Article

Specialization, Subspecialization, and Subsubspecialization in Internal Medicine

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Over the past 75 years, many medical and surgical specialties have emerged. In this Sounding Board article, the authors outline the history of medical and surgical specialization and subspecialization and frame the issues faced by the public and the profession.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... The national physician workforce is becoming increasingly stratified according to discipline both by formal credentials, such as specialty board certifications, and by circumstantial or preferential clinical practice emphasis. 9,10 The requirements for establishing a subspecialty in internal medicine are based on many conditions, including (1) evidence that the new discipline has a definable body of knowledge, (2) a significant number of clinical training programs, and (3) a realistic expectation that clinical services in the subspecialty will improve patient care. ...
... Traditionally, such certifications have required at least a year of authorized instruction. 9 While the relationship between specialization or subspecialization and improved clinical outcomes is well established, 9 this study aims to evaluate point number 3 concerning the discipline of telemedicine and tests the hypothesis that advanced training in telemedicine will improve patient care and clinical outcomes. Of importance to note, telemedicine is not currently an established subspecialty, nor does it have its own residency or fellowship training programs in the United States. ...
... Traditionally, such certifications have required at least a year of authorized instruction. 9 While the relationship between specialization or subspecialization and improved clinical outcomes is well established, 9 this study aims to evaluate point number 3 concerning the discipline of telemedicine and tests the hypothesis that advanced training in telemedicine will improve patient care and clinical outcomes. Of importance to note, telemedicine is not currently an established subspecialty, nor does it have its own residency or fellowship training programs in the United States. ...
Article
Full-text available
Background: COVID-19 caused a dramatic increase in the scope and utilization of telemedicine. However, the sustainability of the permanent integration of telemedicine in the management of chronic disease beyond the pandemic is still enigmatic. The purpose of this retrospective chart review was to analyze the effect of advanced training in telemedicine on clinical outcomes in type II diabetes mellitus (T2DM) in the United States. Methods: A retrospective chart review was conducted in 104 deidentified patients with diabetes from 28 specialized telemedicine agency physicians who had received specialized telemedicine training. After establishing exclusion criteria, the charts of 59 T2DM patients were evaluated. Glycated hemoglobin (HbA1c) percentage and body mass index (BMI) were used as quantitative endpoints. Visit consistency, mediation data, and compliance data were also studied. Results: The mean change in HbA1c for the 42 patients who met the inclusion criteria for evaluating HbA1c (n = 42) was −0.429%. The largest decrease in HbA1c was 5.4%, and the most significant increase was 3.9%. The mean change in BMI for the 16 patients who met the inclusion criteria for evaluating BMI (n = 16) was −2.175 kg/m². The largest decrease in BMI was 9.5 kg/m² and the largest increase was +0.7 kg/m². The average number of visits for patients with a decrease in HbA1c was 3.45. The average number of visits for patients with an increase in HbA1c was 2.62. Conclusions: Outcomes of telemedicine providers with training are comparable with the standard of care. Advanced telemedicine training and its effect on clinical outcomes in the management of chronic disease warrant further investigation. For telemedicine to become a mainstay in U.S. medicine, a standard of best practices should be evaluated and available for providers who wish to continue telehealth care delivery.
... With the advent of technology, the field of medicine has advanced and is now divided into multiple subspecialities. 1 Patients reporting in the Out Patient Department of any hospital are referred to one or multiple sub-specialities depending on their disease and diagnosis. However, in clinical practice there is usually a communication gap between various specialties regarding proper referral of patients. ...
... The reliability of the scale was then calculated which revealed Cronbach's alpha of 0.744. 1 Alpha 0.744 is good interclass coefficient which shows how strongly the subheadings in one group resemble each other. It is a type of correlation which measures the strength of the data in structured groups. ...
Article
Full-text available
Competency in referral writing skill is needed by doctors for which they are not adequately trained. Although there has been a lot of discussion on improvement of skills for writing consultation letters, still priority is not given to this important task. Ideally there should be a course with assessment for teaching and learning medical referral writing skills for students. Currently, there is no such tool to assess the way communication letters are written. An 18-point assessment scale has been developed through Delphi technique to improve the quality of referral letters. The objective of the present study was to design a structured Proforma for writing referrals, with the consensus of seven participants using Delphi. The place of study was Rawalpindi medical university and allied hospitals. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach's alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Proforma for writing referrals, with its interrater reliability calculated, seems effective for writing effective and structured referrals. The study further recommends training junior doctors in making effective referrals.
