Quality among a diversity of health care providers. .
Thirty years' experience in the US with non-physician clinicians shows they can deliver quality care.
Australia↗
Biomedical subjects
Richard A Cooper
Publications and source records attributed to Richard A Cooper.
Indian medical students' views on immigration for training and practice.
PURPOSE: To assess the attitudes of medical students in India about participating in graduate medical education in the United States and other countries and in subsequent clinical practice in those countries. METHOD: A total of 240 students who were attending their final year at two medical schools in Bangalore, India, were surveyed during 2004. Surveys were completed by 166 (69%) of the students. RESULTS: Among the responding students, 98 (59%) thought of leaving India for further training abroad. Of those who wished to leave, 41 (42%) preferred the United States, 42 (43%) preferred the United Kingdom, and 9 (9%) preferred Canada, Australia or New Zealand. Only two students preferred the Middle East. Most who favored training in the United States indicated that they intended to remain after training, whereas fewer than 20% of those who favored training in the United Kingdom had such intentions. While more than 60% perceived greater professional opportunities in the United States than in India, approximately 75% were concerned that the United States had become less welcoming after the terrorist attacks of 9/11, and similar numbers were concerned about the examination administered by the Educational Commission on Foreign Medical Graduates. Conversely, the majority of respondents felt that opportunities for physicians in India were improving. CONCLUSIONS: While optimism about future medical careers in India is increasing, the interest of Indian medical students in training and subsequently practicing in the United States remains high.
Attitude of Health Personnel↗
A comparison of the characteristics and examination performances of U.S. and non-U.S. citizen international medical graduates who sought Educational Commission for Foreign Medical Graduates certification: 1995-2004.
BACKGROUND: International medical graduates (IMGs) make up a substantial part of the U.S. physician workforce. Unfortunately, little is known about the demographic and performance characteristics of these doctors, especially over time. METHOD: Educational Commission for Foreign Medical Graduates (ECFMG) applicants from 1995-2004 were studied. The characteristics and examination performances of U.S. citizen and non-U.S. citizen IMGs were contrasted. RESULTS: ECFMG applications from U.S. citizen IMGs have been increasing. Compared to non-U.S. citizen IMGs, these individuals perform less well on some of the certification examinations, especially in the last 5 years, but are more likely to eventually achieve certification. Based on those medical students/graduates who took the examinations, the performance of U.S. citizen IMGs varied considerably from one medical school to another. CONCLUSION: The composition of the pool of ECFMG-certified IMGs available for graduate medical education has changed over the past 10 years. Shifts in the characteristics and abilities of IMGs are likely to have some future impact on health care delivery in the United States.
Certification↗
Health services delivery: reframing policies for global migration of nurses and physicians--a U.S. perspective.
One half of all of the nurses and physicians in English-speaking countries practice in the United States, yet future shortages of both professions are projected. Because the United States has failed to create sufficient educational capacity for its own needs, it is dependent on foreign health professionals. The magnitude of this dependency has a significant impact on the health care systems of source countries, particularly developing countries, from which the majority of foreign nurses and physicians coming to the United States emigrate. Even emigration from the United Kingdom and other developed countries affects developing countries because it triggers recruitment from developing countries to replace this emigration. To achieve a higher level of self-sufficiency, the United States must establish a national health care workforce policy that gives priority to building adequate educational infrastructure, while also providing assistance to developing countries to train and retain adequate numbers of health professionals.
Developed Countries↗
Physician migration: a challenge for America, a challenge for the world.
For five decades, medical education policy in the United States has been built around the expectation that, if too few physicians were produced, additional physicians would be available from other countries. That policy is examined in the context of the desire for an ever-increasing number of physicians who will provide an ever-expanding array of services in the future. This reality is juxtaposed against the realities that the medical education infrastructure in the United States has yet to respond to the projected needs of the future. Also, other countries have growing needs for English-speaking physicians, particularly the developing countries from which most such physicians migrate. I explore the history of physician migration to the United States, catalogue the countries of origin, examine the attitudes of current students and physicians about migration, and consider the consequences that are likely for donor countries if even higher levels of migration are stimulated. I conclude that the deepening shortages of physicians now being experienced in this country cannot be rectified without substantial increases in the flow of physicians from developing to developed countries. The challenges that this will create call for mutual understanding and a high degree of discipline and creativity among all countries if global health care needs are to be respected.
