Direct graduate medical education payments to teaching hospitals by Medicare: unexplained variation and public policy contradictions.

PURPOSE: To comprehensively examine both inter- and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services. METHOD: Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria for moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined from the Area Resource FILE: RESULTS: Variations in inter- and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAS: CONCLUSION: Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to U.S. physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.     

A consortium-based research education program for residents.

With growing pressures to consolidate and reorganize health care delivery systems, graduate medical education (GME) consortia can draw faculty from affiliated members to assemble educational programs. The authors report on consortium-based research education seminars of a quality that many residency programs would be unable to develop and support on their own. Drawing a diverse faculty from consortium members and area universities, the OHEP Center for Medical Education's annual Research Workshop Series focuses on the design of research projects; data analysis and hypothesis testing; and written and oral presentation of scientific research. Each spring, OHEP sponsors a research forum in which the best research projects from consortium members are presented by the resident-researchers, who compete for recognition and prize money. Further, of the 128 presentations made thus far at the annual OHEP Research Forum, 25% were subsequently published. The consortium's research education program has been well received by residents, is cost-effective, and is an integral component of the research curricula of many area residency programs. Including research training in GME provides residents an opportunity to become more competitive for fellowship, faculty, and leadership positions.     

Measuring the costs of primary care education in the ambulatory setting.

In 1995, the authors obtained cost, operations, and educational activity data from 98 ambulatory care sites across the United States in which primary care teaching was occurring and compared those data with the corresponding data from 84 ambulatory care sites where no teaching was going on. The teaching sites in the sample were found to have 24-36% higher operating costs than the non-teaching sites. This overall difference in costs is approximately the same difference in costs earlier estimated for university teaching hospitals compared with non-teaching hospitals. These costs are shared by all involved in the ambulatory education process: sponsors, sites, and faculty. In a related finding, the authors discovered that 30-50% of all ambulatory care sites thought not to be involved in education are in fact teaching at a high level of involvement. Further research into not only the costs but the value of education in the clinical setting is encouraged. The authors also hope that the publication of this report will encourage accrediting bodies and professional organizations to improve the information available about ambulatory care training in general.     

Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force.

Because of numerous criticisms of the content and structure of residency training, redesigning graduate medical education (GME) has become a high priority for the internal medicine community. From 2005 to 2007, the leadership of the internal medicine community, working under the auspices of the Alliance for Academic Internal Medicine Education Redesign Task Force, developed six recommendations it will pursue to improve residency education: (1) focus education around a "core" of internal medicine, which provides the framework for both the structure and content of residents' educational experiences, (2) fully adopt competency-based evaluation and advancement, which will enhance training by focusing on individual learners' needs, (3) allow for increased, resident-centered education beyond the internal medicine core, because different types of practice require customized knowledge and skills, (4) improve ambulatory training by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities, (5) use new faculty models that emphasize the creation of a core faculty, and (6) align institutional and programmatic resources with the goals of redesign, balancing the clinical mission of the institution with the educational goals of residency training.Adoption of these recommendations will require significant efforts, including pilot projects, faculty development, changes in accreditation requirements, and modifications of GME funding systems. Opportunities are ample for individual programs to develop creative approaches based on the framework for educational redesign outlined in this article, and for these educational and clinical redesign initiatives to work hand-in-hand for the benefit of patients, faculty, trainees, and institutions.     

Improving oversight of the graduate medical education enterprise: one institution's strategies and tools.

Accreditation organizations, financial stakeholders, legal systems, and regulatory agencies have increased the need for accountability in educational processes and curricular outcomes of graduate medical education. This demand for greater programmatic monitoring has placed pressure on institutions with graduate medical education (GME) programs to develop greater oversight of these programs. Meeting these challenges requires development of new GME management strategies and tools for institutional GME administrators to scrutinize programs, while still allowing these programs the autonomy to develop and implement educational methods to meet their unique training needs. At the Medical University of South Carolina (MUSC), senior administrators in the college of medicine felt electronic information management was a critical strategy for success and thus proceeded to carefully select an electronic residency management system (ERMS) to provide functionality for both individual programs and the GME enterprise as a whole. Initial plans in 2002 for a phased deployment had to be changed to a much more rapid deployment due to regulatory issues. Extensive communication and cooperation among MUSC's GME leaders resulted in a successful deployment in 2003. Evaluation completion rates have substantially improved, duty hours are carefully monitored, patient safety has improved through more careful oversight of residents' procedural privileges, regulators have been pleased, and central GME administrative visibility of program performance has dramatically improved. The system is now being expanded to MUSC's medical school and other health professions colleges. The authors discuss lessons learned and opportunities and challenges ahead, which include improving tracking of development of procedural competency, establishing and monitoring program performance standards, and integrating the ERMS with GME reimbursement systems.     

