Osteopathic physician (D.O.) residency programs that do not achieve accreditation under the new Single Accreditation System (SAS) standards by June 30, 2020 will lose access to their share of more than $9,000,000,000 of public tax dollars. This U.S. Centers for Medicare & Medicaid Services (CMS) funding helps sponsoring institutions cover direct and indirect resident physician training expenses. A significant financial burden would then be shifted to marginal costs of the residency program’s sponsoring institution in the absence of CMS funding. The sponsoring institution’s ability or willingness to bare these costs occurs during a time when hospital operating margins are at historic lows (Advisory.com /Daily Briefing /May 18, 2017 | The Daily Briefing / Hospital profit margins declined from 2015 to 2016, Moody's finds). Loss of access to CMS funding may result in potentially cataclysmic reductions in the production and availability of primary care physicians for rural and urban underserved populations. Which osteopathic residency programs will be able to survive the new accreditation requirement changes by the 2020 deadline? What are some of the defining attributes of those programs that already have achieved “initial accreditation” under the new SAS requirements? How can the osteopathic programs in the process of seeking the new accreditation more effectively “pivot” by learning from those programs that have succeeded? What are the potential implications of SAS to both access and quality of health care to millions of Americans? This report is based upon a study that examined and measured how osteopathic physician residency programs in the U.S. are accommodating the substantive structural, financial, political and clinical requirements approximately half way through a five-year adaptation period. In 2014, US Graduate Medical Education (GME) physician program accreditation systems formally agreed to operate under a single accreditation system for all osteopathic (D.O) and allopathic (M.D.) programs in the U.S. Since July 1, 2015, the American Osteopathic Association (AOA) accredited training programs have been eligible to apply for Accreditation Council for Graduate Medical Education (ACGME) accreditation. This agreement to create a Single Accreditation System (SAS) was consummated among the AOA, the American Association of Colleges of Osteopathic Medicine (AACOM) and ACGME with a memorandum of understanding. As this research is published, the ACGME is transitioning to be the single accreditor for all US GME programs by June 30, 2020. At that time, the AOA would fully relinquish all its GME program accreditation responsibilities. The new SAS operates under published ACGME guidelines and governance. Business policy and health care resource allocation question motivated this research. Failure of osteopathic programs to “pivot” to the new standards could result in fewer licensed physicians being produced in the high demand primary care field. Potential workforce shortage areas include urban and especially rural populations (CRS Report 7-5700 R44376 Feb 12, 2016). Large physician shortages already have been projected to care for a rapidly aging US population without considering the impact of the GME accreditation changes currently underway (Association of American Medical Colleges 2017 Key Findings report www.aamc.org/2017projections). The goal of this research is to provide osteopathic GME programs practical insights into characteristics of a sample of osteopathic GME programs that have successfully made the “pivot” into SAS requirements and been accredited by ACGME and those that have not. The study seeks to better understand the experiences, decisions, challenges and expectations directly from osteopathic programs directors as they strive to meet the realities of the new SAS requirements. Do programs that are already accredited differ significantly from those that have not? How do characteristics such as program size, geographic locations, clinical program components, program sponsor structure, number and experience of faculty and administration, cost planning and perceived benefits of the movement to SAS factor into successfully meeting the new requirements before the 2020 closing date? A cross-sectional research survey was designed, tested and deployed to a national sample of currently serving osteopathic GME program directors. The survey elicited data about each program’s “pivot” from AOA GME accreditation practices and guidelines to the new Single Accreditation System (SAS). The survey instrument was designed to obtain information about patterns in osteopathic GME program curricula, administrative support functions, faculty training, compliance requirements and program director characteristics shared by those programs that have been granted “initial accreditation” by the Accreditation Council for Graduate Medical Education (ACGME) who administer SAS. Thirty five (35) osteopathic GME program directors responded to the 26 question survey in June 2017. Descriptive statistics were applied and central tendency measures determined. The majority of survey respondents were Doctors of Osteopathic Medicine (D.O.s) from specialty residency programs sponsoring an average of 16 residents. Respondents were mostly non-profit, urban, multi-facility health system locations with an existing affiliation with a research college or university. About half of the programs had completed some form of fiscal due diligence related to the potential cost impact of SAS. None of those surveyed reported utilizing outside consultants to assist in the SAS “pivot” process. Most programs plan to keep the same number of residents while others expressed an interest in expanding or contracting. None of the respondents planned to close their program. The dichotomous dependent variable (DV) was whether or not the Osteopathic GME program had “achieved or not yet achieved initial SAS accreditation” at the time of the survey. A cross tabulation analysis of the DV with potential predictive variables (IV) was conducted and Chi-square and various exact significance tests were applied to gage goodness of fit. Results were grouped into categories that aligned with the five research questions and hypotheses. Several characteristics were shared by those programs that achieved SAS. GME sponsor institutions that currently have dually accredited programs by the AOA and ACGME seemed to be at a distinct advantage. Although they represented a smaller number of total survey respondents (20%), all primary care program participants reported SAS achievement. Directors reported an average of six (6) full-time paid faculty members teaching in their programs and twice that number of preceptor volunteers in the total sample. Realization of any operational cost savings or efficiencies as a result of moving to a single accreditation system was a principle concern for the majority (86%) of GME program director respondents, regardless of current accreditation status, although most felt SAS would result in offering medical student graduates access to all accredited US GME residency and fellowships programs.