... Paradoxically, the longer the education, the narrower a specialist's scope of practice (Cassel and Reuben 2011). An interventional cardiologist goes through baccalaureate education, medical school, residency, fellowship and subfellowship to end with a highly specialized, but limited scope of practice. ...
... 150). In highly specialized healthcare, the need for generalists in primary care has repeatedly been stressed and debated, but this concern is not easily addressed (Ferrer et al. 2005;Cassel and Reuben 2011;Woods et al. 2021). Nursing is an even more dynamic domain, with proliferations of specialties, often following restructurings in health care and hospitals (Currie and Carr Hill 2012). ...
Article
Healthcare has become highly specialized. Specialists, in medicine as well as in nursing, determine much of the high quality of current health care. But healthcare has also become increasingly fragmented, with professionals trained in separate postgraduate silos, with boundaries often difficult to cross. While a century ago, generalists dominated patient care provision, now specialists prevail and risk becoming alienated from each other, losing the ability to adapt to neighboring professional domains. Current health care requires a flexible workforce, ready to serve in multiple contexts, as the COVID-19 crisis has shown. The new concept of transdisciplinary entrustable professional activities, EPAs applicable in more than one specialty, was recently conceived to enhance collaboration and transfer between educational programs in postgraduate nursing in the Netherlands. In this paper, we reflect on our experiences so far, and on practical and conceptual issues concerning transdisciplinary EPAs, such as: who should define, train, assess, and register transdisciplinary EPAs? How can different prior education prepare for similar EPAs? And how do transdisciplinary EPAs affect professional identity? We believe that transdisciplinary EPAs can contribute to creating more flexible curricula and hence to a more coherent, collaborative healthcare workforce, less determined by the boundaries of traditional specialties.
... With the advent of technology, the field of medicine has advanced and is now divided into multiple subspecialities. 1 Patients reporting in the Out Patient Department of any hospital are referred to one or multiple sub-specialities depending on their disease and diagnosis. However, in clinical practice there is usually a communication gap between various specialties regarding proper referral of patients. ...
... The reliability of the scale was then calculated which revealed Cronbach's alpha of 0.744. 1 Alpha 0.744 is good interclass coefficient which shows how strongly the subheadings in one group resemble each other. It is a type of correlation which measures the strength of the data in structured groups. ...
Article
Competency in referral writing skill is needed by doctors for which they are never trained. Although there is a lot of work done about improvement of consultation letters still priority is not given. There must be a course for teaching and learning medical referral writing skills to students along with the assessment. Currently there is such tool to assess the way communication letter are written. An 18-point assessment scale has been developed through Delphi technique to increase the quality of referral letters. The objective of the present study was to design a structured Performa for writing referrals, validated by 7 participants using Delphi. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach’s alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Performa for writing referrals, with its inter-rater reliability calculated, is best for writing effective and structured referrals. The study further recommending training junior doctors in making proper referrals. MeSH Words: Referral and consultation, improving quality and referral, Checklists and referrals and consultation.
... Our results demonstrate that false positives are used by decision-makers to justify taking action (Newell and Marabelli, 2015), at times without a comprehensive understanding of what the outliers represent (Mayer-Schonberger and Cukier, 2013). For specialized industries, such as healthcare (Cassel and Reuben, 2011;van Capelleveen et al., 2016), consideration should be given to critically evaluating the output of data analytic tools and technology driven fraud detection initiatives seeking to normalize behavior may not be appropriate (Sargiacomo et al., 2015;Sharma and Lawrence, 2015). As risks identified may merely represent false positives, algorithmic decisionmaking can result in suboptimal outcomes when blindly followed by decision-makers (Arnold and Sutton, 1998). ...
... Industry-specific factors create an abundance of specialization within the healthcare industry (Cassel and Reuben, 2011;Mashaw and Marmor, 1994;van Capelleveen et al., 2016), rendering the adoption of a one-size-fits-all fraud-detection approach inadvisable (SAS, 2014). Specialization in the healthcare industry advances knowledge to improve society as a whole (Mashaw and Marmor, 1994). ...
