bowel syndrome. The data presented are a blend of scientific insight to date and more than four decades of clinical experience with this disorder.