Education, Medical↗
Viewpoint: New physicians for a new century.
How to train competent and compassionate physicians has assumed a new urgency. The authors propose that these concerns be approached by radically restructuring the medical school curriculum in ways that place facts and skills within the context of ethics and values. Doing so will require that the positivist stance of medical education be coupled to strategies that deal with ambiguity and uncertainty, communication and empathy, and, most important, physician self-awareness. Achieving such balance will require fundamental change in medicine's education philosophy along five general lines: (1) assertion of medical ethics as the foundation of clinical medicine; (2) recognition of the central place of values in clinical decision making; (3) cultivation of the ethos of humane care; (4) selection of medical students with the dual capacities of strong cognitive skills and empathy; and (5) encouragement and support of faculty who can transmit the knowledge of clinical science coupled to the principles of humane care. Such changes are both timely and necessary. Although they will be difficult to accomplish, they offer an opportunity for medical educators to foster the development of physicians with the range attributes that this new century demands.
Communication↗
Weighing the evidence for expanding physician supply.
For 2 decades, health planners have forecasted impending physician surpluses, and policy decisions related to medical schools and residency programs have been based on such expectations. However, these much-heralded surpluses never materialized, and a growing body of data and opinion now point in the other direction. The question at the forefront is whether the United States is instead headed for a physician shortage. What is the evidence? This paper reviews the trends that link economic growth to health care spending and to the demand for physicians. It assesses the current environment by examining trends in the characteristics of clinical practice, signals from the medical market, and recent experiences of physician shortages in other English-speaking countries; it also discusses why past forecasting approaches may have failed. Taken together, this body of information indicates that physician shortages are emerging and that they will probably worsen over the next 2 decades. By 2020 or 2025, the deficit could be as great as 200,000 physicians--20% of the needed workforce. If remedies are to be found, the nature of the problem must be appreciated, and a consensus to solve it must be reached.
Allied Health Personnel↗
Perceptions of medical school deans and state medical society executives about physician supply.
CONTEXT: Physician shortages are appearing, yet controversy about their significance and uncertainty about their remedy exist. OBJECTIVES: To sample the perceptions of medical school deans and state medical society executives about the adequacy of physician supply, to determine the perceived impact of any shortages on medical schools, and to assess the capacity of medical schools to expand. DESIGN, SETTING, AND PARTICIPANTS: Medical school deans in the United States and Puerto Rico were surveyed by means of a structured questionnaire, and officials of US state medical societies were queried by means of open-ended telephone interviews. Information was obtained from 58% of medical school deans and 86% of state medical society executives. MAIN OUTCOME MEASURE: Reported perceptions of shortages or surpluses of physicians by specialty and plans to increase medical school class size. RESULTS: Approximately 85% of both deans and medical society respondents perceived shortages of physicians, usually in multiple specialties, while 10% perceived surpluses, usually coexisting with shortages. Among deans reporting shortages, 83% described a negative impact on their schools. Recent or planned increases in class size were reported by 27% of deans and expansion capacity by another 34%, but 7% noted recent decreases in class size. Applied generally, these changes in class size could yield 7.6% additional matriculants annually. CONCLUSIONS: Physician shortages are prevalent and they are negatively affecting medical schools. Little capacity exists to alleviate these shortages through class size expansion.
Administrative Personnel↗
Impact of trends in primary, secondary, and postsecondary education on applications to medical school. I: gender considerations.
The number of applications to medical schools has been declining at a time when attention is beginning to focus on the potential need to expand the infrastructure of medical education to meet the nation's growing consumption of health care services. To gain an understanding of the dynamics affecting the availability of medical applicants, the author used data from several decades to study the transitions that occur throughout the process of education-from primary and secondary education to four-year colleges and, ultimately, to medical school application-from the standpoint of individuals' gender. (A companion article in this issue reports the findings of a parallel study from the standpoint of individuals' race and ethnicity.) A progressive erosion was found in the level of participation of men in postsecondary education over the past 25 years, and a parallel decline was observed in the percentage of baccalaureate men who sought further education at the doctoral level, including medicine. These dynamics have occurred aside rising levels of achievement of girls in early education, increasing numbers of women in four-year colleges, and high levels of interest among college women in medical education. But despite this peak of interest, women baccalaureates have displayed a low frequency of application to medical schools. Based on these observations and on population trends among 20 year olds, it is projected that the number of women applying to medical school will continue to increase, but only modestly, while the number of men who apply will remain relatively unchanged. The resulting growth will be sufficient to alleviate the recent paucity of medical school applications, but it will not be adequate for the needs that any significant expansion of medical school seats will create nor for the numbers of physicians that a predominantly female profession will require.