Article
This study explores how government-adopted audit data analytic tools promote the abuse of power by auditors enabling politically sensitive processes that encourage industry-wide normalization of behavior. In an audit setting, we investigate how a governmental organization enables algorithmic decision-making to alter power relationships to effect organizational and industry-wide change. While prior research has identified discriminatory threats emanating from the deployment of algorithmic decision-making, the effects of algorithmic decision-making on inherently imbalanced power relationships have received scant attention. Our results provide empirical evidence of how systemic and episodic power relationships strengthen each other, thereby enabling the governmental organization to effect social change that might be too politically prohibitive to enact directly. Overall, the results suggest that there are potentially negative effects caused by the use of algorithmic decision-making and the resulting power shifts, and these effects create a different view of the level of purported success attained through auditor use of data analytics.
... In larger communities, this creates a division of labour as well as disjuncture between the management and caring professionals. The division of labour not only divides management from those who deliver care firsthand but, within a global marketplace, this division easily leaves gaps in understanding between each party (Cassel & Reuben, 2011). ...
Article
Full-text available
This article explores the challenges of professional identities and delivery of care in humanitarian work and nursing practices. Using a twofold methodology comprising a literature review and analysis of two case studies – humanitarian responses to the 2004 tsunami in Sri Lanka and responses to the COVID-19 pandemic in a hospital setting in the USA – the authors highlight how traditional education may fall short in preparing individuals to be compassionate and effective caregivers. This article suggests that drawing on ideas from ancient philosophies beyond the Euro-North American perspective could help to improve learning. By incorporating values like teamwork, joyfulness, openness, and humility, we might create better strategies for training and avoid conflicts within caring professions such as nursing and humanitarianism.
... Specialisation has brought numerous benefits across various fields [1] and is often regarded as a marker of scientific advancement [2]. It has also been crucial in modern medicine [3], significantly enhancing the quality of life [1]. ...
Article
Full-text available
Background Different countries have varying dental specialities, shaped by diverse factors. The determinants influencing the development of these specialities differ between developed and developing countries. This study aimed to explore the factors contributing to the establishment of dental specialities in Iran, a developing country with a wide range of recognised dental specialities. Methods A qualitative case study was carried out, involving the review of 25 in-depth interviews and 47 documents. The data were organised using Atlas.ti (version 7.57) software and analysed through content analysis. This process included transcribing the interviews, identifying meaning units, abstracting content, categorising codes, and developing themes. Results The results identified three key factors influencing the development of dental specialities in Iran: stakeholders, contextual factors, and the specialisation process. Stakeholders encompass influential figures such as abroad-trained specialists, the government, the Ministry of Health and Medical Education, and scientific associations, along with their position, perceptions, and power. Contextual factors include cultural norms, sociopolitical relationships, political shifts, economic conditions, and academic disciplines. The process of establishing new dental specialities revealed several gaps, including the absence of formal needs assessments, advocacy plans, career planning, effective partnerships, and adequate evaluation mechanisms. Conclusion Contextual factors have played a crucial role in shaping dental specialisation in Iran, driving the formation of ideas in this field. Key players, including dentists trained abroad, have significantly influenced this process, often motivated by the desire to mirror practices in other countries. However, it did not address the specific oral health needs of the Iranian population. Due to limited awareness and the cost disparity between specialised and general services, there has been little public demand for dental specialisation. However, the process of establishing these specialities faces significant gaps that need to be addressed.
... These referral requests have also been remarkably increased over the past few years (5,7). These increases may be attributed to increasing complexity of the required care which subsequently requires more specialised physicians as well as the increasing demands of health care services which is likely due to the growing number of people (5,8,9). Subsequently, meeting the increasing number of referral requests is therefore challenging. ...
