The implications of the hospitalist phenomenon

OBJECTIVE

To evaluate the effect of 2 different systems of hospital care by means of a literature review.

QUALITY OF EVIDENCE

Many areas remain unclear because several of the studies are opportunistic and report only isolated experiences or simple before-after observations. Few studies are really experimental, and all were conducted in academic settings, which limits their validity outside these settings.

MAIN MESSAGE

The evidence supports the use of hospitalists who devote a minimum of 2 months each year to hospital work and practice full-time on the wards. More often than not, costs are reduced and better education for residents is provided with the hospitalist system. An important point regarding quality of care is that mortality rates are similar with both systems.

CONCLUSION

Some questions remain unanswered. For example, what is the best type of training for preparing residents for hospital work and what is the best way for physicians to maintain their skills in this area?Au Canada et aux États-Unis, de plus en plus de médecins consacrent des blocs de temps exclusivement aux soins de patients hospitalisés plutôt que de venir quotidiennement à l’hôpital suivre leurs propres patients. Dans la majorité des hôpitaux québécois, les soins aux personnes hospitalisées relèvent de la responsabilité des médecins de famille, présents dans l’hôpital toute la journée, avec les autre spécialistes comme consultants. De plus en plus de médecins de famille ne pratiquent qu’en centre hospitalier¹.Le Collège des médecins de famille du Canada affirmait en 2003, qu’on ne peut sous-estimer l’importance d’avoir des médecins de famille compétents qui dispensent leurs soins au chevet du malade². Mais on concède une absence de données probantes pour corroborer cette affirmation. Aux États-Unis, les médecins hospitaliers travaillent dans un seul hôpital en y consacrant des plages de temps continues d’une durée de 2 à 6 mois par année^3–5. Le sentiment d’appartenance à un lieu hospitalier caractérise les médecins hospitaliers américains^6–8. Les médecins hospitaliers gèrent l’épisode de soins en remplacement du médecin de première ligne qui, auparavant, suivait son patient au moyen d’une visite quotidienne. Le nombre de médecins hospitaliers connaît même une accélération croissante^9,10.L’intérêt est grandissant au Canada^6,11. Une tension initiale avec les médecins de famille est souvent manifeste. Dans certains cas, c’est une source directe d’échecs^12–14. La mise en place d’un tel système exige des précautions et pose certains risques. Par exemple, il existe un risque de rupture d’information au sujet du patient, par opposition à la continuité garantie si le médecin traitant à l’hôpital est le même qu’au bureau^6,15–17.L’utilisation adéquate des meilleurs systèmes d’information ne peut que partiellement garantir le transfert d’information¹¹. L’introduction des médecins hospitaliers s’accompagne souvent de nouveaux agencements organisationnelsdont une gestion plus proactive et intense de l’épisode de soins^7,18,19.Le phénomène des médecins hospitaliers soulève plusieurs questions interpellant aussi bien les décideurs gouvernementaux que les départements universitaires de médecine familiale. Le but de cet article est de découvrir, à l’aide d’une revue systématique des ouvrages scientifiques, les données connues sur les coûts, la qualité des soins, la satisfaction des usagers et des médecins et la qualité de l’enseignement. À cause de leur intérêt particulier, les auteurs détailleront les résultats concernant ce dernier facteur.     

Predicting international medical graduate success on college certification examinations: Responding to the Thomson and Cohl judicial report on IMG selection

Objective

To determine predictors of international medical graduate (IMG) success in accordance with the priorities highlighted by the Thomson and Cohl judicial report on IMG selection.

Design

Retrospective assessment using regression analyses to compare the information available at the time of resident selection with those trainees’ national certification examination outcomes.

Setting

McMaster University in Hamilton, Ont.

Participants

McMaster University IMG residents who completed the program between 2005 and 2011.

Main outcome measures

Associations between IMG professional experience or demographic characteristics and examination outcomes.

Results

The analyses revealed that country of study and performance on the Medical Council of Canada Evaluating Examination are among the predictors of performance on the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada certification examinations. Of interest, the analyses also suggest discipline-specific relationships between previous professional experience and examination success.

Conclusion

This work presents a useful technique for further improving our understanding of the performance of IMGs on certification examinations in North America, encourages similar interinstitutional analyses, and provides a foundation for the development of tools to assist with IMG education.     

Residents’ perceptions of patient management and the value placed on family medicine: Quebec perspective

Objective

To document the perceptions that family medicine residents have of patient management.