Traditionelle Krankenhaushierarchie und Ökonomisierungsdruck, aber auch Unkenntnis über berufsrechtliche Grundlagen des Arztberufs beeinflussen die Therapiefreiheit des einzelnen Arztes. Die gesetzlich und berufsständisch normierte ärztliche Tätigkeit als freier Beruf erfordert vom einzelnen Arzt, medizinische Entscheidungen nicht einfach zu befolgen, sondern seiner Qualifikation gemäß zu überprüfen. Das Weisungsrecht vorgesetzter Ärzte und die Pflicht nachgeordneter Ärzte, Weisungen zu befolgen, finden ihre Grenzen in den Rechtsnormen, die das Prinzip des freien Berufs setzt. Unkritisches Befolgen von Anweisungen kann auch für nachgeordnete Ärzte straf-, zivil- und berufsrechtliche Folgen haben. Die vorliegende Studie legt dar, in welcher Weise auch der Krankenhausarzt einen freien Beruf ausübt. Und weiter, welchen Stellenwert die Therapiefreiheit als Kern dieser Berufsfreiheit für die verschiedenen etablierten Hierarchiestufen des ärztlichen Dienstes hat. Dabei wird aufgezeigt, ob und inwiefern die traditionelle hierarchische Struktur des ärztlichen Dienstes in deutschen Krankenhäusern mit dem Berufsrecht vereinbar ist.

This paper utilizes data on physician malpractice insurance premiums and state tort law to analyze how physicians in various medical specialties are differentially affected by caps on noneconomic damages. As higher premiums put pressure on legislators to enact damage caps, I instrument caps on noneconomic damages with enactment of tort reform measures that do not affect malpractice premiums to uncover the effect of caps on noneconomic damages on such premiums. I find evidence to support that, in terms of dollars saved, physicians in high risk specialties benefit more from noneconomic damage caps than physicians in low risk specialties. However, in percentage terms, I find that physicians in all specialties essentially benefit equally from caps on noneconomic damages.