Article
Full-text available
Introduction An effective referral system is necessary to ensure quality and an optimum continuum of care. In the Kingdom of Saudi Arabia, an e-referral system known as the Saudi Medical Appointments and Referrals Centre (SMARC), has been fully functioning since 2019. This study aims to explore the rate of medical e-referral request acceptance in the KSA, and to study the factors associated with acceptance. Methods This period cross-sectional study utilised secondary collected data from the SMARC e-referral system. The data spans both 2020 and 2021 and covers the entirety of the KSA. Bivariate analyses and binary logistic regression analyses were performed to compute adjusted Odds Ratios (aORs) and 95% confidence intervals. Results Of the total 632,763 referral requests across the 2 years, 469,073 requests (74.13%) were accepted. Absence of available machinery was a significant predictor for referral acceptance compared to other reasons. Acceptance was highest for children under 14 with 28,956 (75.48%) and 63,979 (75.48%) accepted referrals, respectively. Patients requiring critical care from all age groups also had the highest acceptance including 6,237 referrals for paediatric intensive care unit (83.54%) and 34,126 referrals for intensive care unit (79.65%). All lifesaving referrals, 42,087 referrals, were accepted (100.00%). Psychiatric patients were observed to have the highest proportion for accepted referrals with 8,170 requests (82.50%) followed by organ transplantations with 1,005 requests (80.92%). Sex was seen to be a significant predictor for referrals, where the odds of acceptances for females increased by 2% compared to their male counterparts (95% CI = 1.01–1.04). Also, proportion of acceptance was highest for the Eastern business unit compared to all other units. External referrals were 32% less likely to be accepted than internal referrals (95% CI = 0.67–0.69). Conclusion The current findings indicate that the e-referral system is mostly able to cater to the health services of the most vulnerable of patients. However, there remains areas for health policy improvement, especially in terms of resource allocation.
... Current available literature indicates a significant variation in the rate of referral requests made by physicians, with a notable increase in referral requests in recent years [2,[10][11][12][13]. This increase in referral requests can be attributed to several factors, including a growing and aging population, and the increased complexity of required care, which requires the involvement of specialized physicians [2,14,15]. While effectively managing the surge of referral requests poses a significant challenge, doing so is crucial to guarantee that patients receive needed care in a timely manner without unnecessary delays in disease diagnosis and treatment. ...
Article
Full-text available
Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.
... Trend of becoming specialist among our doctors seems to be associated with innovation in medical technology as well as medical education (Flexner, 1910). A few decades back, an unethical practice was observed to recruit the general practitioners for the post of specialized healthcare professionals due to limited opportunities but scenario has substantially been reversed nowadays (Cassel, 2011). Although postgraduate trainees not only have to pass their entrance exam for getting into training; but their pervious academic achievements were also considered for finalizing the selection merit. ...
Article
Full-text available
Pakistan with respect to gender and training program. Data pertaining to postgraduate trainees enrolled in both FCPS and MS / MD programs was gathered from administrative staff of 3 teaching hospitals of Rawalpindi which were Holy Family Hospital (HFH), Benazir Bhutto Hospital (BBH) and DHQ Hospital through informed consent. Data was collected regarding number of male and female trainees enrolled in each training program. Data was analyzed by using MS Excel 2016. Chi-square test was applied to measure the gender and program-wise (FCPS / MS /MD) difference in opting Medicine versus Surgery & Allied training programs for postgraduation. P<0.05 was considered significant. About 57.1% and 42.9% trainees were enrolled in FCPS part-II training and MS / MD programs respectively. Most (55.1%) were females. Of the total 635 trainees, 189 were enrolled in Surgery & Allied programs while 160 were registered in Medicine & Allied specialties. About 99 were enrolled in Gynecology & Obstetrics and relatively less trainees were registered in Pediatrics, Anesthesia, Radiology, ENT and Ophthalmology. Difference in opting FCPS or MS /MD program for Medicine and Surgery & Allied disciplines among trainees was statistically insignificant (P > 0.20). More males were enrolled in Surgery and Allied programs (P<0.05). Recommendation is relaxing the selection criteria of Central Induction in Punjab for getting more doctors trained in our country in sub-specialties and hence improvement of healthcare outcome of the nation.
... A total of 17,510,578 discharge episodes in patients over 14 years of age (excluding deliveries) were analyzed corresponding to the period 2016---2020. Of these patients, 12% had at least one primary diagnosis of infectious disease (2,158,871). The number of discharges involving infectious diseases increased over the years, with a marked rise in 2020 due to the SARS-CoV-2 pandemic, from 334,017 patients discharged in 2016 to 603,738 in 2020. ...
Article
Aims: This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. Materials and method: This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016-2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. Results: Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. Conclusions: At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients.
... Sub-specialization involves a focused and intellectual pursuit of a better understanding of a speci c aspect of a specialty [1].It is a necessary and logical phenomenon which results from a tremendous expansion of the knowledge base, technical skills and the technology of a specialty [2]. The main factor that is possibly driving sub-specialization is the advancing body of knowledge [3,4,5]. ...