Design

Bilingual, quantitative questionnaire consisting of 10 questions.

Setting

Quebec.

Participants

All (n = 747) family medicine residents in Quebec.

Main outcome measures

The questionnaire was designed to capture residents’ perceptions of patient management, their plans to incorporate patient management into their practice, and how they thought this aspect of family medicine practice should be promoted.

Results

In all, 289 residents (38.7%) completed the questionnaire. Of these, 201 reported that they planned to accept patients during their first 5 years of practice. The most common inhibiting factors were the difficulty of taking time off, complex cases, and the responsibilities that come with continuity of care. Neither Quebec’s regional medical staffing plans nor its specific medical activities emerged as important inhibiting factors. Respondents indicated that raising the profile of family medicine could be achieved by promoting it to medical students, changing the institutional culture, and increasing the visibility of family medicine residents and supervisors on the teams working in training settings.

Conclusion

Quebec residents plan to include patient management in their practices. However, solutions must be found for the heavy burden of responsibility that comes with an office practice and for continuing to make patient management appealing to young family physicians.The cornerstone of family medicine is patient management. And yet, in spite of the efforts that have been made to make the inclusion of patient management in one’s medical practice attractive, it is a different story in the field. In a study of physicians in general practice conducted by the Fédération des médecins omnipraticiens du Québec in 2006 and 2007,¹ 64% of young physicians had chosen to work primarily in secondary care settings. In addition, although 60% of family physicians practised primary care, more than 64% had been in practice for longer than 20 years, compared with 14% who had practised for less than 10 years.¹ Data collected in 2010 show that family physicians with 15 years of practice or less work in hospitals 70% of the time.² The shortage of Quebec physicians delivering patient management is alarming: 1 in 5 Quebec residents does not have a family physician.³ Secondary medical care is just as important to the proper functioning of Quebec’s health care system as primary care is. Reconciling these 2 aspects of the system, which are so closely linked when family medicine is promoted, is essential to the survival of this specialty, which affects both the delivery of patient care in the physician’s office and the practice of general medicine in a hospital setting.Because most young physicians decide during their residency whether they will provide patient management, we believe that it is important to know what students currently doing their residency plan to practise, and to ask them how patient management could be portrayed as a stimulating and enriching way to practise family medicine. We also believe that it is important to highlight factors that, according to residents, could help to promote family medicine, with patient management as a central focus. To begin evaluating these complex, yet important, aspects, we asked the 2011 and 2012 cohorts of family medicine residents about their plans regarding patient management and their perceptions of the value placed on family medicine.     

Debiasing the hidden curriculum: academic equality among medical specialties

Objective

To compare the academic performance of students who entered family medicine residency programs with that of students who entered other disciplines and discern whether or not family physicians are as academically talented as their colleagues in other specialties.

Design

Retrospective quantitative study.

Setting

University of Calgary in Alberta.

Participants

Three graduating classes of students (2004 to 2006) from the University of Calgary medical school.

Main outcome measures

Student performance on various undergraduate certifying examinations in years 1, 2, and 3, along with third-year in-training evaluation reports and total score on the Medical Council of Canada Qualifying Examination Part I.

Results

Complete data were available for 99% of graduates (N = 295). In the analysis, residency program (family medicine [n = 96] versus non–family medicine [n = 199]) served as the independent variable. Using a 1-way multivariate ANOVA (analysis of variance), no significant difference among any of the mean performance scores was observed (F₅₂₈₉ = 1.73, P > .05). Students who entered family medicine were also well represented within the top 10 rankings of the various performance measures.

Conclusion

The academic performance of students who pursued careers in family medicine did not differ from that of students who chose other specialties. Unfounded negativity toward family medicine has important societal implications, especially at a time when the gap between the number of family physicians and patients seeking primary care services appears to be widening.     

Validation of a large-scale clinical examination for international medical graduates

Objective

To evaluate a new examination process for international medical graduates (IMGs) to ensure that it is able to reliably assign candidates to 1 of 4 competency levels, and to determine if a global rating scale can accurately stratify examinees into 4 levels of learners: clerks, first-year residents, second-year residents, or practice ready.

Design

Validation study evaluating a 12-station objective structured clinical examination.

Setting

Ontario.

Participants

A total of 846 IMGs, and an additional 63 randomly selected volunteers from 2 groups: third-year clinical clerks (n = 42) and first-year family medicine residents (n = 21).