The Veterans Affairs Learners' Perceptions Survey: the foundation for educational quality improvement.

PURPOSE: The U.S. Department of Veterans Affairs (VA) supports 8,700 resident positions nationally to enhance quality of care for veterans and to educate physicians. This study sought to establish a yearly quality indicator to identify and follow strengths and opportunities for improvement in VA clinical training programs. METHOD: In March 2001, the VA Learners' Perceptions Survey, a validated 57-item questionnaire, was mailed to 3,338 residents registered at 130 VA facilities. They were asked to rate their overall satisfaction with the VA clinical training experience and their satisfaction in four domains: faculty/preceptor, learning, working, and physical environments using a five-point Likert scale. Questionnaires were received from 1,775 residents (53.2%). A full analysis was conducted using 1,436 of these questionnaires, whose respondents were categorized in four training programs: medicine (n = 706), surgery (n = 291), subspecialty (n = 266), and psychiatry (n = 173). RESULTS: On a scale of 0 to 100, residents gave their clinical training experience an average score of 79. Eighty-four percent would have recommended VA training to peers, and 81% would have chosen VA training again. Overall, 87% were satisfied with their faculty/preceptors, 78% with the learning environment, and 67% with the working and physical environments. The survey was sensitive to differences in satisfaction among the trainee groups, with residents in internal medicine (IM) the least satisfied. CONCLUSION: The VA Learners' Perceptions Survey is the first validated survey to address comprehensive satisfaction issues in clinical training. The survey highlights strengths and opportunities for improvement in VA clinical training and is the first step toward improving education.     

Implementation of a college-wide GME core curriculum.

As health care delivery and its associated costs have been scrutinized carefully over the past decade, educational institutions have been expected to demonstrate how a particular educational requirement such as residency training brings benefit to the purchasers and users of their health care services. As part of this trend, the Accreditation Council for Graduate Medical Education recently enacted new accreditation standards mandating the inclusion of curricular elements that expose residents to basic concepts and principles of the non-technical areas of health care across a variety of topics, including ethics, cost containment, socioeconomics, medical-legal issues, communication skills, research design, statistics, and critical review of the medical literature. The authors report the efforts at the Medical University of South Carolina to overcome obstacles and successfully implement an institution-wide core curriculum program, dealing with the kinds of topics mentioned above, across 47 specialty and subspecialty programs with over 500 residents and fellows. The seminal events and critical strategies are described, along with lessons learned along the way. The following were key elements to success: (1) adhering to a strategic plan assigning oversight of residency education to the graduate medical education (GME) office; (2) gaining strong support from the dean and other college officials; (3) creating a stepwise centralization of residencies in college via the GME committee; (5) making the first core curriculum element one that had an excellent chance to succeed; (6) having core curriculum sessions begin in evenings and weekends to not interfere with regular curriculum, but later, when the value of the curriculum became evident to departments, moving the sessions to be within the week; (7) having the philosophy of the GME office be to maintain a flexible approach and serve departments.     

The history of calls for reform in graduate medical education and why we are still waiting for the right kind of change

The author reviews the history of calls for reform of graduate medical education (GME), beginning with the Rappleye report of 1940, the first report on GME. Several continuities emerge. First, the reports have regularly called for GME to serve the "health needs of society." However, these perceived "needs" have continually been shifting as medicine and society evolve, thereby presenting GME a moving target. Second, the reports have regularly called for GME to focus more on education and less on service in order to avoid exploiting residents and compromising their training. Third, GME is a multifaceted subject. Reports on GME have typically addressed one part or another but not the subject as a whole. In their selectivity, the reports have reflected the particular perspective of the sponsoring groups. What the reports have generally not discussed, but what is underscored by calls for reform, is that GME is expensive, and any effort to improve its quality will be costly in terms of money, faculty time, or both. Thus, the profession has become complicit in maintaining the status quo. Any successful effort toward reform must acknowledge that GME functions as part of the larger health care delivery system, whose fate will ultimately determine the quality and robustness of GME in America.     

Benchmarks of support in internal medicine residency training programs.

