Quais os impactos de curto prazo ocorridos a partir dos ciclos iniciais de implantação do “Programa Mais Médicos” (PMM) em municípios do Rio Grande do Sul? Essa dissertação versa um sobre subtipo de ensaio comunitário acerca da problemática em questão, com estudo agregado com múltiplos grupos, longitudinal em série temporal retrospectiva, a partir de dados de fontes secundárias, com análise descritiva de propósito exploratório. Trata-se de 10 grupos conformados por agregados de municípios do Rio Grande do Sul, selecionados e estratificados em 5 faixas populacionais, estando pareados pela condição de implantação e não implantação do PMM. Realizou-se análise comparativa e descritiva de um conjunto selecionado de indicadores correlatos aos serviços de Atenção Primária à Saúde (APS). De um modo geral, observou-se o incremento de indicadores de estrutura nos agregados de municípios com implantação do PMM, notadamente nos agregados com faixas de menores populações. Em termos de indicadores de resultados observou-se discreto incremento na produção de serviços nos agregados com implantação do PMM, contudo, não foram identificadas diferenças significativas de internações por causas sensíveis e de outros indicadores de impacto próprios da APS. As hipóteses mais plausíveis para explicar os achados estão referidas ao exíguo tempo decorrido entre a implantação do PMM e a realização do estudo, além da constatação de que nos ciclos iniciais de implantação do programa houve predominância de caráter substitutivo de trabalho profissional médico nos municípios selecionados para o estudo. / What are the short-term impacts occurred in the early cycles implementation of the "More Doctors Program" (PMM) in municipalities of Rio Grande do Sul? This research focuses on one community trial subtype, added to multiple groups, in longitudinal retrospective time series, based on data from secondary sources, with descriptive analysis of exploratory purpose. It is conformed by 10 groups clusters of municipalities of Rio Grande do Sul, selected and stratified into five population groups, being matched by the deployment condition and not implementation of PMM. We carried out comparative and descriptive analysis of a selected set of indicators related to the services of Primary Health Care (PHC). In general, there was the structure of indicators of growth in clusters of municipalities with implementation of PMM, especially in conglomerates with smaller populations tracks. In terms of outcome indicators showed a slight increase in the production of services in conglomerates with implementation of PMM, however, significant differences in hospital admissions were identified by sensitive causes and other APS's own impact indicators. The most plausible hypotheses to explain the findings are referred to the narrow time between the implementation of the PMM and the study, besides the fact that in the early cycles of program implementation was substitute character predominance of medical professional working in selected municipalities to the study.

Up to the middle of the 1970's most government policies dealing with physician manpower dealt with the problems of increasing the supply of physicians, rather than changing the geographic disparity of physicians between urban and rural areas. In 1983 the British Columbia government introduced legislation (passed in a modified form in 1985) that would restrict certain groups of physicians from obtaining Medical Service Plan billing numbers in certain areas of the province, in an attempt to change the geographic distribution of physicians in this province. Regulation is only one of a number of approaches to altering the distribution of physicians. The purpose of this study is to attempt to recommend other approaches that could be used to alter the geographic distribution of physicians, based on the factors which the residents and interns of British Columbia would consider necessary before they will establish practices in the rural areas of the province. The literature was examined to determine the present supply and distribution of physicians in the province of British Columbia. It was shown that the metropolitan areas had much higher concentrations of physicians than did the non-metropolitan regions. The literature was then searched to determine what types of policies had been used in an effort to change this geographic disparity and also to determine what factors influence physicians to locate their practices where they do. From this research a questionnaire was developed and mailed to all residents and interns registered in the University of British Columbia medical program in the academic year 1984-85. A response rate of 31.8% was obtained in this survey. It was found that many physicians were raised in large communities and planned to locate their practices in similar geographic areas to where they were raised. It was also found that the factors which the residents and interns considered to be the most important fell into the "Fixed Determinant" category, that is factors that are personal preferences of the physician. This makes it very difficult to formulate any type of non-regulatory policy to affect the geographic distribution of physicians in British Columbia / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