Main outcome measures

The accuracy of the stratification of the examinees into learner levels, the impact of the patient-encounter ratings and postencounter oral questions, and between-group differences in total score.

Results

Reliability of the patient-encounter scores, postencounter oral question scores, and the total between-group difference scores was 0.93, 0.88, and 0.76, respectively. Third-year clerks scored the lowest, followed by the IMGs. First-year residents scored highest for all 3 scores. Analysis of variance demonstrated significant between-group differences for all 3 scores (P < .05). Postencounter oral question scores differentiated among all 3 groups.

Conclusion

Clinical examination scores were capable of differentiating among the 3 groups. As a group, the IMGs seemed to be less competent than the first-year family medicine residents and more competent than the third-year clerks. The scores generated by the postencounter oral questions were the most effective in differentiating between the 2 training levels and among the 3 groups of test takers.     

Determinants of first practice location: Among Manitoba medical graduates

Objective

To help understand physician movement out of Manitoba by determining the factors that influence Manitoba medical graduates’ choices about practice locations.

Design

Cross-sectional, within-stage, mixed-model survey.

Setting

Manitoba.

Participants

All University of Manitoba medical graduates from classes 1998 to 2009 for whom we had valid contact information (N = 912 of 943 graduates) were invited in August 2009 to participate in a survey.

Main outcome measures

Demographic information; ratings, on a 5-point scale, of the importance when choosing first practice locations of 12 practice characteristics, 3 recruitment strategies, and 4 location characteristics listed in the survey; free-text narratives on unlisted factors; and estimates of likely practice location upon completion of training for recent graduates still in residency training.

Results

Completed surveys were received from 331 (35.1%) graduates of the surveyed classes, 162 (53.3%) of whom chose Manitoba for their first practice location. Multiple regression analyses indicated that graduates choosing Manitoba for their first practice location were significantly more likely to have done their residency training in Manitoba (P < .05), whether or not they gave a high rating to the importance of being near family and friends. Also, graduates choosing Manitoba were significantly more likely to be recent graduates (P = .007) and less likely to be members of a visible minority (P = .018). These associations were robust even when analyses were restricted to responses from practitioners without cause to estimate practice locations. Early self-selection of graduates during entry into specific residency programs, results of the residency match process, and “putting down roots” during residency years were 3 important interrelated themes identified through qualitative analyses.

Conclusion

Residency education in Manitoba is the overwhelming factor influencing graduates’ choice of Manitoba as their first practice location, regardless of graduates’ rating of the importance of being near family or friends. Graduates’ narratives provided insights into the complexities of choosing practice locations and enhanced the interpretive and theoretical validity of the study findings. More extensive studies involving all Canadian residents could further define the role residency location plays in physician practice location.     

Residency research requirements and the CanMEDS-FM scholar role: Perspectives of residents and recent graduates

Objective

To explore the perspectives of family medicine residents and recent family medicine graduates on the research requirements and other CanMEDS scholar competencies in family practice residency training.

Design

Semistructured focus groups and individual interviews.

Setting

Family practice residency program at the University of British Columbia in Vancouver.

Participants

Convenience sample of 6 second-year family medicine residents and 6 family physicians who had graduated from the University of British Columbia family practice residency program within the previous 5 years.

Methods

Two focus groups with residents and individual interviews with each of the 6 recently graduated physicians. All interviews were audiotaped, transcribed, and analyzed for thematic content.

Main findings

Three themes emerged that captured key issues around research requirements in family practice training: 1) relating the scholar role to family practice, 2) realizing that scholarship is more than simply the creation or discovery of new knowledge, and 3) addressing barriers to integrating research into a clinical career.

Conclusion

Creation of new medical knowledge is just one aspect of the CanMEDS scholar role, and more attention should be paid to the other competencies, including teaching, enhancing professional activities through ongoing learning, critical appraisal of information, and learning how to better contribute to the dissemination, application, and translation of knowledge. Research is valued as important, but opinions still vary as to whether a formal research study should be required in residency. Completion of residency research projects is viewed as somewhat rewarding, but with an equivocal effect on future research intentions.     

Real-Time Continuous Glucose Monitoring Significantly Reduces Severe Hypoglycemia in Hypoglycemia-Unaware Patients With Type 1 Diabetes

OBJECTIVE

To evaluate the effect of continuous glucose monitoring (CGM) on the frequency of severe hypoglycemia (SH) in patients with established hypoglycemia unawareness.

