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Managed care is affecting the business of medical practices. Many physicians are joining with larger organizations and employee benefits are even more significant in each physician's financial security. Background on benefit issues and common areas of caution when contemplating joining a large entity are addressed.
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In this session, Ms. Smith and Ms. Sims outlined the practice milieu for today's nephrology nurse. The speakers portrayed the end stage renal disease (ESRD) environment by defining the providers of care, outlining the changing characteristics of the recipients of care, and describing the effects of health care reform.
The search by physicians for opportunities to improve the short-term performance and long-term value of their practices has resulted in the creation of a range of affiliation and group practice structures and changed the traditional private practice profile. The resulting ability to structure an environment that is optimal for each practitioner or group of practitioners can enhance the delivery of medical care and serve to attract an array of individuals to private practice. In order for this evolution to be successful, however, the entities must be developed with thoughtful and detailed analysis and should be flexible enough to adapt to the continually changing environment.
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To elicit the opinions of practicing internists who had graduated from a single internal medicine residency program about the adequacy of their training and its relevance to their medical practice, we mailed a survey to 1,342 physicians who had spent at least 1 year in the Mayo internal medicine residency training program. Of this group, 703 alumni (52%) responded to the survey, 532 of whom were currently practicing internal medicine. Our detailed analysis was based on responses from these 532 and, for some aspects of evaluation, on the 121 general internists who had completed residency training after 1970. Of the respondents, 42% spent more than 80% of their time in general medicine, and 53% had at least some subspecialty practice; 55% were involved in teaching, 20% in some research, and 37% in various administrative duties. In 27%, all patient-care activities involved primary care, an increase from 18% in a 1979 survey and 9% in 1972. Of those who were subspecialists, 67% spent more than half their time in subspecialty practice. Of those who were trained after 1970, 90% were board certified. Most respondents thought that their training in the internal medicine subspecialties was adequate, that additional procedure training was needed in joint aspiration, line placement, and flexible sigmoidoscopy, and that many allied medical areas were important to their practice and necessitated additional training. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient training. Alumni surveys can be useful in restructuring a residency program to meet the needs of the trainees.
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Medical education and training programs generally have been slow to introduce curriculum content that reflects important changes in practice organization and health services delivery. However, impetus for curricular reform is gaining momentum as national organizations endorse new content for both medical school and residency education. The authors and colleagues at Tufts Managed Care Institute reviewed nine reports by key national organizations to assess their positions on curricular reform in light of changes in practice and the system of care. The reports agree generally on the evolving nature of practice, the need to address these changes during medical school and residency training, and the description of the new curriculum content that they advocate. The authors grouped these reports' specific recommendations under ten curriculum domains: health care system overview; population-based care; quality measurement and improvement; medical management; preventive care; physician-patient communication; ethics; teamwork and collaboration; information management and technology; and practice management. They describe the reports' rationales and cite specific knowledge and skills that these national organizations identify within each domain. This domain-based framework synthesizes and complements the recommendations of these national organizations. The authors conclude that implementing curricular reform remains a challenge. The information and competencies need to be organized and sequenced for stage of training and specialty, and barriers to change require strategic and operational planning. Having a common nomenclature and framework will facilitate the introduction of new content within schools and programs, across departments, and among institutions nationwide.
A general working definition of medical malpractice is provided. Relevant factual situations as well as applicable decisional and statutory laws are delineated. This information will allow the nurse to understand the legal standards that apply to nursing practice in a variety of health care environments.
Hygiene education for dental students is crucial in order to control and reduce the risk of infections in their future professional practices. The aim of this study was to evaluate the improvement in university students' knowledge of infectious disease prevention, dental instruments and environmental decontamination following the Course in Dental Hygiene and Prevention. 595 questionnaires were submitted to dental students at twelve Italian Universities; 335 were filled out before the Course began and 260 at the end of the same course. The students in both the PRE-course and at the POST-course evaluations demonstrated adequate knowledge regarding the transmission of infections in dental practices, knowledge improved following the Hygiene course.
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Pregnant women are a natural part of the workforce in Sweden. A few types of exposure in the work environment are strictly regulated for pregnant women due to well-known risks of miscarriage, malformations or mental retardation in the child. However, a much larger number of types of exposure may pose risks for negative effects on the pregnancy. Chemical, physical and psychosocial factors may interact with personal medical conditions, and a risk assessment must always be performed with the individual in mind. This article addresses the most common questions about pregnancy and the work environment. According to Swedish law, an employer must perform an assessment of the risks in the work environment for the pregnant woman. If the work environment is considered to be hazardous, the particular exposure in question should be reduced or work tasks changed. If neither of these are possible, the woman has a right to compensation from the Social Insurance Office. Self-employed women are currently excluded from this right.
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The purpose of planned clinical experience for students of nursing is primarily to provide students with the opportunity to develop their clinical skills, integrate theory and practice, and assist with their socialization into nursing. Nursing, in the main, is a practice-based profession. To this extent, it is essential that nurse education continues to have a strong practical element despite its full integration into higher education institutions (Department of Health, 1999). However, providing adequate support and supervision for learners is challenging. Undoubtedly, exacerbated by increasing numbers of learners, staff shortages and mentors training deficits. This article aims to critically analyse several strategies, which can be used to promote clinical learning.
Nonmedical factors affecting obstetric decisions regarding abnormal labor were investigated in Maine, a rural state. Obstetricians were questioned about practice structure, hospital services, anesthesia support, and legal liability. Cesarean section rates specific for abnormal labor, based on hospital discharge summaries in the previous two years, correlated inversely with improved night coverage support, 24-hour blood bank availability, and more adequate anesthesia services. Neither the payment differential between vaginal and cesarean delivery nor previous legal liability were associated with increased cesarean rates for abnormal labor. We conclude that improved ancillary services may lead to lower dystocia-specific cesarean section rates.
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