Background The landscape of clinical decision support systems (CDSSs) is evolving to include increasingly sophisticated data-driven methods, such as machine learning, to provide clinicians with predictions about patients’ risk for negative outcomes or their likely responses to treatments (predictive CDSSs). However, trust in predictive CDSSs has shown to challenge clinician adoption of these tools, precluding the ability to positively impact patient outcomes. This is particularly salient in the hospital setting where clinician time is scarce, and predictive CDSSs have the potential to decrease preventable mortality. Many have advised that clinicians should be involved in the development, implementation, and evaluation of predictive CDSSs to increase translation from development to adoption. Yet, little is known about the prevalence of clinician involvement or the factors that influence clinicians’ trust in predictive CDSSs for the hospital setting. The specific aims of this dissertation were: (a) to survey the literature on predictive CDSSs for the hospital setting to describe the prevalence and methods of clinician involvement throughout stages of system design, (b) to identify and characterize factors that influence clinicians’ trust in predictive CDSSs for in-hospital deterioration, and (c) to explore the use of a trust conceptual framework for incorporating clinician expertise into machine learning model development for predicting rapid response activation among hospitalized non-ICU patients using electronic health record (EHR) data. Methods To address the first aim (presented in Chapter Two), a scoping review was conducted to summarize the state of the science of clinician (nurse, physician, physician assistant, nurse practitioner) involvement in predictive CDSS design, with a specific focus on systems using machine learning methods with EHR data for in-hospital decision-making. To address the second aim (presented in Chapter Three), semi-structured interviews with nurses and prescribing providers (i.e., physicians, physicians assistants, nurse practitioners) were conducted and analyzed inductively and deductively (using the Human-Computer Trust conceptual framework) to identify factors that influence trust in predictive CDSSs, using an implemented predictive CDSS for in-hospital deterioration as a grounding example. Finally, to address the third aim (presented in Chapter Four), clinician expertise was elicited in the form of model specifications (requirements, insights, preferences) for facilitating factors shown to influence trust in predictive CDSSs, as guided by the Human-Computer Trust conceptual framework. Specifications included: (a) importance ranking of input features, (b) preference for a more sensitive or specific model, (c) acceptable false positive and negative rates, and (d) prediction lead time. Specifications informed development and evaluation of machine learning models predicting rapid response activation using retrospective EHR data. Results The scoping review identified 80 studies. Seventy-six studies described developing a machine learning model for a predictive CDSS, 28% of which described involving clinicians during development. Clinician involvement during development was categorized as: (a) determining clinical relevance/correctness, (b) feature selection, (c) data preprocessing, and (d) serving as a gold standard. Only five studies described implemented predictive CDSSs and no studies described systems in routine use. The qualitative investigation with 17 clinicians (9 prescribing providers, 8 nurses) confirmed that the Human-Computer Trust concepts of perceived understandability and perceived technical competence are factors that influence hospital clinicians’ trust in predictive CDSSs and further characterized these factors (i.e., themes). This study also identified three additional themes influencing trust: (a) actionability, (b) evidence, and (c) equitability, and found that clinicians’ needs for explanations of machine learning models and the impact of discordant predictions may vary according to the extent to which clinicians rely on the predictive CDSS for decision-making. Only two of 28 categories/sub-categories and one theme emerged uniquely to nurses or prescribing providers. Finally, the third study elicited model specifications from fifteen total clinicians. Not all clinicians answered all questions. Vital sign frequency was ranked the most important feature category on average (n = 8 clinicians), the most frequently preferred prediction lead time was shift-change/8-12 hours (n = 9 clinicians), most preferred a more specific than sensitive model (71%; n = 7 clinicians), the average acceptable false positive rate was 42% (n = 9 clinicians), the average acceptable false negative rate was 29% (n = 6 clinicians). These specifications informed development and testing of four machine learning classification models (ridge regression, decision trees, random forest, and XGBoost). 249,676 patient admissions from 2015–2018 at a large northeastern hospital system were modeled to predict whether or not patients would have a rapid response within the 12-hour shift. The random forest classifier met clinician’s average acceptable false positive (27.7%) and negative rates (28.9%) and was marginally more specific (72.2%) than sensitive (71.1%) on a holdout test set. Conclusions Studies do not routinely report clinician involvement in model development of predictive CDSSs for the hospital setting and publications on implementation considerably lag those on development. Nurses and prescribing providers described largely shared experiences of trust in predictive CDSSs. Clinicians’ reliance on the predictive CDSS for decision-making within the target clinical workflow should be considered when aiming to facilitate trust. Incorporating clinician expertise into model development for the purpose of facilitating trust is feasible. Future research is needed on the impact of clinician involvement on trust, clinicians’ personal attributes that influence trust, and explanation design. Increased education for clinicians about predictive CDSSs is recommended.