Preprint
Full-text available
Purpose: To determine the status of sub-specialization among Nigerian ophthalmologists as well as their dispositions and barriers against sub-specialization with a view to providing valuable information for the purpose of human resources for eye care planning thereby providing useful insight into the future of ophthalmic practice in Nigeria. Methods: This was a web-based, cross-sectional study conducted among Ophthalmologists in Nigeria. An online questionnaire was distributed through e-mails using Qualtrics software (Qualtrics, Provo, UT, USA). Information concerning socio-demographic characteristics, type of practice, location of practice, years of practice, status and disposition to sub-specialization as well as barriers to sub-specialization were obtained through the questionnaire. Results: two hundred and four Nigerian Ophthalmologists participated in the study out of which 118 (57.8%) were females. One hundred and ten (54.0%) respondents had undergone sub-specialty training. The sub-specialties with the highest number of patronage was Paediatric Ophthalmology and Strabismus (14.2%). Respondents older than 46 years were three times more likely to have undergone subspecialty training compared to respondents who were aged 46 years and below [odds ratio (OR) = 3.01, 95% Confidence interval (CI) = 1.33 – 6.83, p = 0.01]. The main barriers to the availability and uptake of sub-specialty services as well as the challenges of sub-specialty services at the centres with established sub-specialty practice were non-availability/inadequate trained specialist and inadequate equipment. Conclusion: Nigerian Ophthalmologists are well disposed to sub-specialization although the extent of sub-specialization among them was a little above average. The main barriers to the availability and uptake of sub-specialty services as well as the challenges of sub-specialty services at the centres with established sub-specialty practice in this study were non-availability/inadequate trained specialist and inadequate equipment.
... Subspecialization involves devoting intellectual resources toward detailed learning about a narrower and specific area of a specialty [1]. The radiology subspecialty must comprise a distinct area of knowledge that cannot be incorporated into the general radiology curriculum. ...
Article
Background and objective There are numerous reasons why radiologists would be interested in seeking additional fellowship training, some of which are personal, such as the possibility of bettering their career prospects, while others are work-related. This study aimed to identify whether the Sudanese radiology trainees wanted to pursue fellowship and what were the motivating and restricting factors affecting their career choices. Methods This was a re-do research of a study from Saudi Arabia previously published in the Cureus journal in 2019. This was a descriptive cross-sectional study conducted among the radiology registrars training under Sudan Medical Specialization Board (SMSB) in 2022 (n=90). By using convenient sampling, 74 of the 90 registrars were contacted, and a response rate of 81% (n=60) was achieved. Data were collected using a pre-tested self-administered online questionnaire. Data were analyzed using IBM SPSS® Statistics version 25.0 (IBM Corp., Armonk, NY). A p-value ≤0.05 was considered statistically significant. Results The majority of the trainees in our study were females (61.7%, 37/60). More than 93% (n=56) of our participants were training in Khartoum, the capital of Sudan. The most commonly chosen subspecialties in our study were as follows: neuroradiology (33.3%, n=20) body imaging (26.7%, n=16), and interventional radiology (25%, n=15). In contrast, nuclear medicine (1.7%, n=1) and emergency radiology (3.3%, n=2) were among the least popular subspecialties. The top influencing factors among our trainees in choosing a subspecialty included "strong personal interest," "lifestyle," and "area of strong personal knowledge." The most common factors preventing trainees from opting for a fellowship were "financial restriction" (55%, n=33) and "family obligation" (28.3%, n=17). Of those with no plans to subspecialize, 75% (six out of eight) stated that the lack of a fellowship program in Sudan is a possible deterrent. A statistically significant association was found between gender and the choice of subspecialty in interventional radiology and women’s/mammogram imaging. Our findings revealed that there are currently no trainees in the first year of radiology residency because the last selection exam had been conducted in 2019. Despite the current unavailability of subspecialty training in Sudan, 75% (n=45) of trainees in our study were interested in joining a local program for fellowship training in the future. Conclusion Radiology trainees in Sudan share similar interests and influencing and restricting factors when pursuing subspecialty training, as reported in the literature. Unlike other countries, females predominate in the field of radiology training in Sudan at the moment. Radiologists from Sudan who are interested in subspecializing usually travel abroad for training; and once they find better prospects, many of them may not return. Programs offering subspecialization locally could mitigate the attrition of radiologists in Sudan. When designing subspecialty training programs in Sudan, stakeholders should use knowledge of influential factors and understanding of subspecialty decision trends among radiology trainees as a reference point. To the best of our knowledge, this study is the first of its kind to be conducted in this field in Sudan.