PURPOSE: To identify benchmarks of financial and staff support in internal medicine residency training programs and their correlation with indicators of quality. METHOD: A survey instrument to determine characteristics of support of residency training programs was mailed to each member program of the Association of Program Directors of Internal Medicine. Results were correlated with the three-year running average of the pass rates on the American Board of Internal Medicine certifying examination using bivariate and multivariate analyses. RESULTS: Of 394 surveys, 287 (73%) were completed: 74% of respondents were program directors and 20% were both chair and program director. The mean duration as program director was 7.5 years (median = 5), but it was significantly lower for women than for men (4.9 versus 8.1; p =.001). Respondents spent 62% of their time in educational and administrative duties, 30% in clinical activities, 5% in research, and 2% in other activities. Most chief residents were PGY4s, with 72% receiving compensation additional to base salary. On average, there was one associate program director for every 33 residents, one chief resident for every 27 residents, and one staff person for every 21 residents. Most programs provided trainees with incremental educational stipends, meals while oncall, travel and meeting expenses, and parking. Support from pharmaceutical companies was used for meals, books, and meeting expenses. Almost all programs provided meals for applicants, with 15% providing travel allowances and 37% providing lodging. The programs' board pass rates significantly correlated with the numbers of faculty fulltime equivalents (FTEs), the numbers of resident FTEs per office staff FTEs, and the numbers of categorical and preliminary applications received and ranked by the programs in 1998 and 1999. Regression analyses demonstrated three independent predictors of the programs' board pass rates: number of faculty (a positive predictor), percentage of clinical work performed by the program director (a negative predictor), and financial support from pharmaceutical companies (also a negative predictor). CONCLUSIONS: These results identify benchmarks of financial and staff support provided to internal medicine residency programs. Some of these benchmarks are correlated with board pass rate, an accepted indicator of quality in residency training. Program directors and chairs can use this information to identify areas that may benefit from enhanced financial and administrative support.     

Education costs in two public teaching hospitals

The authors examined the impact of costs of education on the overall expenses of two major teaching hospitals during a period of rapid growth and change in the Minneapolis and St. Paul, Minnesota, health care environment. By using a retrospective faculty-time study and the two hospitals' estimated costs for education, education costs of each hospital were compared--within and across facilities--with annual hospital operating expenses, with inflation, and by educational program. Unit costs were estimated for undergraduate and graduate medical students. Over the study period, allocated education costs averaged 13-14% of the hospitals' operating budgets. The combined mean allocated cost per medical student and resident was approximately +73,000 in 1983-84. During this period, allocated education costs were in line with medical inflationary trends and did not drive hospital expense increases. These findings suggest that policymakers wishing to restrain the rise in health care costs should look beyond cutting the costs of education programs and find other solutions.     

Physician attitudes, opinions, and referral patterns: comparisons of those who have and have not taken an allergy/immunology rotation.

BACKGROUND: Interest in the field of allergy/immunology (A/I) is increasing, yet resident training programs are under pressure to shorten elective rotations such as A/I. It is unclear if there are differences between those who have and have not taken an A/I rotation. OBJECTIVE: To evaluate differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. METHODS: An anonymous questionnaire was sent to 375 primary care physicians at one academic medical center. Subjects were separated into 5 cohorts based on specialty and level of training (internal medicine faculty, internal medicine resident, pediatric faculty, pediatric resident, and internal medicine-pediatric resident). RESULTS: Of the participants, 227 (61.0%) completed the survey. Compared with those who had not taken an A/I rotation, those who had taken an A/I rotation were more likely to feel they knew the types of cases seen by an allergist (75.9% vs 33.3%), to feel they knew an adequate amount about A/I (59.3% vs 19.5%), to feel they were exposed to an adequate amount of A/I during residency (64.8% vs 9.8%), to view immunotherapy as effective (70.0% vs 52.3%), and to have referred a patient to an allergist (77.8% vs 46.0%). CONCLUSIONS: There are significant differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. Allergic diseases are increasing, yet residency training programs are under pressure to shorten rotations such as A/I to accommodate federally mandated work hour restrictions. The potential for inadequate care of allergic diseases may be an important issue if these trends continue.     

Recognizing clinical faculty's contributions in education.

