The Troubled Road to Universal Health Care

In our country the increasing commercialization of medicine is taking control of our medical school faculties, hospitals, and education. There is an overemphasis on health care efficiency, with a dramatic decrease in the commitment to research, an increase in the cost of medical education and resultant staggering student debt, an increasing number of medically uninsured, and an ever-widening gap between the best that American medicine can offer and that which the indigent receive. [Goldfrank LR: The troubled road to universal health care. Ann Emerg Med December 1997;30:737-738.]     

Medical debt and aggressive debt restitution practices

BACKGROUND: Health care providers are increasingly relying on collection agencies to recoup charges associated with medical care. Little is known about the prevalence of this practice in low-income communities and what effect it has on health-seeking behavior. METHODS: Cross-sectional survey at 10 "safety net" provider sites in Baltimore, Md. Specific queries were made to underlying comorbidities, whether they had a current medical debt, actions taken against that debt, and any effect this has had on health-seeking behavior. RESULTS: Overall, 274 adults were interviewed. The average age was 43.9 years, 77.3% were African American, 54.6% were male, 47.2% were homeless, and 34.4% had less than a 12th grade education. Of these, 46.2% reported they currently had a medical debt (average, 3,409 dollars) and 39.4% reported ever having been referred to a collection agency for a medical debt. Overall, 67.4% of individuals reported that either having a current medical debt or having been referred to a collection agency for a medical debt affected their seeking subsequent care: 24.5% no longer went to that site for care; 18.6% delayed seeking care when needed; and 10.4% reported only going to emergency departments now. In the multiple logistic regression model, having less than a 12th grade education (odds ration [OR], 2.5; 95% confidence interval [CI], 1.0 to 6.0) and being homeless (OR, 4.1; 95% CI, 1.4 to 12.3) were associated with a change in health-seeking behavior while having a chronic medical condition (OR, 0.2; 95% CI, 0.1 to 0.5) and going to a community clinic for usual care (OR, 0.2; 95% CI, 0.1 to 1.0) were protective. CONCLUSIONS: Aggressive debt retrieval for medical care appears to be indiscriminately applied with a negative effect on subsequent health-seeking behavior among those least capable of navigating the health system.     

航空航天生理学本科教育中学员“体医结合”能力培养的探究

心血管耐力是飞行耐力的重要组成部分，心血管耐力的提升可以通过体能训练方式提高，从目前基层部队飞行员训练安排来看，体能训练安排如果能融入医学背景知识，以更科学、专业的方法开展，飞行员才能更好的完成飞行训练、运输以及作战等任务。本文笔者结合当前一线飞行员日常训练中存在问题，结合航空航天生理学本科阶段教育现状，融入“体医结合”新概念，以飞行员心血管耐力提升为切入点，以期完善当前航空航天生理学本科阶段教育，培养新时期作战需要的航空军医。     

Cultivating Medical Education Research Mentorship as a Pathway Towards High Quality Medical Education Research

The lack of effective and consistent research mentorship and research mentor training in both undergraduate medical education (UME) and graduate medical education (GME) is a critical constraint on the development of innovative and high quality medical education research. Clinical research mentors are often not familiar with the nuances and context of conducting education research. Clinician-educators, meanwhile, often lack the skills in developing and conducting rigorous research. Mentors who are not prepared to articulate potential scholarship pathways for their mentees risk limiting the mentee’s progress in early stages of their career. In fact, the relative paucity of experienced medical education research mentors arguably contributes to the perpetuation of a cycle leading to fewer well-trained researchers in medical education, a lack of high quality medical education research, and relative stagnation in medical education innovation. There is a path forward, however. Integration of doctoral-level educators, structured inter-departmental efforts, and external mentorship provide opportunities for faculty to gain traction in their medical education research efforts. An investment in medical education research mentors will ensure rigorous research for high quality innovation in medical education and patient care.The recent report from the Institute of Medicine (IOM)¹ calling for finance reform for graduate medical education based its findings on evidence within medical education, while simultaneously acknowledging that there was a limited amount of such evidence. In response, Asch & Weinstein² noted that the paucity of medical education research and funding for such research “reflects a systematic lack of research investment in an area of health care that we believe deserves better.” However, inadequate funding is only one aspect of the complex problem of increasing the quality and quantity of medical education research (MER). To cultivate the high quality MER that can support critical decision-making, medical education must focus on the development of highly qualified MER mentors.     