OBJECTIVE: Primary care physicians (PCPs) are positioned to mitigate opioid morbidity and mortality, but their engagement in primary, secondary, and tertiary opioid-related prevention behaviors is unclear. The objective of this study was to evaluate Tennessee PCPs' engagement in and intention to engage in multiple opioid-related prevention behaviors. METHODS: A survey instrument was developed, pretested, and pilot tested with practicing PCPs. Thereafter, a census of eligible Tennessee PCPs was conducted using a modified, four-wave tailored design method approach. Three patient scenarios were employed to assess physician intention to engage in 10 primary, secondary, and tertiary prevention behaviors. Respondents were asked to report, given 10 similar scenarios, the number of times (0-10) they would engage in prevention behaviors. Descriptive statistics were calculated using SPSS version 25. RESULTS: A total of 296 usable responses were received. Physician intention to engage in prevention behaviors varied across the 10 behaviors studied. Physicians reported frequently communicating risks associated with prescription opioids to patients (8.9 ± 2.8 out of 10 patients), infrequently utilizing brief questionnaires to assess for risk of opioid misuse (1.7 ± 3.3 out of 10 patients), and screening for current opioid misuse (3.1 ± 4.3 out of 10 patients). Physicians reported seldomly co-prescribing naloxone for overdose reversal and frequently discharging from practice patients presenting with an opioid use disorder. CONCLUSIONS: This study noted strengths and opportunities to increase engagement in prevention behaviors. Understanding PCPs' engagement in opioid-related prevention behaviors is important to effectively target and implement morbidity and mortality reducing interventions.

By applying the theory of compensating differentials on a self-compiled data set on the 67 sites in Sweden that offer medical internships, I seek to identify the factors of an internship that determine its salary. Because prospective interns tend to queue for popular internships, I use an estimated equilibrium salary that incorporates the opportunity cost of delaying the internship. I find a significant independent correlation between the travel time to the nearest major city and salary that is suggestive of a compensating differential. The results imply that a larger salary differentiation can mitigate the widespread phenomena of maldistribution of physicians.

Doctor of Philosophy / Department of Educational Leadership / Sarah Jane Fishback / This bounded case study explored ten purposefully selected physician participants’ perceptions of the effectiveness of an eight session, two year in-house physician leadership development program at a major Academic Medical Center (AMC) in the Midwest. While physicians are generally educated to care for patients in their specialty area, reforms necessitate the need for physician leadership involvement in metric tracking by healthcare organizations in order to provide a focus on quality patient care and safety. Participants indicated finding the course effective, especially the negotiations and finance modules. These modules provided new language, a better understanding of processes and an opportunity to develop skills through interactive class exercises such as case studies. Participants described an increased self-awareness of their interpersonal skills and expressed a desire for greater exposure to emotional intelligence principles. Participants experienced a transformational shift in how they constructed their identity as a physicians and leaders, and questioned assumptions about the physician’s role in healthcare. While effective in initiating a process of exploration, this course was not sufficient to meet the goals and objectives of the program. Therefore, recommendations for the advanced course included a focus on leadership competencies identified by Dye and Garman (2006) as cited by Dye and Sokolov (2013), emotional intelligence, and transformational leadership.

Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Homoeopathy, Durban University of Technology, 2011. / Recent homoeopathic graduate studies (Babaletakis, 2006 and Sweidan, 2007) indicate that the majority of qualified Homoeopaths are currently practicing yet are experiencing many difficulties along the way. These setbacks are largely related to financial stresses and the difficulties experienced with regards to maintaining a practice. However, a minority of successful homoeopaths that have managed to overcome these difficulties have been identified. AIM This study aimed to identify a minimum of nine successful homoeopaths, and, through an in-depth interview discover their views on success and how they have managed to build up viable practices. The study aimed to identify the factors contributing to the success of these Homoeopathic practices and establish relationships that may have existed between these factors. METHODOLOGY This research was conducted in a qualitative manner, following an ethnographic approach, which also guided the method of data analysis. It was thus a descriptive, case study research design. Interviewees/subjects were selected through snowball sampling. Semi-structured in-depth interviews were conducted with each subject, in which the researcher followed an interview guideline. These interviews were recorded and analysed conceptually. All the transcribed interviews were then further organised by using the software programme NVivo 8.0. which allowed for the process of coding. iv RESULTS Common themes as related to success emerged from the data that was collected. Further analysis revealed links between certain factors that had been identified within the themes. The results reflected that honesty and the ability to listen and understand people, together with perseverance and determination, were qualities that enabled these homoeopaths to achieve success. It was evident that valuing oneself as a practitioner and thus charging accordingly, as well as minimising overheads where possible, all contributed to the viability of the practice. The use of modalities impacted on financial gain and was found to enhance patient numbers. Availability, success of healing and an interactive practitioner - patient relationship was also found to have an effect on patient base stability and size. Burnout was identified as being related to the balance in a practitioner’s lifestyle. A high self-esteem coupled with a good support structure, were factors that minimised burnout. Continued professional development was important to these practitioners as evidently one’s knowledge was seen to have an impact on confidence, patient numbers and thus overall success as a healer. CONCLUSION Success has been attributed to many factors in this study, many of which are interlinked. These findings have provided valuable insight into a successful homoeopathic career.

