Recommended reading from Anne Taylor-Vaisey: From the January 3 2006 issue of Annals of Internal Medicine:

Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK. Who Is maintaining certification in internal medicine–and why? A National survey 10 years after initial certification. Ann Intern Med 2006; 144(1):29-36.

Background: The American Board of Medical Specialties (ABMS) adopted a framework, called Maintenance of Certification (MOC), for all certifying boards to evaluate physicians’ competence throughout their careers, with the goal of improving the quality of health care. The MOC participation rates of the American Board of Internal Medicine (ABIM) show that 23% of general internists and 14% of subspecialists choose not to renew their respective certificates.

Objective: To study U.S. internists’ perceptions about the forces driving them to maintain certification.

Design: Mail survey.

Setting: A nationally representative sample of certified internists in the United States.

Participants: Physicians originally certified in internal medicine, a subspecialty, or an area of added qualifications in 1990, 1991, or 1992.

Results: The overall rate of response to the survey was 51%. Although 91% of all participants are still working in internal medicine or its subspecialties, this percentage is notably lower among general internists (79%). Of those still working in the field of internal medicine or its subspecialties, approximately half report being required to maintain their specialty certificate by at least 1 employer, but only approximately one third of those who completed or enrolled in MOC report this requirement as a reason for participating. Those who completed or enrolled in MOC do so more for positive professional reasons than for monetary benefits or professional advancement. The most common reasons for not participating are the perceptions that it takes too much time, is too expensive, and is not required for employment. Limitations: Respondents were volunteers from an early cohort of diplomates entering the program, and those with less positive attitudes may have responded at higher rates. Results are based on self-reported data, and misconceptions about program requirements may have led to some inaccurate responses.

Conclusions: The relatively large percentage of general internists who left internal medicine mostly to work in another medical field explains why rates of MOC participation for general internists seem lower than those for subspecialists (77% vs. 86%). Although positive professional reasons clearly have a compelling internal influence on program participation, it is less clear whether employers’ requirements are an equally compelling external influence. Although half of all respondents report that MOC is required by 1 of their employers, only one third of those who participate in the program describe it as a reason for participating.

Despite journal editors’ efforts to crack down on ill-doings and conflicts of interest in the studies they publish, the Wall Street Journal reports that malfeasance is still rampant. One clip from the article (subscription req’d):

Several major pharmaceutical companies are withholding important details about clinical drug trials, despite urging from federal regulators and medical-journal editors to be more forthcoming, according to a study published in this week’s New England Journal of Medicine.



The study says that companies including Merck & Co., Pfizer Inc., and GlaxoSmithKline PLC are obscuring basic information — including the names of some drugs under study — in reporting on trials of drugs to treat serious or life-threatening diseases. Some of the drugs involved are already on the market, and the companies are seeking approval for new uses of them. In an editorial, the medical journal calls for investigators and patients to avoid participating in drug trials where companies take a secretive approach.

Recommended reading from Anne Taylor-Vaisey:I always enjoy this annual tradition … The BMJ Christmas Double Issue. Here is the 2005 edition:

BMJ Christmas Double Issue; December 24 2005; 331 (7531):

Check out the Sex, Drugs and Rock and Roll section

Also, there are changes coming in 2006 re pricing: All original research articles and selected other articles will be freely available on bmj.com and accessible from the moment of publication. The full text of all other articles wil! l require a subscription for the first 12 months, after which they will be freely accessible. Abstract and extract views of these articles will remain freely accessible as will other website content and functions.

Recommended reading from Anne Taylor-Vaisey:

Academic Medicine January 2006; 81(1):

Most Frequently Accessed Articles, September 2004-September 2005:

These lists are based on the total number of times Academic Medicine Online users downloaded the full text PDFs of our published articles. This is a different calculation than the one used in past years. The range of total downloads is 535 to 137. [Available by subscription. A selection is below.]

“>Articles

1. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them

Pat Croskerrry Aug 2003 78: 775ˆ80.

2. Teaching Inpatient Communication Skills to Medical Students: An Innovative Strategy

David P. Losh, Larry B. Mauksch, Richard W. Arnold, Theresa M. Maresca, Michael G. Storck, Raye R. Maestas, Erika GoldsteinFeb 2005 80: 118ˆ24.

3. Generation X: Implications for Faculty Recruitment and Development in Academic Health Centers

Janet Bickel, Ann J. BrownMar 2005 80: 205ˆ10.