Objetivos. Estimar la frecuencia y los factores asociados a la violencia laboral externa tipo amenaza (VLETA) contra médicos en servicios de salud hospitalarios de Lima Metropolitana, Perú. Materiales y Métodos. Se desarrolló un estudio transversal analítico que incluyó médicos del Ministerio de Salud (MINSA), la Seguridad Social (EsSalud) y el subsector privado. Se midió la frecuencia de VLETA durante toda la práctica profesional, en los últimos doce meses y en el último mes. Se midieron variables relacionadas al médico, al agresor y al servicio de salud. Se estimaron razones de prevalencia (RPs) cruda y ajustada mediante un modelo lineal generalizado familia Poisson con bootstrap no paramétrico. Resultados. Participaron 406 médicos. El 31,5% fueron víctimas de VLETA al menos una vez durante su práctica profesional; 19,9% en los últimos doces meses y 7,6% en el último mes. La probabilidad de ser amenazado en los últimos doce meses aumentó si el médico era varón (RPa:1,7;IC95%:1,1-2,8), egresado de una universidad peruana fuera de Lima Metropolitana (RPa:1,5; IC95%:1,1-2,4), laboraba en MINSA (RPa:7,9;IC95%:2,24-50,73) o en EsSalud (RPa:8,68; IC95%:2,26-56,17), y atendía en emergencia (RPa:1,9;IC95%:1,2-3,6) o en sala de operaciones (RPa:1,6 IC95%:1,1-2,3). La edad, los años de práctica profesional o ser médico residente no se asociaron a VLETA. Conclusiones. En los hospitales estudiados, una alta proporción de médicos ha sido víctima de VLETA. Laborar en servicios públicos aumenta dicha probabilidad. Se sugiere implementar estrategias de prevención primaria, identificación y soporte en los establecimientos hospitalarios. / Objectives. To calculate the frequency and factors associated with external workplace violence (EWV) against doctors in health inpatient services in the metropolitan area of Lima (Spanish: Lima Metropolitana), Peru. Materials and methods. A cross-sectional analytic study, which included doctors from the Ministry of Health (MINSA), Social Security (EsSalud), and the private subsector, was carried out. The frequency of EWV was measured throughout the entire professional practice during the previous 12 months and during the last month. Variables related to the doctor, assailant, and health service were measured. Raw and adjusted prevalence ratios (PR) were calculated by means of a Poisson-family generalized linear model with non-parametric bootstrapping. Results. A total of 406 doctors participated; 31.5% were victims of EWV at least once during their professional practice, with 19.9% over the past 12 months and 7.6% during the last month. The chances of being threatened in the last 12 months increased if the doctor was male (adjusted PR [aPR]: 1.7; 95% confidence interval [CI] = 1.1- 2.8), had graduated from a Peruvian university outside of the metropolitan area of Lima (aPR: 1.5; 95% CI = 1.1-2.4), worked at MINSA (aPR: 7.9; 95% CI = 2.24-50.73) or EsSalud (RR: 8.68; 95% CI = 2.26-56.17), and worked in the emergency (aPR: 1.9; 95% CI = 1.2-3.6) or operating room (aPR: 1.6; 95% CI = 1.1-2.3). Age, years of professional practice, or being a medical resident were not associated with EWV. Conclusion. In the hospitals studied, a large number of doctors have been victims of EWV. Working in public services increases the possibility of violence. Implementation of support, identification, and primary prevention strategies in hospitals is recommended.

No description available.

As an effort to guide patients toward being more informed and more involved as healthcare decision makers in the clinical processes, health care organizations have adopted a new technology referred to as an integrative social media platform (ISMP). This ISMP combines features of mobile technology and those of social media technology, integrating healthcare systems in order to support a more patient-centered healthcare process. However, users, both physicians and patients, have showed varied usages of ISMP, as a results, have shown mixed results of ISMP. To provide a better understanding of the use of ISMP, especially the interaction between patients and physicians, I turned to the concept of affordances. Affordances describe the possibilities for goal-oriented actions that a technical object offers to a user. Using a mixed-method approach with real archival event log data, conversation texts, documents, interview, and focus-group data from a large hospital which had adopted an ISMP, I confirmed three types of affordance: perceived affordance, behavioral affordance, and interactive affordance. I identified two key affordances of ISMP that lead to patient-centered care, namely ubiquitous access and virtual healthcare consultation, which represent a behavioral affordance and an interactive affordance, respectively. I also explored how different types of affordances are actualized and how they interact with each other to contribute to patient-centered care.