Adult↗
Impact of trends in primary, secondary, and postsecondary education on applications to medical school. II: considerations of race, ethnicity, and income.
The availability of sufficient numbers of qualified medical school applicants has been a periodic source of concern. Over the past few years, this concern has emerged again, as fewer men have applied to medical school and as the number of minority applicants has stagnated. This time, however, the cause for concern is greater, because these declining numbers coincide with a growing need for physicians and the possibility that medical school capacity will have to be expanded to avert future physician shortages. Against this background, applications by members of racial and ethnic minorities, who represent an increasing fraction of the college age population, become particularly important. The author reports the trends in education, over several decades, by members of the principal racial-ethnic groups-whites, blacks, Hispanics, and Asians-traces their participation from kindergarten through college, and projects the likelihood of their applying to medical school over the next two decades. (A companion article in this issue reports a parallel study from the standpoint of gender.) One prominent observation is the firm link between academic achievement in the earliest grades and success thereafter. A second is the profound influence of parents' education, income, and expectations at each step along the way. Inadequacies in either sphere erode the potential for children to reach college and to do so in ways that predict interest in and capacity for medical school. Yet, even when that potential emerges, inadequate finances deflect qualified high school and college students from the paths that lead to medical education. These factors weigh most heavily on black and Hispanic children, particularly boys, but are prevalent among whites, as well. Without aggressive education in the earliest years and without adequate financial support in the later years, it is not clear that there will be a sufficiently large pool of qualified applicants for the number of medical school seats that must exist in the future.
Adult↗
Chiropractic in the United States: trends and issues.
Chiropractic is the best established of the alternative health care professions. Although marginalized for much of the 20th century, it has entered the mainstream of health care, gaining both legitimacy and access to third-party payers. However, the profession's efforts to validate the effectiveness of spinal manipulative therapy, its principal modality, have yielded only modest and often contrary results. At the same time, reimbursement is shrinking, the number of practitioners is growing, and competition from other healing professions is increasing. The profession's efforts to establish a role in primary care are meeting resistance, and its attempts to broaden its activities in alternative medicine have inherent limitations. Although patients express a high level of satisfaction with chiropractic treatment and politicians are sympathetic to it, this may not be enough as our nation grapples to define the health care system that it can afford.
Adult↗
Economic expansion is a major determinant of physician supply and utilization.
OBJECTIVE: To assess the relationship between levels of economic development and the supply and utilization of physicians. DATA SOURCES: Data were obtained from the American Medical Association, American Osteopathic Assocation, Organization for Economic Cooperation and Development (OECD), Bureau of Health Professions, Bureau of Labor Statistics, Bureau of Economic Analysis, Census Bureau, Health Care Financing Administration, and historical sources. STUDY DESIGN: Economic development, expressed as real per capita gross domestic product (GDP) or personal income, was correlated with per capita health care labor and physician supply within countries and states over periods of time spanning 25-70 years and across countries, states, and metropolitan statistical areas (MSAs) at multiple points in time over periods of up to 30 years. Longitudinal data were analyzed in four complementary ways: (1) simple univariate regressions; (2) regressions in which temporal trends were partialled out; (3) time series comparing percentage differences across segments of time; and (4) a bivariate Granger causality test. Cross-sectional data were assessed at multiple time points by means of univariate regression analyses. PRINCIPAL FINDINGS: Under each analytic scenario, physician supply correlated with differences in GDP or personal income. Longitudinal correlations were associated with temporal lags of approximately 5 years for health employment and 10 years for changes in physician supply. The magnitude of changes in per capita physician supply in the United States was equivalent to differences of approximately 0.75 percent for each 1.0 percent difference in GDP. The greatest effects of economic expansion were on the medical specialties, whereas the surgical and hospital-based specialties were affected to a lesser degree, and levels of economic expansion had little influence on family/general practice. CONCLUSIONS: Economic expansion has a strong, lagged relationship with changes in physician supply. This suggests that economic projections could serve as a gauge for projecting the future utilization of physician services.