4. How Can Physicians’ Learning Styles Drive Educational Planning?

Elizabeth Armstrong, Ramin Parsa-ParsiJul 2005 80: 680ˆ84.

5. Preparing Health Professions Students for Terrorism, Disaster, and Public Health Emergencies: Core Competencies

David Markenson, Charles DiMaggio, Irwin RedlenerJun 2005 80: 517ˆ26.

6. Teaching the Psychosocial Aspects of Care in the Clinical Setting: Practical Recommendations

David E. Kern, William T. Branch, Jeffrey L. Jackson, Donald W. Brady, Mitchell D. Feldman, Wendy Levinson, Mack LipkinJan 2005 80: 8ˆ20.

7. The Importance of Anatomy in Health Professions Education and the Shortage of Qualified Educators

Robert S. McCuskey, Stephen W. Carmichael, Darrell G. KirchApr 2005 80: 349ˆ51.

8. Teaching Professionalism Within a Community Context: Perspectives from a National Demonstration Project

Thomas P. O’Toole, Navneet KathuriaMahita Mishra, Daniela SchukartApr 2005 80: 339ˆ43.

9. Toward a Normative Definition of Medical Professionalism

Herbert M. SwickJun 2000 75: 612ˆ16.

10. Sexual Harassment in Medical Education: Liability and Protection

Patricia Ryan Recupero, Alison M. HeruMarilyn Price, Jody AlvesSept 2004 79: 817ˆ24.

Or so it would seem when it comes to bad medical students becoming less-than-stellar docs, according to a new study in the New England Journal of Medicine (subscription req’d. Here’s a link to a writeup of it in Forbes, which you don’t need a subscription to read online). From Forbes:

Doctors who had exhibited unprofessional behavior in medical school were three times more likely to be disciplined by a medical board than students who had not had such problems in medical school, the study found.



But doctors who had exhibited certain types of behavior in medical school were even more likely to be cited by a medical board: Those who behaved unprofessionally in school were 8.5 times more likely to be disciplined while those with a diminished capacity for self-improvement were 3.1 times more likely to be disciplined, according to the study.




The students were deemed irresponsible if they were late for rounds, didn’t show up for the clinics they were assigned to, or didn’t finish taking care of a patient.

And the things they end up being disciplined for as docs “use of drugs or alcohol, negligence, sexual misconduct, fraud and failure to meet continuing medical education requirements.” And many of them are repeat offenders. So, it makes sense to try to nip this in the bud in med school. But what to do for today’s former irresponsible students-turned irresponsible doctors? Somehow, I don’t think there’s much CME can do to help develop that sense of professionalism (especially if they’re already skipping out on their CME requirements) once they’ve been in practice a while. Is it possible to reform these people?

As Bard Parker says on A Chance to Cut is a Chance to Cure:

My program director always told us that a residency program can’t purge someone of their personality disorders. Goes along with the conventional wisdom of being unable to change someone after you marry them. This has been my anecdotal experience as well. In Georgia the quarterly report from the medical board has the names of physicians placed on the naughty list during that time period. Occasionally I will recognize a classmate’s name and recall what a buffoon/screwball/jackass he/she was. Could have saved the board a lot of time.

Recommended reading from Anne Taylor-Vaisey:

Journal of Continuing Education in the Health Professions

December 2005; 25 (4) [Epub ahead of print]

Maisonneuve H. Medical education and the physician workforce of France. J Contin Educ Health Prof 2005; 25(4):289.

PubMed

Hinchman J, Beno L, Dennison D, Trowbridge F. Evaluation of a training to improve management of pediatric overweight. J Contin Educ Health Prof 2005; 25(4):259-267.

Introduction: Despite widespread concern about pediatric obesity, health care professionals report low proficiency for identifying and treating this condition. This paper reports on the evaluation of pediatric overweight assessment and management training for clinicians and staff in ! a managed care system. The training was evaluated for its impact on assessment practices and utilization of management tools.

Methods: A delayed-control design was utilized to measure the effects of two 60-minute interactive Continuing Medical education (CME) trainings for the pediatric health care teams. Chart abstraction was conducted at 0-, 3- and 6-months after training, recording the proportion of charts containing the recommended assessment methods and management tools.Results: The training was associated with a significant increase in the utilization of some tools and practices, including charting BMI-for-age percentile (p<0.001) and using a nutrition and activity self-history form (p<0.001). Overall, from baseline to 3-months post training, charting BMI-for-age percentiles increased from zero to 25.2% and utilization of the self-history form increased from zero to 35.3%. These increases were sustained at 6-months post training. Other tools guiding clinician co! unseling were less widely utilized, although a behavioral prescription pad was used with 20% of overweight patients.