Physician well-being has become an important area of interest given that reduced well-being can have a negative effect on patient outcomes. However, research has predominantly focused on impairment thus studies addressing physicians' positive functioning are limited. The purpose of this two-phase, mixed methods study was to investigate the well-being and self-regulation capacity of physicians using a positive psychology lens. In Phase 1, 132 physicians (n = 40 physicians; n = 92 resident physicians) completed online questionnaires to assess their levels of psychological and affective well-being and self-regulation capacity. Selected based on Phase 1 data, 12 physicians then took part in an in-depth individual interview in Phase 2 to discuss their experiences of psychological well-being and self-regulation. Results of Phase 1 showed that physicians and resident physicians had moderate and high levels of self-regulation capacity, respectively. While both groups reported high levels of psychological well-being, they had average levels of positive and negative affect. MANOVAs confirmed the hypothesis that high self-regulating physicians and resident physicians would have higher levels of psychological well-being and positive affect compared to those with lower levels. However, those with higher self-regulation capacity did not have lower negative affect, nor did physicians have significantly higher levels of psychological and affective well-being than resident physicians. Regression analyses confirmed the hypothesis that a significant amount of variance in levels of psychological well-being would be explained by self-regulation capacity. There was a particularly strong relationship between self-regulation capacity and the dimensions of purpose in life and environmental mastery, which suggests that physicians who effectively self-manage may be better able to preserve a sense of purpose and an adequate work-life balance in their daily life. A qualitative content analysis of the Phase 2 qualitative data revealed that physicians had both high and low functioning experiences of psychological well-being across the dimensions of self-acceptance, positive relations with others, environmental mastery, and autonomy. They, however, reported high functioning for the dimensions of personal growth and purpose in life. Their experiences also varied based on their professional and personal life contexts, with work-life balance emerging as a prevalent theme. Physicians' self-regulation experiences involved individualized preparation, performance, and evaluation processes that were perceived to influence their well-being. Results of a composite analysis suggest that the development of effective self-regulation skills could be one way to help physicians achieve satisfactory levels of well-being.

This experimental study was designed to evaluate the effect of planned teaching on the self-medication practices of ambulatory cardiac patients. The sample was composed of forty male and female cardiac patients who were over the age of forty-five years, who lived at home and were of low socio-economic status. They all lived in a large urban centre and attended an outpatient clinic for medical attention. All were taking digoxin and thirty-six, 18 from each group, were also taking a diuretic. They were randomly assigned to two groups, experimental and control, when they visited the outpatient clinic. The twenty patients in the control group were given the usual routine factual information during their clinic visit. The twenty patients in the experimental group received additional planned teaching over a thirty-minute period by the researcher. The data were gathered by means of a twenty-item questionnaire designed to elicit information regarding the self-medication behavior of the study population. The questionnaire was administered in the homes of the patients ten to fourteen days following their visit to the outpatient clinic. Three hypotheses were tested in the study. Analysis of the data in relation to Hypothesis I indicated a statistically significant difference in the number of self-medication errors in digoxin and diuretics made in a twenty-four-hour period by patients in the experimental group as compared with the control group. The experimental group made significantly fewer errors. Although patients in the experimental group made fewer errors of the four types of errors studied with regard to Hypothesis II, there was not a statistically significant difference in errors related to time, dosage and non-prescribed medications made in a twenty-four-hour period by patients in the experimental group as compared with the control group. There was, however, a statistically significant difference in the fourth type of error--that of omission. The testing of Hypothesis III showed a statistically significant difference in the level of knowledge of the two groups of patients. The experimental group had a higher level of knowledge of their medications. The study concludes with consideration of implications for nursing practice and research. / Applied Science, Faculty of / Nursing, School of / Graduate