RESEARCH DESIGN AND METHODS

We conducted a retrospective audit of 35 patients with type 1 diabetes and problematic hypoglycemia unawareness, despite optimized medical therapy (continuous subcutaneous insulin infusion/multiple daily insulin injections), who used CGM for >1 year.

RESULTS

Over a 1-year follow-up period, the median rates of SH were reduced from 4.0 (interquartile range [IQR] 0.75–7.25) episodes/patient-year to 0.0 (0.0–1.25) episodes/patient-year (P < 0.001), and the mean (±SD) rates were reduced from 8.1 ± 13 to 0.6 ± 1.2 episodes/year (P = 0.005). HbA_1c was reduced from 8.1 ± 1.2% to 7.6 ± 1.0% over the year (P = 0.005). The mean Gold score, measured in 19 patients, did not change: 5.1 ± 1.5 vs. 5.2 ± 1.9 (P = 0.67).

CONCLUSIONS

In a specialist experienced insulin pump center, in carefully selected patients, CGM reduced SH while improving HbA_1c but failed to restore hypoglycemia awareness.Although real-time continuous glucose monitoring (CGM) has been shown in randomized controlled trials to improve glycemic control and mild-to-moderate hypoglycemia, studies to date have not shown convincing reductions in severe hypoglycemia (SH) (1,2). Clinically, CGM may benefit patients with impaired awareness of hypoglycemia (IAH), who have an increased risk of SH (3), by alerting them to impending hypoglycemia, and thus providing them with “technological” awareness to replace the loss of their “physiological” awareness. In our clinical service, across two associated tertiary hospitals, we have obtained case-specific funding for CGM for 35 patients with type 1 diabetes, IAH, and problematic hypoglycemia limiting daily activities during intensified insulin therapy. This audit evaluates outcomes at 1 year to see whether the use of CGM can reduce SH or improve awareness.     

Pharmacists teaching in family medicine residency programs: National survey

Objective

To determine the percentage of family medicine residency programs that have pharmacists directly involved in teaching residents, the types and extent of teaching provided by pharmacists in family medicine residency programs, and the primary source of funding for the pharmacists.

Design

Web-based survey.

Setting

One hundred fifty-eight resident training sites within the 17 family medicine residency programs in Canada.

Participants

One hundred residency program directors who were responsible for overseeing the training sites within the residency programs were contacted to determine the percentage of training sites in which pharmacists were directly involved in teaching. Pharmacists who were identified by the residency directors were invited to participate in the Web-based survey.

Main outcome measures

The percentage of training sites for family medicine residency that have pharmacists directly involved in teaching residents. The types and the extent of teaching performed by the pharmacists who teach in the residency programs. The primary source of funding that supports the pharmacists’ salaries.

Results

More than a quarter (25.3%) of family medicine residency training sites include direct involvement of pharmacist teachers. Pharmacist teachers reported that they spend a substantial amount of their time teaching residents using a range of teaching modalities and topics, but have no formal pharmacotherapy curriculums. Nearly a quarter (22.6%) of the pharmacists reported that their salaries were primarily funded by the residency programs.

Conclusion

Pharmacists have a role in training family medicine residents. This is a good opportunity for family medicine residents to learn about issues related to pharmacotherapy; however, the role of pharmacists as educators might be optimized if standardized teaching methods, curriculums, and evaluation plans were in place.     

Practice and payment preferences of newly practising family physicians in British Columbia

Objective

To examine the remuneration model preferences of newly practising family physicians.

Design

Mixed-methods study comprising a cross-sectional, Web-based survey, as well as qualitative content analysis of answers to open-ended questions.

Setting

British Columbia.

Participants

University of British Columbia family practice residents who graduated between 2000 and 2009.

Main outcome measures

Preferred remuneration models of newly practising physicians.

Results

The survey response rate was 31% (133 of 430). Of respondents, 71% (93 of 132) preferred non–fee-for-service practice models and 86% (110 of 132) identified the payment model as very or somewhat important in their choice of future practice. Three principal themes were identified from content analysis of respondents’ open-ended comments: frustrations with fee-for-service billing, which encompassed issues related to aggravations with “the business side of things” and was seen as impeding “the freedom to focus on medicine”; quality of patient care, which embraced the importance of a payment model that supported “comprehensive patient care” and “quality rather than quantity”; and freedom to choose, which supported the plurality of practice preferences among providers who strived to provide quality care for patients, “whatever model you happen to be working in.”