Continuing education for healthcare professionals: time to prove its worth.

With escalating financial pressures being placed upon health services, it becomes increasingly hard to justify spending on education and training. At the same time, however, primary care practitioners are being expected to take on new roles in the management of long term conditions which were once the domain of their secondary care colleagues. This Discussion paper highlights the importance of expanding the evidence base for healthcare professional training - particularly in terms of its positive effects on patient care - and emphasises how important it is that those responsible for commissioning training continue to see the importance of doing so. It cites a randomised controlled trial of education in the primary care management of rhinitis as an example of the way in which healthcare professional education can improve patients' quality of life. Without continued investment in healthcare professionals' education, the vision of high quality, guideline-driven, evidence-based health care will never come to fruition.     

The development of academic geriatric medicine: progress toward preparing the nation's physicians to care for an aging population

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full-time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy-one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.     

A Cross-sectional Measurement of Medical Student Empathy

BACKGROUND: Empathy is important in the physician-patient relationship. Prior studies have suggested that physician empathy may decline with clinical training. OBJECTIVE: To measure and examine student empathy across medical school years. DESIGN AND PARTICIPANTS: A cross-sectional study of students at Boston University School of Medicine in 2006. Incoming students plus each class near the end of the academic year were surveyed. MEASUREMENTS: The Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated 20-item self-administered questionnaire with a total score ranging from 20 to 140. JSPE-S scores were controlled for potential confounders such as gender, age, anticipated financial debt upon graduation, and future career interest. RESULTS: 658 students participated in the study (81.4% of the school population). The first-year medical student class had the highest empathy scores (118.5), whereas the fourth-year class had the lowest empathy scores (106.6). Measured empathy differed between second- and third-year classes (118.2 vs 112.7, P < .001), corresponding to the first year of clinical training. Empathy appears to increase from the incoming to the first-year class (115.5 vs 118.5, P = .02). Students preferring people-oriented specialties had higher empathy scores than students preferring technology-oriented specialties (114.6 vs 111.4, P = .002). Female students were more likely than male students to choose people-oriented specialties (51.5 vs 26.9%, P < .001). Females had higher JSPE-S scores than males (116.5 vs 112.1, P < .001). Age and debt did not affect empathy scores. CONCLUSIONS: Empathy scores of students in the preclinical years were higher than in the clinical years. Efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education. Future research is needed to confirm whether clinical training impacts empathy negatively, and, if so, whether interventions can be designed to mitigate this impact.     

素质教育在人体寄生虫学教学中的应用

人体寄生虫学是医学高等专科学校学生的一门必修课,在教学过程中实施素质教育,培养具有创新精神和实践能力的高素质实用性医学人才是该课程教学的重要目的。在人体寄生虫学教学中,提高教师综合素质,积极改进教学方法,引入启发式教学、案例式教学和多媒体教学等多种教学方法及手段,创新实验教学模式是提高教学质量、实施素质教育的有效途径。     

The Transformation of Cardiology Training in Response to the COVID-19 Pandemic: Enhancing Current and Future Standards to Deliver Optimal Patient Care

The COVID-19 pandemic has had an unprecedented impact on cardiology training. Novel opportunities have been identified in several domains: patient exposure, procedural experience, didactic education, research and development, advocacy and well-being, and career advancement. Lessons learned from COVID-19 should be used to further improve fellowship training such as, for example, through the development of a competency-based training and evaluation system. Multimodality teaching that incorporates telelearning provides creative solutions for trainee and continuing medical education. Fellow-initiated research should be supported and nurtured. Enhanced attention to trainee well-being and burnout is particularly important. The emerging cardiologists of the future and the way they are trained will be shaped by the COVID-19 challenge of our generation.     