... The organisation of hospital care is highly specialied (Cassel & Reuben, 2011;Genentech Oncology Trend Report, 2018), with medical specialists and healthcare professionals tending to mainly treat specific health problems in their field of expertise (Ariela Lowenstein Phd, 2000;Elhauge, 2010). Being treated by different specialists for each individual ailment increases the risk of fragmentation of care, defined as follows: "the delivery of care involving multiple providers and organizations with no effective coordination of different aspects of care" (Frandsen et al., 2015). ...
Article
Patients with multiple health problems are a growing population at high risk of receiving fragmented care, resulting in a poorer quality of care, preventable hospitalisations, and higher costs. Health agencies such as the World Health Organization (WHO) advocate the implementation of interprofessional care, which should lead to better patient care. This retrospective cohort study investigated the effect of combined interprofessional and intraprofessional collaboration on the management of mainly elderly patients with multiple health problems on an Intensive Collaboration Ward (ICW). Patient health outcomes, patient experience, and the cost and value of care were assessed. In total, 200 patients admitted to the ICW were compared with 51 control patients with an indication for the ICW who were admitted to a regular ward because of a shortage of ICW beds. Patients admitted to the ICW had a shorter length of hospital stay than control patients (median 5 vs 7 days, p = .004) and had fewer in-hospital consultations (p = .003). Patient satisfaction did not differ between the ICW and control patients (mean rating (1–10) 8.22 vs 8.75, p = .060). This study indicates that interprofessional and intraprofessional clinical collaboration reduces the length of hospital stay and the number of in-hospital consultations, without affecting patient satisfaction.
... Sub-specialization involves a focused and intellectual pursuit of a better understanding of a specific aspect of a specialty [1]. It is a necessary and logical phenomenon which results from a tremendous expansion of the knowledge base, technical skills and the technology of a specialty [2]. ...
Article
Full-text available
Purpose To determine the status of sub-specialization among Nigerian ophthalmologists as well as their dispositions and barriers against sub-specialization with a view to providing valuable information for the purpose of human resources for eye care planning thereby providing useful insight into the future of ophthalmic practice in Nigeria. Methods This was a web-based, cross-sectional study conducted among ophthalmologists in Nigeria. An online questionnaire was distributed through e-mails using Qualtrics software (Qualtrics, Provo, UT, USA). Information concerning socio-demographic characteristics, type of practice, location of practice, years of practice, status and disposition to sub-specialization as well as barriers to sub-specialization were obtained through the questionnaire. Results Two hundred and four Nigerian ophthalmologists participated in the study out of which 118 (57.8%) were females. One hundred and ten (54.0%) respondents had undergone sub-specialty training. The sub-specialties with the highest number of patronage was Paediatric Ophthalmology and Strabismus (14.2%). Respondents who had practised for more than 7 years were three times more likely to have undergone sub-specialty training compared to respondents who had practised for 7 years and below [odds ratio (OR) = 3.01, 95% confidence interval (CI) = 1.33–6.83, p = 0.01]. The main barriers to the availability and uptake of sub-specialty services as well as the challenges of sub-specialty services at the centres with established sub-specialty practice were non-availability/inadequate trained specialist and inadequate equipment. Conclusion Nigerian ophthalmologists are well disposed to sub-specialization although the extent of sub-specialization among them was a little above average. The main barriers to the availability and uptake of sub-specialty services as well as the challenges of sub-specialty services at the centres with established sub-specialty practice in this study were non-availability/inadequate trained specialist and inadequate equipment.
... At the cusp of educational transition in athletic training, leaders in the profession articulated a framework for the future. 1 In this framework, there was a call to develop clinical specialists, advanced practice leaders, and stewards of the profession to serve as guides for the delivery of postprofessional residencies, advanced practice doctorates, and research doctorates. 1 Clinical specialty has existed in medicine for over a century, with the first specialty emerging in ophthalmology. 2 Specialization, regardless of health care profession, has historically been driven by innovation, preference, and economy. 3 Innovation in health care delivery occurs through the expansion of knowledge and technology, much of which cannot be taught in professional-level education because of its foundational role. ...