A role description for a medical coordinator in extended and long term care facilities in British Columbia has been defined using a Delphi method. Also obtained during the study was a long term care philosophy. Three groups - nurses, administrators, and physicians took part in three rounds of the Delphi study. Thirty-five respondents were interviewed in the first round. During this interview the researcher obtained from the respondents the statements that they considered should be included in this role and philosophy description. During the second round the respondents rated the responses of the first round and in the third round those of the second round were revised after seeing the mean scores of the whole group and the three separate groups. The description of the role of a medical coordinator developed describes the role as it applies to: resident care; private physicians; planning, development and evalution of care; staffing of a facility; education; administration; and the training, experience, skills and attitude of a medical coordinator. When the description created was compared with that for the medical director in a long term care facility in the United States it was found that this study had described additional dimensions of the role, in particular the multi-disciplinary approach and the physician's knowledge, training, experience, skills and attitude. The results of the study show where there was agreement and where there were differences of opinion between the three professional groups. A long term care philosophy which was considered very important for a medical coordinator to promote, has been defined during the study. It focuses on the resident reaching his full potential, the creation of a special environment, as well as acceptance of disability, dying and death. Recommendations from the study are made for facilities which might be considering employing a medical coordinator, for planners deciding whether to provide funds for medical coordinators, for geriatric medical education and for the acceptance of a long term care philosophy in all parts of the health care system where there are long term care clients. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

Les recommandations de bonne pratique, issues de la médecine des preuves, s’insèrent dans un processus ancien visant à asseoir la légitimité médicale sur la science et se sont déployées en tant qu’instrument politique de rationalisation des pratiques.Comment rencontrent-elles les valeurs professionnelles et l’exercice de la médecine ?La question est traitée dans le cadre de la médecine générale et de l’hypertension artérielle (HTA) dont la mise en recommandations est exemplaire de la construction d’un risque en santé publique.La première partie s’intéresse à l’origine de la médecine des preuves et en quoi ce mouvement est porteur de continuité et de modification dans les relations entre Médecine et État, au sein de la profession, entre médecin et patient.La seconde partie, centrée sur une microsociologie des consultations de patients hypertendus, montre que les recommandations constituent un appui pour le travail médical de prise de conscience par le patient de la réalité pathologique de l’HTA et des risques cardiovasculaires associés. Mais le généraliste inscrit son action dans la durée et, sous influence du patient, négocie et fait des compromis voire déroge aux « bonnes pratiques », considérant que ce qui n’est pas réalisable aujourd’hui le sera demain.Les recommandations sont intégrées dans les pratiques sous forme d’un modèle hybride associant la référence aux données scientifiques et l’adaptation à la singularité de la situation. La figure du patient statistique porté par la médecine des preuves est confrontée à la réalité sociale de l’individu plus ou moins doté d’autonomie et de ressources dont il s’agit pour le médecin d’acquérir la confiance et de la conserver. / Best practice recommendations, stemming from evidence based medicine, are part of a well versed process aiming to claim medical legitimacy based on science and are used as policy tools in practice. How do they relate to professional values, and to the practice of medicine?This question is examined within the framework of recommendations regarding the treatment, control and prevention of arterial hypertension (AH) in general practice which can be said to exemplify the construction of a public health risk.The first part of this work is centred on the origins of evidence based medicine, and the way in which it brings continuity as well as change to the relationships between: medical professionals; the institution of medicine and the state; doctors and patients.The second part, a microsociological study of GP consultations with hypertensive patients, shows that recommendations are used to reinforce the doctor’s efforts to increase patients’ awareness of AH and the ensuing cardiovascular risks. However, GPs use their influence over a long time period and, influenced by their patients, they negotiate, compromise and even disregard some of the best practice recommendations, considering that what may not be achievable in the present, may be achievable in the long term. Recommendations are therefore used in practice in hybrid form, where science is merged with an adaptation to each unique situation. The ‘average patient’ as the basic unit of evidence based medicine is opposed with the social reality of an individual with a certain level of autonomy and resources whose trust the doctor needs to gain and maintain.