Cross-Sectional Studies↗
Where is psychiatry going and who is going there?
Explore the source record for details and available documents.
Education, Medical↗
Credentialing complementary and alternative medical providers.
Since the late 19th century, state legislatures and professional medical organizations have developed mechanisms to license physicians and other conventional nonphysician providers, establish standards of practice, and protect health care consumers by establishing standardized credentials as markers of competence. The popularity of complementary and alternative medical (CAM) therapies presents new challenges. This article describes the current status of, and central issues in, efforts to create models for health care credentialing of chiropractors, acupuncturists, naturopaths, massage therapists, and other CAM practitioners. It also suggests a strategy of CAM provider credentialing for use by physicians, health care administrators, insurance companies, and national professional organizations. The credentialing debate reflects fundamental questions about who determines which providers and therapies will be accepted as safe, effective, appropriate, and reimbursable. More nationally uniform credentialing mechanisms are necessary to ensure high standards of care and more generalizable clinical research. However, the result of more uniform licensure and credentialing may be excessive standardization and a decrease in individualization of services. Thus, increased standardization of credentialing for CAM practitioners may alter CAM practice substantially. Furthermore, even credentialed providers can deliver ineffective therapy. The suggested framework balances the desire to protect the public from dangerous practices against the wish to grant patients access to reasonably safe and effective therapies.
Acupuncture↗
Availability of neonatal intensive care and neonatal mortality.
Explore the source record for details and available documents.
Humans↗
There's a shortage of specialists: is anyone listening?
The author critiques the long-standing belief that there will be too many physicians, particularly specialists, a view put forth by the Bureau of Health Professions and the Council on Graduate Medical Education in the 1990s and held by many medical organizations, including the Association of American Medical Colleges. He cites his own research, which predicts, to the contrary, that the United States will experience progressively more severe shortages of specialists, and he quotes a wide variety of anecdotal evidence indicating that such shortages are beginning to appear already. He maintains that most previous workforce studies were handicapped by their use of micro-quantitative models. Instead, his research has been structured around four broad trends: economic expansion (which directly influences the demand for physicians), physician work-effort (which is declining), the provision of physicians' services by non-physician clinicians (which is increasing), and the growth of the U.S. population (which often has not been factored in adequately). It is the intertwining of these four major trends that reveals the impending shortages of physicians. He recommends that attention be directed to training more specialists, but cautions against a further dependence on international medical graduates to fill the gap. Instead, he calls upon academic medicine to expand the infrastructure for medical education. However, despite what he sees as a growing cacophony of voices expressing alarm about the developing shortages, he is concerned that academic medicine may not be listening.
Health Workforce↗
Acute thrombocytopenia in patients treated with the oral glycoprotein IIb/IIIa inhibitors xemilofiban and orbofiban: evidence for an immune etiology.
Thrombocytopenic episodes occurring in 18,845 patients treated with the GPIIb/IIIa inhibitors xemilofiban and orbofiban ("fibans") were analyzed by a blinded review panel and 73 patients were classified as having "possible fiban-induced thrombocytopenia". When the treatment codes were broken, a significant association between drug exposure and assignment to this group was found (p <0.001). Twenty-eight (82%) of 34 archived serum samples from these patients contained fiban-dependent antibodies specific for GPIIb/IIIa, but no such antibodies were found in 61 drug treated patients not classified as having "possible fiban-induced thrombocytopenia" (p <0.001). We conclude that fiban-dependent antibodies were the major cause of acute, severe thrombocytopenia in patients judged on the basis of clinical findings to have thrombocytopenia "possibly-induced" by xemilofiban and orbofiban. Measurement of drug-dependent antibodies may be helpful in determining the basis for acute thrombocytopenia in fiban-treated patients and possibly for identification of patients at risk to develop thrombocytopenia.
Acute Disease↗