Discussion: A modest investment in clinician and staff training designed to be feasible in a clinical setting was associated with substantial increases in the use of appropriate tools and practices for the assessment and management of pediatric overweight. Such training may help to augment and improve the processes of pediatric health care delivery for addressing overweight. The training provides a viable model for future CME efforts in other health care settings.

PubMed

Price DW, Xu S, McClure D. Effect of CME on primary care and OB/GYN treatment of breast masses. J Contin Educ Health Prof 2005; 25(4):240-247.

Abstract: Introduction: CME program planners are being asked to move beyond assessments of knowledge to assessing the impact of CME on practice and patient outcomes.

Methods: We conducted a pre-post analysis of administrative data from 107 physicians, nurse practitioners (NPs), or physician’s assistants (PAs) who attended one or two continuing medical education (CME) programs (an in-person, mainly didactic session on breast complaints in women, or an individual mentorship with general surgeons) between August ! 2002 and March 2003. We examined associations between the number of trainings and attempted breast mass aspirations or general surgery referrals for breast masses; individual training and breast mass aspiration attempts or general surgery referrals; and provider type and attempted breast mass aspirations. Generalized linear mixed models were used to model dichotomous outcomes.

Results: Clinicians who participated in individual trainings performed more breast mass aspirations after training (odds ratio (OR) 3.07, [95% confidence interval 1.10-8.54]). Participants who completed two trainings performed more breast mass aspirations after training (OR 2.33, [1.19-4.57]), while those who completed just one did not (OR 1.34, [0.39, 4.58]) but the effect started after the first training and did not strengthen after the second training. NPs and PAs attempted more aspirations after training (OR 6.1, [1.54, 24.1]), whereas physicians did not (OR 0.89 [0.36, 2.22]). Training was not a! ssociated with a change in referrals to general surgery. Referral appropriateness, pre-training readiness to change, and previous training in breast mass aspiration were not assessed.

Discussion: Attempts to aspirate breast masses may increase after CME training. Individual training may be more effective than group training in increasing the likelihood of attempted aspirations.

PubMed

Olson CA, Tooman TR, Leist JC. Contents of a core library in continuing medical education: A Delphi study. J Contin Educ Health Prof 2005; 25(4):278-288.

Introduction: In developing their professional competence, those who are interested in the practice of continuing medical education (CME) should recognize the knowledge base that defines their field. This study systematically identifies and organizes a list of books and journals comprising a core library (100 books/15 journals) for CME professionals.

Methods: The Delphi method was applied to elicit and combine the judgments of a fifty member panel considered knowledgeable about the CME field. The panelists participated in three iterations of the survey to first identify and then rank order nominated works. Separate ranked lists were created for books and journals.Results: Forty-four participants completed the study (88% response rate). 268 books and 34 journals were identified. Mean ratings ranged from 4.78 (high) to 1.50 (low).

Discussion: The results of the study reflect the panel’s judgment. The list is not definitive; instead, it describes what a select group of individuals knowledgeable about the CME field considered important. The list should therefore be seen as a general guide and a resource to facilitate decision-making, not as a prescription for creating a library.

PubMed

This post courtesy of Anne Taylor-Vaisey:

Following is a list of current systematic reviews from the EPOC Cochrane review group. Included are the ‘plain language summaries‘ and links to the full abstracts. Full text of the Cochrane reviews is available by subscription only. (The Cochrane Database of Systematic Reviews 2005 Issue 4. Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Not included in this list are organizational interventions, structural interventions, or reviews to improve specific types of practice. All are available here.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

Educational meetings are one of the most common types of continuing education for health professionals, and an important aim of continuing education is to influence professional practice. This review looked at whether educational meetings and workshops aimed at qualified health professionals were effective in improving professional practice or health care outcomes. The following types of planned educational activities were included: meetings, conferences, lectures, workshops, seminars, symposia and courses that occurred off-site from the practice setting. The review found that interactive workshops could result in moderately large changes in professional practice. Lectures or presentations alone were unlikely to change professional practice.

Link

Educational outreach visits: effects on professional practice and health care outcomes

An outreach visit is a personal visit to a health care provider in his or her own setting. It is also called ‘detailing’, and is a strategy commonly used by pharmaceutical companies. The review found that educational outreach visits combined with social marketing strategies appears to change professional practice, especially prescribing. The effects are small to moderate, although potentially important.