Article
Context Athletic training residency programs are proliferating rapidly, yet only 1 accredited residency is housed outside of physician-practice or clinic settings. Objective The focus of this article was to explore the structural and cultural factors that support a residency program in a college/university athletic training facility. Design Qualitative ethnographic study. Setting Boston University Commission on Accreditation of Athletic Training Education–accredited residency program. Patients or Other Participants The unit includes 16 full-time athletic trainers (2 of whom are residents, 6 of whom are residency faculty/preceptors) and 3 fellowship-trained primary care sports medicine physicians. Data Collection and Analysis I made observations, engaged in discussions, and conducted interviews for 34 days (159.5 hours) over 4 months. Data analysis involved examining transcriptions, field notes, and observational summaries of dialogue and behaviors, reactions, and my own interpretations. I used an inductive coding process to develop meaningful concepts, grouping them together to classify the data and identify themes and subthemes characterizing the structures of the culture. Results I identified 3 themes: resident preparation and expectations, residency experience, and environment. In the first theme, I identified that the residents came into the residency having some deficiencies and incongruent expectations of the program. In the second theme, I observed the residents gained depth of knowledge, skills, and abilities in their focused area of practice, and they improved self-reflective practices through their exposure to clinical specialists and the varied pedagogical approaches within the program. The environment included both benefits and challenges in having a residency. Engagement in interprofessional and collaborative practice and a culture of teaching and learning supported the residency environment. Conclusions Athletic health care administrators must clearly communicate expectations when recruiting candidates, consider the training and commitment of their staff, and ensure culture of health care education within their unit before developing a residency, regardless of setting.
... It provides an intense exposure to a subspeciality area allowing a focused development of clinical and surgical skills related to that subspeciality area. 11,12 Subspecialisation requires knowledge, expertise, and practice beyond that of a specialisation. Specific personnel, equipment, technology, dedicated curriculum, accredited training centres, logbooks, exposure to complex cases, high case volumes, subspecialist international journals, international subspecialist societies/associations, and relevant scientific breakthroughs in the field are the sine qua non of subspecialisation. ...
Article
Full-text available
Background: Radiology subspecialisation is well-established in much of Europe, North America, and Australasia. It is a natural evolution of the radiology speciality catalysed by multiple factors. Objectives: The aim of this article is to analyse and provide an overview of the current status of radiology subspecialisation in African countries. Methods: We reviewed English-language articles, reports, and other documents on radiology specialisation and subspecialisation in Africa. Results: There are 54 sovereign countries in Africa (discounting disputed territories). Eighteen African countries with well-established radiology residency training were assessed for the availability of formal subspecialisation training locally. Eight (Egypt, Ethiopia, Kenya, Morocco, Nigeria, South Africa, Tanzania, and Tunisia) out of the 18 countries have local subspecialist training programmes. Data and/or information on subspecialisation were unavailable for three (Algeria, Libya, and Senegal) of the 18 countries. Paediatric Radiology (Ethiopia, Nigeria, South Africa, Tunisia) and Interventional Radiology (Egypt, Kenya, South Africa, Tanzania) were the most frequently available subspecialist training programmes. Except Tanzania, all the countries with subspecialisation training programmes have ≥ 100 radiologists in their workforce. Conclusion: There is limited availability of subspecialist radiology training programmes in African countries. Alternative models of subspecialist radiology training are suggested to address this deficit.
... Nearly 26% of our study population did not present to one of our prespecified physician specialties at their index visit, but with billing for a classic ovarian cancer symptom, the symptom warranted enough physician attention to require a plan and could have been an opportunity for workup or referral. Women in our study saw an increasing number of physician specialties over the time period of our study, which perhaps reflected the increasing subspecialization of medical care in the United States, [28][29][30] and seeing more physicians was associated with a longer TTD. ...