研究生双导师制培养模式探讨

双导师制是为培养创新性、实用性人才需要而建立的一种新型研究生培养模式。本文以基础医学研究生教育为切人点,系统介绍医学研究生双导师制的优势、管理及效果评价,探讨双导师制培养模式在医学研究生培养中的作用和意义,寻求一条适应在扩招条件下提高研究生培养质量的新途径。     

A primer on medical education in the United States through the lens of a current resident physician

Physician training and standards for medical licensure differ widely across the globe. The medical education process in the United States (US) typically involves a minimum of 11 years of formal training and multiple standardized examinations between graduating from secondary school and becoming an attending physician with full medical licensure. Students in the US traditionally enter a 4-year medical school after completing an undergraduate bachelor’s degree, in contrast to most other countries where medical training begins after graduation from high school. Medical school seniors planning to practice medicine in the US must complete postgraduate clinical training, referred to as residency, within the specialty of their choosing. The duration of residency varies depending on specialty, typically lasting between 3 and 7 years. For subspecialty fields, additional clinical training is often required in the form of a fellowship. Many experts have called for changes in the medical education system to shorten medical training in the US, and reforms are ongoing in some institutions. However, physician education in the US generally remains a progression from undergraduate premedical coursework to 4 years of medical school, followed by residency training with an optional subspecialty fellowship.     

Teaching Anti-Racism in the Clinical Environment: The Five-Minute Moment for Racial Justice in Healthcare

Dismantling racism in health care demands that medical education promote racial justice throughout all stages of medical training. However, racial bias can be fostered unintentionally, influencing the way we make decisions as clinicians with downstream effects on patient health and health equity. The development of any anti-racism curriculum in medicine requires the ability to identify racial bias in practices we have not previously recognized as explicitly racist or unjust. This has limited the creation and delivery of effective anti-racism education in health care.     

Sex-work harm reduction

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.     

Politics and Graduate Medical Education in Internal Medicine: A Dynamic Landscape

The promotion of change and growth within medical education is oftentimes the result of a complex mix of societal, cultural and economic forces. Graduate medical education in internal medicine is not immune to these forces. Several entities and organizations can be identified as having a major influence on internal medicine training and graduate medical education as a whole. We have reviewed how this is effectively accomplished through these entities and organizations. The result is a constantly changing and dynamic landscape for internal medicine training.     

Geriatric medicine in the European Union: unification of diversity

The numbers of older people in the European Union are increasing and, with their associated health needs, there is a requirement for the specialty of Geriatric Medicine to be available throughout Europe. At present, specialists in Geriatric Medicine are not recognised in some of the European Union member countries. It is imperative that training in Geriatric Medicine should take place throughout Europe, starting at undergraduate level and progressing through postgraduate training. There must be a programme of continuing medical education and personal development. This paper highlights some of these challenges and suggests a possible way forward.     