Link

Local opinion leaders: effects on professional practice and health care outcomes

Local opinion leaders can also theoretically influence the behaviour of their colleagues. However, exactly how they might influence them remains unclear. The review concluded that while most trials found some benefit from using local opinion leaders to improve practice, only a few found any important impact on patients’ outcomes. If it is possible to identify local opinion leaders, they may be important agents for change for some problems, but not others.

Link

Audit and feedback: effects on professional practice and health care outcomes

Providing healthcare professionals with data about their performance (audit and feedback) may help improve their practice.

Audit and feedback can improve professional practice, but the effects are variable. When it is effective, the effects are generally small to moderate. The results of this review do not provide support for mandatory or unevaluated use of audit and feedback.

Link

Mass media interventions: effects on health services utilisation

Mass media information on health-related issues may induce changes in health services utilisation, both through planned campaigns and unplanned coverage. Further research could target how best to compose media messages, and whether they have a different impact on members of the public and health professionals. More information is needed on whether mass media coverage brings about appropriate use of services in those patients who will benefit most.

Link

Interprofessional education: effects on professional practice and health care outcomes

Interprofessional education (IPE) is defined as any type of educational, training or teaching initiative involving more than one profession in joint, interactive learning. This review looked at the effectiveness of IPE compared to educational interventions in which doctors, nurses etc were learning separately from one another. Although a large body of literature was identified on the evaluation of IPE, none of the studies met the inclusion criteria for the review. More rigorous studies, such as randomised trials, are needed in order to provide reliable evidence of the impact of IPE on professional practice and health care outcomes.

Link

Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes

Some strategies to change the practice or behaviour of health care professionals are successful in improving health care while others are not. One explanation may be that there are different barriers to change in different settings and at different times. Change may be more likely if the strategies are specifically chosen to address the identified barriers. Barriers could be related to the individual (e.g. uncertainty about the risks of a procedure); related to social issues (e.g. peer pressure to perform a certain way); or related to the organisation (e.g. no access to equipment). And to successfully change behaviour, barriers should be identified and a strategy developed to overcome those barriers. In other words, it is thought that strategies tailored to overcome barriers should be more effective to change behaviour than non-tailored strategies or no strategy at all.

Fifteen studies evaluated tailored strategies for behaviour change in health care professionals. The results were mixed. It is therefore, unclear whether tailored strategies are more effective than non-tailored strategies or no strategy. Due to a small number of studies, it is also not possible to determine whether strategies tailored to overcome organisational barriers are more effective than those that were not. It is also not clear whether all barriers or important barriers were identified and addressed by the strategies. More research about how to identify and overcome barriers is needed.

Link

Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians

This review examined the impact of different payment systems on primary care physician behaviour. Three payment systems were included: capitation (payment is made for every patient for whom care is provided), salary, and fee for service (payment is made for every item of care provided). There was some evidence that primary care physicians provide a greater quantity of primary care services under fee for service payment compared with capitation and salary, although long-term effects are unclear. There was no evidence, however, concerning other important outcomes such as patient health status, or comparing the relative impact of salary versus capitation payment.

Link

Target payments in primary care: effects on professional practice and health care outcomes

This review looked at the effects of target payments on the behaviour of primary care physicians (e.g. general practitioners and family physicians). Under a target payments system a lump sum is paid to physicians who provide a certain quantity or level of care. Two studies assessed the impact of target payments on immunisation rates. There was some evidence that target payments resulted in an increase in immunisations by primary care physicians. However there was insufficient evidence to provide a clear answer as to whether target payments were an effective method of improving quality of care.

Link

Telemedicine versus face to face patient care: effects on professional practice and health care outcomes

Telemedicine is using telecommunications technology for medical diagnosis and health care. It includes transmitting test results down phone lines, using video technology for long distance consultations or education, and many other uses. The review found studies showing various forms of telemedicine are feasible, but there is not yet enough evidence to show the effects on health outcomes or costs of many expensive uses of technology. Overall, people self-monitoring at home or having video consultations were satisfied with their experience. More research is needed to assess the effects of the range of telemedicine techniques.

Link

Guidelines in professions allied to medicine

The issuing of clinical guidelines to nurses, midwives, dieticians and other health-care professionals allied to medicine may reduce variations in practice and improve patient care. This review found that, despite limited research, there is some evidence that guidelines can improve care and that professional roles can be substituted effectively, for instance a nurse can perform the function of a physician in certain circumstances. Such interventions offer the possibility of reduced costs but further research is needed in all areas of this topic.