OBJECTIVE: A faculty productivity profile system was designed to recognize faculty's contributions to administrative, educational, and research activities. It has long been recognized that clinical faculty receive little recognition or compensation for their efforts in education. Our surgery department previously had in place a recognition program for research achievements, but not for educational contributions. The new system was designed to recognize and reward all aspects of faculty contributions, including education. DESCRIPTION: The faculty productivity profile is a simple Excel document sent to each faculty member once a year. We piloted the program for the first time in 2001, recognizing faculty's contributions for the previous year. The pilot began with the formation of a committee whose first function was to identify all possible opportunities for faculty to participate as educators at our institution. This included giving lectures, participating in faculty development programs, serving as mentors, interviewing student or resident candidates, serving in administrative educational roles (e.g., clerkship or residency director), giving oral exams, or attending conferences and journal club. The committee then developed a point scale assigning each activity or contribution a value on a scale of 0-25. Each activity was then listed on the Excel form. Faculty were to fill in the number of times each activity was performed and this was multiplied by the points to obtain a weighted value. Point values for conferences were determined by percentage of conferences attended for a year (i.e., for grand rounds, those attending 0-49%, 50-75%, 75-90%, and more than 90% received 0, 20, 40, and 60 points, respectively). Points were also assigned for teaching awards and high scores on student and resident evaluations. After approval by the committee and the department chairman, the form was presented at a faculty meeting. Each faculty member then received a floppy disk with the form and was asked to complete the form and attach a supporting copy of his or her CV. The form required only input of numbers or a "yes" or "no." After submission, the clerkship coordinator input additional data from a database of conference attendance and student evaluations. Points were then calculated for each faculty member based upon his or her contributions and each activity's weighted value. A dinner was held to recognize outstanding faculty contributions. All faculty completing the form were invited and recognized and those with outstanding contributions received awards. DISCUSSION: Teaching medical students and residents is a rewarding experience; however, it requires significant time and effort. Faculty who feel their contributions are unrecognized may be more likely to burn out and less likely to continue contributing. We believe it is worthwhile to recognize faculty contributions in all areas, including education. Our pilot program had excellent participation due to the ease of using the form. We believe it has improved faculty morale and willingness to participate. We are continuing the program and plan to evaluate its impact on encouraging continued participation in teaching.     

Direct observation of students during clerkship rotations: a multiyear descriptive study.

PURPOSE: To determine how often students report that they are observed while performing physical examinations and taking histories during clerkship rotations. METHOD: From 1999-2001, 397 students at the University of Virginia School of Medicine were asked at the end of their third year to report the number of times they had been observed by a resident or faculty member while taking histories and performing physical examinations on six rotations. RESULTS: Three hundred and forty-five students (87%) returned the survey instrument; of these, 322 (81%) returned instruments with complete information. On average, the majority reported that they had never been observed by a faculty member while taking a history (51%), performing a focused physical examination (54%), or a complete physical examination (81%). The majority (60%) reported that they had never been observed by a resident while performing a complete physical examination. Faculty observations occurred most frequently during the four-week family medicine rotation and least frequently during the 12-week surgery rotation. The length of the clerkship rotation was inversely related to the number of reported observations, chi(2) (5, n = 295) = 127.85, p <.000. CONCLUSIONS: Although alternative assessments of clinical skills are becoming more common in medical education, faculty ratings based on direct observation are still prominent. The data in this study reflect that these observations may actually be occurring quite infrequently, if at all. Decreasing the evaluative weight of faculty and resident ratings during the clerkship rotation may be necessary. Otherwise, efforts should be made to increase the validity of these ratings.     

Financing graduate medical education.

The direct costs of residency training in the United States are over $1 billion per year. These educational programs have been organized predominantly around hospital services and supported by hospital revenues. Pressure has been increasing to reduce the rate of increase in hospital expenditures or costs or both. This article describes alternative methods for financing graduate medical education. Debate over the current sources of financing reveals several troublesome issues: the presence of residents allegedly decreases the productivity of professionals and leads to overusage of ancillary services, proposed methods to pay for faculty salaries and services have created confusion and concern, and the financing of ambulatory-care training has been insufficient and poorly coordinated. The medical-education community must resolve these professional and educational problems so that financing issues can be debated and properly defended.     

Description of a novel curriculum on equity,diversity and inclusion for pediatric residents

BackgroundAccreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training.MethodsA needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content.Results109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ “eye opening” content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues.ConclusionsThe implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.     

Sponsored-research funding by newly recruited assistant professors: can it be modeled as a sequential series of uncertain events?