Conclusion

Newly practising physicians in British Columbia preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.     

DESCRIPTIVE ANALYSIS OF PITCH VOLUME IN SOUTHEASTERN CONFERENCE BASEBALL PITCHERS

Background:

Representative data on typical pitch volume for collegiate pitchers functioning in their specific roles is sparse and is needed for training specificity.

Objective:

To report pitch volumes in Division I collegiate pitchers. The authors hypothesize that pitcher role will result in different pitch volumes.

Methods:

Pitchers from twelve Division I collegiate baseball teams pitch volume during the 2009 baseball season was retrospectively reviewed through each team''s website. The number of pitches and innings pitched for each pitcher were recorded. Pitchers were categorized based on their role as “Starter-only” (n=15), “Reliever-only” (n=76), or “Combined Starter/Reliever” (n=94) and compared using ANOVA.

Results:

“Starter-only” pitchers threw the most pitches (97±10) and pitched the most innings (6.0±1.0) per appearance (p=<.001). “Combined Starter/Reliever” functioning as a starter threw significantly more pitches (68±19) and pitched more innings (4.0±1.3) per appearance compared to “Combined Starter/Reliever” functioning as a reliever and “Reliever-only” pitchers (p=<.001). The cumulative volume during a 13 week regular season revealed that “Starter-only” pitchers threw significantly more total pitches (1204±387) compared to “Combined Starter/Reliever” pitchers (613±182) who threw significantly more than “Reliever-only” pitchers (254±77) (P<.001).

Discussion:

Pitcher''s specific roles and representative volumes should be used to design training and rehabilitation programs. Comparison of this data to reported adolescent pitch volumes reveal that adolescent pitch volume per appearance approaches collegiate levels.

Conclusions:

Collegiate pitcher roles dictate their throwing volume. Starter-only pitchers (8%) throw the greatest cumulative number of pitches and should be trained differently than the majority of college pitchers (92%) who function primarily as a reliever or in combination starter/reliever roles that on average only requires approximately 40 pitches per appearance.     

Shifting into third gear: Current options and controversies in third-year postgraduate family medicine programs in Canada

Objective

To summarize current options for postgraduate third-year programs in family medicine in Canada and compile current controversies about the expanding number of programs available and the trend toward subspecialization in family medicine.

Design

A literature search was conducted by the Regina Qu’Appelle Health Region Library research staff for Canadian family medicine fellowships and residency programs using MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature from the beginning of 2005 to September 1, 2011. All available websites for programs offering third-year options were reviewed.

Setting

Canadian family medicine residency programs.

Methods

A list of current third-year residency programs was generated from the Canadian Post-MD Education Registry. In addition, the current Canadian Resident Matching Service website was reviewed, along with every program-specific website, for current third-year programs offered.

Main findings

More than 30 different options for third-year residency programs are available, including a number of community-influenced and resident-directed enhanced-skills programs. In 2010 to 2011 there were 237 postgraduate third-year family medicine residents compared with 128 in 2010 to 2011, an increase of 109 positions.

Conclusion

Controversies over the benefits to the patient population, the practice patterns of third-year residency graduates, and the influence of a subspecialty trend against a stated goal of comprehensive family medicine continue to exist, while the number of available third-year residency options continues to expand.     

Residents as teachers: Survey of Canadian family medicine residents

Objective

To examine Canadian family medicine residents’ perspectives surrounding teaching opportunities and mentorship in teaching.

Design

A 16-question online survey.

Setting

Canadian family medicine residency programs.

Participants

Between May and June 2011, all first- and second-year family medicine residents registered in 1 of the 17 Canadian residency programs as of September 2010 were invited to participate. A total of 568 of 2266 residents responded.

Main outcome measures

Demographic characteristics, teaching opportunities during residency, and resident perceptions about teaching.

Results

A total of 77.7% of family medicine residents indicated that they were either interested or highly interested in teaching as part of their future careers, and 78.9% of family medicine residents had had opportunities to teach in various settings. However, only 60.1% of respondents were aware of programs within residency intended to support residents as teachers, and 33.0% of residents had been observed during teaching encounters.

Conclusion

It appears that most Canadian family medicine residents have the opportunity to teach during their residency training. Many are interested in integrating teaching as part of their future career goals. Family medicine residencies should strongly consider programs to support and further develop resident teaching skills.