Submitted in partial compliance with the requirements for a Master’s Degree in Technology: Homoeopathy, Durban University of Technology, Durban, South Africa, 2015. / South Africa has a dual healthcare system which consists of the public and private healthcare sectors. The private healthcare sector is used by a small percentage of South Africans as its services are more expensive. It makes provision for both allopathic and Complementary Alternative Medicine (CAM) practitioners. In contrast, the public healthcare sector employs only allopathic practitioners. Due to its services being rendered free of charge or at very low cost, it caters for the majority of the population and as a result has become overburdened. South Africa’s healthcare system is undergoing major changes in order to ease the burden on the public sector. The integration of homoeopathy into this sector is a possible viable solution. In order to facilitate integration, homoeopathic practitioners should be in agreement with this radical change and suggest ways in which this paradigm shift can be initiated. Hence, the overall aim of this study was to explore the perceptions of homoeopathic practitioners on their role in the public healthcare system in South Africa. The paucity of research on the perceptions of homoeopathic doctors suggests that this is an unexplored topic. This study therefore employed a qualitative approach based on the grounded theory method. Semi-structured interviews were conducted to determine homoeopathic practitioners’ perceptions of this phenomenon. Participants were selected using snowball sampling. Inclusion and exclusion criteria were also used to guide the selection of the research participants. The participants were interviewed individually using an interview guideline. Each interview was audio recorded and transcribed prior to data analysis. Once transcribed, the data was evaluated and analyzed manually. Four commons themes emerged from the data. The prevalence, frequency and variation (in the frequency) of each theme amongst the participants was established. Further analysis revealed links between all four themes. It was evident that knowledge/awareness of homoeopathy, the homoeopathic education system and the in-practice experiences of homoeopathic doctors all influence integration. These factors represented homoeopathic practitioners’ perceptions on such integration. The identification of the factors that influence integration is a clear indication that the homoeopathic practitioners who participated in this study are aware of their role in the public healthcare system and that the majority would welcome a shift from the private to the public healthcare sector. There is thus a need for further nationwide and more in-depth research on integration. / M

published_or_final_version / Community Medicine / Master / Master of Public Health

The primary purpose of this study was to examine the relationship between educational and curricular factors and physician location decisions. As a background to the study, a literature search traced the history of medical education in the U.S., focusing on various influences on physician distribution. In the research on physician location decision, this study is unique in its use of the constant comparative method. This method is an inductive approach developed and refined by Glaser and Strauss, used in this study to generate theory regarding the role of educational factors in physician location decisions. In this research, two groups of physicians who completed training after 1965 were selected for study, based on their locations in distinctly different practice settings in Arizona: urban and rural. An open-ended interview format was developed, and each physician was interviewed, with data analysis beginning during the first interview and continuing through the entire period of data collection. Using the constant comparative method, similar groups (rural physicians) were compared to bring out basic properties of categories, and different groups (urban physicians) were then compared to establish boundaries of applicability of the theory. As the interviews proceeded a basic theoretical framework emerged, enabling development of a grounded theory of physician location decisions. The study presents strong empirical evidence in support of the proposition that educational factors are influential in the decision of a physician to enter practice in a rural area. Four primary influences were identified: faculty role modeling, participation in rural clerkships, preceptorships, or required family practice rotations, service activities related to health care for medically underserved populations, and education in a non-traditional setting, or residency training in a rural area. Curriculum content and requirements take on major significance when these influences are subsumed under the major influence of socialization. The extent to which these educational factors play a role in the practice locations of physicians varies according to educational opportunities available during the training period.