PURPOSE: Recruitment of junior faculty with an investigative focus is essential to regenerate and expand the research mission of academic health centers. Predicting funding profiles for junior faculty is limited by variability in the timing, magnitude, and duration of projected research grant funding. The author demonstrated the validity of Monte Carlo simulation to predict sponsored-research revenues by newly recruited faculty. METHOD: Demographic characteristics and funding profiles were determined for assistant professors recruited to Yale University School of Medicine in four separate fiscal years (1992-93, 1993-94, 1996-97, 1997-98). These data were applied to develop and assess the simulation model. RESULTS: Only when assistant professors were subcategorized by type of research was it possible to accurately predict recovery of both direct research costs and facilities and administrative costs. Simulations illustrated both the high degree of variability among individual faculty and also the advantage of a prediction tool that displays the range and probability of all possible outcomes. CONCLUSION: Sponsored-research funding by newly recruited assistant professors can be modeled as a sequential series of uncertain events and used to predict consequences of imminent changes in federal funding for biomedical research.     

Service utilization and associated direct costs for bipolar disorder in 2004: an analysis in managed care

BACKGROUND: Bipolar disorder is a chronic and costly condition. This analysis examines health care costs associated with bipolar disorder in 2004 and contrasts them with those for depression, a better understood mental illness. METHODS: Health care costs associated with bipolar disorder and non-bipolar depression were determined using private payer administrative claims. Individuals having 2 claims with a primary ICD-9-CM code for bipolar disorder or depression were categorized as bipolar disorder or non-bipolar depression patients, respectively. Comparisons between patient groups were adjusted for demographic differences and comorbid diagnoses. RESULTS: On average, bipolar patients (n=6072) used significantly more psychiatric resources per person than depression patients (n=60,643), and had more mean psychiatric hospital days, psychiatric and medical emergency room visits, and psychiatric office visits (p<.001 for all). Bipolar patients were slightly less likely to be treated with antidepressants, but substantially more likely to be treated with antipsychotics, anticonvulsants, lithium, and benzodiazepines (p<.001 for all). Mean direct per-patient costs were $10,402 for bipolar patients and $7494 for depression patients (p<.001), with the primary differences observed for psychiatric medication ($1641 vs. $507) and psychiatric hospitalization ($1187 vs. $241). LIMITATIONS: Patients were categorized based on diagnostic codes in administrative claims data, which may not always be accurate. Results may not generalize beyond private payer populations in the US. CONCLUSIONS: Bipolar disorder is associated with significantly greater per-patient total annual health care costs than non-bipolar depression, as well as significantly greater psychiatric costs. Bipolar disorder, a chronic condition often suboptimally treated, may represent a good target for disease-management programs.     

Rationale for cost-effective laboratory medicine.

There is virtually universal consensus that the health care system in the United States is too expensive and that costs need to be limited. Similar to health care costs in general, clinical laboratory expenditures have increased rapidly as a result of increased utilization and inflationary trends within the national economy. Economic constraints require that a compromise be reached between individual welfare and limited societal resources. Public pressure and changing health care needs have precipitated both subtle and radical laboratory changes to more effectively use allocated resources. Responsibility for excessive laboratory use can be assigned primarily to the following four groups: practicing physicians, physicians in training, patients, and the clinical laboratory. The strategies to contain escalating health care costs have ranged from individualized physician education programs to government intervention. Laboratories have responded to the fiscal restraints imposed by prospective payment systems by attempting to reduce operational costs without adversely impacting quality. Although cost containment directed at misutilization and overutilization of existing services has conserved resources, to date, an effective cost control mechanism has yet to be identified and successfully implemented on a grand enough scale to significantly impact health care expenditures in the United States.     

Mandatory postgraduate medical training in Japan--present state of Nihon University as a private medical school

This is a time of considerable uncertainty about the future of the postgraduate medical education policy of the Japanese government. Strong and visionary academic leadership of laboratory physicians in private medical schools is needed. The medical schools must not only adapt to a changing health care system, but also maintain excellence in education, patient care, and clinical research. In Japan, tradition has it that the comparatively few faculty members at national medical schools are mostly promoted only on the basis of research in experimental medicine, therefore, young medical graduates are increasingly drawn to bench work or molecular medicine, not to clinical practice. Single-minded specialization tends to produce single track minds, which may lack balanced judgment in approaching the appropriateness of both investigation and management. For continuity of care and containment of costs, a year or two of general professional training after graduation preceded by a broad medical education is an invaluable investment. All medical graduates, whatever their intended or unintended final destination (even if not clinical), should spend more than six months in medicine and four or five months in surgery, at least half of each to be spent in the general disciplines, including responsibilities for acute emergency admissions. As certified laboratory physicians we must attempt to attract graduates into laboratory medicine by developing imaginative training programs including common laboratory procedures such as Gram's stain, Wright-Giemsa stain and point of care testing at the patient's bedside or in ambulatory clinics, not only in central clinical laboratories.