Reinventing specialty training of physicians? Principles and challenges

In a world undergoing constant change, in the era of globalisation, the training of medical professionals should be under constant review so that it can be tailored to meet the needs of this society in transition. This is all the more true at times of economic uncertainty, such as the current conditions, which have a direct impact on health services. Professionals need new Competencies for new times. Over the last decade initiatives have emerged in various Anglo-Saxon countries which have defined a framework of basic Competencies that all medical specialists should demonstrate in their professional practice. In addition to this, we must respond to the creation of the European Higher Education Area which has implications for specialised training. In Spain, training for medical specialists was in need of an overhaul and the recently passed law (Real Decreto 183/2008) will allow us to move forward and implement, in medical education, initiatives and innovations required in our medical centres, to respond to the new society and bring us in line with international professional education and practice. The way forward is a Competency-based model for medical education with assessment of these Competencies using simple instruments, validated and accepted by all the stakeholders. The institutions involved (hospitals, medical centres and other health care services) should trial different approaches within the general framework established by the current legislation and be conscious of the duty they have to society as accredited training organisations. Accordingly, they should consolidate their teaching and learning structures and the various different educational roles (Director of Studies, Tutors, and other teaching positions), showing the leadership necessary to allow proper implementation of their training programmes. For this, the Spanish Autonomous Regions must develop their own legislation regulating Medical Specialty Training. So, medical professionals should receive training, based on ethical values, behaviours and attitudes that considers humanistic, scientific and technical factors, developing an understanding of the scientific method; ability to put it into practice; skills to manage complexity and uncertainty; a command of scientific, technical and IT terminology to facilitate independent learning; and a capacity for initiative and teamwork, as well as skills for dealing with people and for making an effective, democratic contribution both within health organisations and in the wider society.     

以“心血管反应能力提升”为核心，开展抗荷生理训练教学的思考

抗荷生理训练是提高飞行员自身抗荷能力的综合训练方法,其核心是有效提升飞行人员的心血管反应能力。本文通过分析心血管反应能力在抗荷生理训练组织实施各环节的作用地位,探讨了如何围绕心血管反应能力提升这一核心,以系统开展抗荷生理教育、抗荷基础体能训练、抗荷动作训练和载人离心机训练等抗荷生理训练的教学实践。     

Management of geriatric urinary incontinence: A multi-institutional project

Conclusion This project is unique because it combines the fields of geriatrics, urology, community health, nursing and social work in order to search for a viable solution to a common but very neglected problem among the elderly in Israel. The centre’s activity brings both a collaboration and a close alliance between the medical centres and the peripheral clinics in the community. The project has produced, and continues to produce, a deeper knowledge on incontinence in the elderly. This project has only begun and has yet a long way to go. Parallel to developing education and training programs, we are also developing models for applying our conclusions from data being accumulated. A program for establishing similar centres throughout the country is on its way. In the meantime, we are doing our best to help incontinent patients achieve a continent state, and with continence, bringing an emotional peace, tranquility, and a better quality of life. About the authors: I. Gruenwald, R. Michalak, E. Gaitsgori and Y. Vardi are all medical doctors practicing in Haifa, Israel. Dr. Gruenwald is with the Department of Urology, Carmel Medical Centre; Dr. Michalak and Dr. Gaitsgori are with the Fleiman Geriatric Rehabilitation Centre; and Dr. Vardi is with the Neurourology Unit, Rambam Medical Centre.     

初级卫生保健人员的糖尿病继续医学教育方式

检索、分类并分析糖尿病继续医学教育方式（EMDCME）的相关文章.将EMDCME分为6类,即分发教育资料、教育性会议、舆论领袖、共识进程、审查和反馈、教育推广访问,分析上述方式优劣.根据当地初级卫生保健人员的实际情况选择EMDCME,合理评估教育效果及经济学效益,探索出最合适的教育方式,取得最佳的卫生经济学效益.     

?rztliche Ausbildung an deutschen internistischen Intensivstationen

Working on an intensive care unit (ICU) requires a broad medical knowledge as well as safe execution of practical medical procedures. As yet there are no data available on the education and training in German ICUs. Using a questionnaire ICU ward physicians were surveyed over various aspects of the local training modalities and their satisfaction with the education in local ICUs. Of the 300 dispatched questionnaires 106 (35%) could be included in the analysis. The results of the survey revealed that the mainstay of training and education was mainly self-instruction using medical textbooks. Depending on different fields of intensive care medicine education is provided by the whole ICU-team. The training in intensive care medicine was rated as good by the majority of respondents and 56% plan to become qualified for the subspeciality intensive care medicine. A larger collective would be desirable, e.g. in a further education survey accomplished by the respective medical associations.