Link

Organisational infrastructures to promote evidence based nursing practice

Organisational infrastructures may be important in the development of evidence based nursing practice. We did not find any evaluated infrastructure developments that were of sufficient quality to be included in the systematic review. There are no clear implications for organisational practice as there is no good evidence about the impact of organisational infrastructures on the development of evidence based nursing practice.

Link

Teaching critical appraisal skills in health care settings

Critical appraisal involves interpreting information in a systematic and objective manner. This review looked at whether teaching critical appraisal skills to health professionals led to changes in the process of care, patient outcomes or health professionals’ knowledge/awareness. The review found that teaching critical appraisal skills to health professionals improved their knowledge of these skills. However there was a lack of good quality evidence as to whether teaching critical appraisal skills led to changes in the process of care or to changes in patient outcomes.

Link

This post courtesy of Anne Taylor-Vaisey:

The October 2005 issue of Business Ethics Quarterly is a special issue: ETHICAL RESPONSIBILITIES REGARDING DRUGS, PATENTS, AND HEALTH

Here are a couple of abstracts from this issue:

De George RT. Intellectual property and pharmaceutical drugs: an ethical analysis. Business Ethics Quarterly 2005; 15(4):549-575.

Abstract: The pharmaceutical industry has in recent years come under attack from an ethical point of view concerning its patents and the non-accessibility of life-saving drugs for many of the poor both in less developed countries and in the United States. The industry has replied with economic and legal justifications for its actions. The result has been a communication gap between the industry on the one hand and poor nations and American critics on the other. This paper attempts to present and evaluate the arguments on all sides and suggests a possible way out of the current impasse. It attempts to determine the ethical responsibility of the drug industry in making drugs available to the needy, while at the same time developing the parallel responsibilities of individuals, governments, and NGOs. It concludes with the suggestion that the industry develop an international code for its self-regulation.

PubMed link

Leisinger KM. The corporate social responsibility of the pharmaceutical industry: idealism without illusion and realism without resignation. Business Ethics Quarterly 2005; 15(4):577-594.

Abstract: In recent years society has come to expect more from the “socially-responsible” company and the global HIV/AIDS pandemic in particular has resulted in some critics saying that the “Big Pharma” companies have not been living up to their social responsibilities. Corporate social responsibility can be understood as the socio-economic product of the organizational division of labor in complex modern society. Global poverty and poor health conditions are in the main the responsibilities of the world’s national governments and international governmental organizations, which possess society’s mandate and appropriate organizational capabilities. Private enterprises have neither the societal mandate nor the organizational capabilities to feed the poor or provide health care to the sick in their home countries or in the developing world. Nevertheless, private enterprises do have responsibilities to society that can be categorized as what they must do, what they ought do, and what they can do.

PubMed link

Business Ethics Quarterly

This post courtesy of Anne Taylor-Vaisey: From the November 2005 issue of Journal of Philosophy of Education: Erlandson P. The body disciplined: rewriting teaching competence and the doctrine of reflection. Journal of Philosophy of Education 2005; 39(4):661-670.

Abstract: Shortly after the publication of The Reflective Practitioner (1983) and the sequel Educating the Reflective Practitioner (1987) ‘reflection-in-action’ became a major concept in teacher education. The concept has, however, been criticised on ontological/epistemological as well as practice oriented accounts (Van Manen, 1995; Newman, 1999; Erlandson, 1995). In this paper I argue that reflection-in-action is a theoretical construction that snatches the interactin! g, working, and producing bodies from their practices, and consequently, matters of politics, of discipline, of institutional interaction and of the workings of social categories are reduced to matters of thinking. Turning to Foucault (1991) I claim that the doctrine of reflection is interwoven in the logic of discipline.

Link

I recently got this request from a reader, and was hoping you all could help. If you can, please leave a citation in the comments, or e-mail it to me and I’ll pass it along.

I am trying to locate research that supports the idea that case vignettes are a reliable way to measure level 5 outcomes. I have attended a few seminars where this idea has been perpetuated by some of our more distinguished members of the CME community however they only reference two citations (written by the same author) as evidence. I read the study done by Peabody et. al. that was published in JAMA and in the Annals of Internal Medicine but I believe putting all of our eggs in one basket based on one study is not good science.

 

Are you aware of any other studies that support this idea or has this topic come up and been discussed by others?

Thanks in advance for any help you can provide!