Article
Full-text available
Background Patients with ovarian cancer often present with late‐stage disease and nonspecific symptoms, but little is known about factors affecting the time to diagnosis (TTD) in the United States. Methods A retrospective, population‐based study of the Surveillance, Epidemiology, and End Results–Medicare database was conducted. It included women 66 years old or older with stage II to IV epithelial ovarian cancer with at least 1 code for abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of the cancer diagnosis. TTD was defined from the first claim with a prespecified symptom to the ovarian cancer diagnosis. Kruskal‐Wallis tests were used to assess for differences in TTD by group medians. Univariate and generalized linear models with a log‐link function evaluated TTD by covariables. Results For the 13,872 women analyzed, the mean and median times to diagnosis were 2.9 and 1.1 months, respectively. The median TTD differed significantly by first symptom (P < .001), number of symptoms (P < .001), and first physician specialty seen (P < .001). In a multivariable analysis, TTD differed significantly according to race/ethnicity (P < .001), geographic region (P = .001), urban‐rural location (P = .031), emergency room presentation (P < .001), and number of specialties seen (P < .001). A shorter TTD was associated with a diagnosis in 2006‐2010 (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87‐0.98) or 2011‐2015 (RR, 0.87; 95% CI, 0.81‐0.93) in comparison with 1992‐1999. Conclusions The time from a symptomatic presentation to care to a diagnosis of ovarian cancer is influenced by clinical and demographic variables. This study's findings reinforce the importance of educating all physicians on ovarian cancer symptoms to aid in diagnosis. Lay Summary Ovarian cancer is often diagnosed once disease has spread because the classic symptoms of ovarian cancer—abdominal or pelvic pain, bloating, difficulty eating, and urinary issues—can be mistaken for other problems. This study examined the time between when women with classic ovarian cancer symptoms went to a physician and when they received a cancer diagnosis in a large database population. The authors found that the time to diagnosis differed according to the type and number of symptoms and what type of physician a woman saw as well as factors such as race, geographic location, and year of diagnosis.
... w ww.archbronconeumol.org Editorial Áreas de Capacitación Específica (ACE) en neumología Areas of Specific Subspecialization (ACE) in Pulmonology Desde hace años es evidente que el desarrollo de especialidades clínicas con un campo de actuación muy amplio, como es la neumología, ha comportado el nacimiento de áreas más específicas del conocimiento y el uso de técnicas cada vez más sofisticadas 1 . Todo ello precisa de un reconocimiento formal. ...
Article
Full-text available
Archivos de Bronconeumología xxx (xxxx) xxx-xxx w ww.archbronconeumol.org Editorial Áreas de Capacitación Específica (ACE) en neumología Areas of Specific Subspecialization (ACE) in Pulmonology Desde hace años es evidente que el desarrollo de especialidades clínicas con un campo de actuación muy amplio, como es la neu-mología, ha comportado el nacimiento de áreas más específicas del conocimiento y el uso de técnicas cada vez más sofisticadas 1. Todo ello precisa de un reconocimiento formal. Es más, ello permitiría que la provisión de plazas en los hospitales del Sistema Nacional de Salud respondiera a las necesidades concretas de desarrollo en cada servicio concreto de neumología. En línea con esa evidencia y necesidad, el Ministerio de Sani-dad lleva tiempo preparando lo que sería la regulación de las denominadas «Áreas de Capacitación Específica» (familiarmente conocidas como ACE). En este sentido está prevista la aprobación de un decreto ley que recogería este punto, además de una regu-lación de especialidades actualmente no reconocidas y un nuevo intento de instaurar o reforzar la troncalidad 2 , ahora denominada «transversalidad». Aunque este último punto también es contro-vertido y probablemente precisa de nuestro posicionamiento como sociedad científica, el presente editorial se centra únicamente en las ACE y su formulación. Así, parece que el planteamiento inicial que se propone para dicha capacitación es su inclusión en los actua-les 4 años escasos de residencia. De hecho, y paradójicamente, la subespecialización se formula como un período de uno o 2 años. Es obvio que dicho planteamiento es difícilmente compatible con una buena formación como neumólogo general y al tiempo como subespecialista, al reducirse la formación básica del especialista a un año y medio escaso (a lo que cabe restar las libranzas de guardia y períodos vacacionales), por quedar «pinzada» entre la formación troncal-transversal (año y medio) y la pro-puesta de subespecialización. Además, conlleva la imposibilidad de seguir y completar el actual programa de formación general en la especialidad 3,4. De hecho, ya viene demandándose por SEPAR desde hace tiempo que la propia formación como especialista general en patología del aparato respiratorio comprenda 5 años de residencia 5,6. Pretender que se añada un período de especialización durante los 4 años actuales de la residencia, de los cuales casi 3 serían «para otra cosa», resulta no ya difícil y problemático, sino sencillamente imposible y temerario. Lo lógico sería realizarlo tras el período de residencia, y de forma independiente y posterior al ya reclamado quinto año para la especialización básica en neumología, como sucede tanto en otros países europeos como en Norteamérica 5-8. Además, tanto la formación en la especialidad general como en sus subespecialidades (ACE) deberían armonizarse con los países de nuestro entorno, lo que probablemente debiera conllevar una convergencia normativa e impulso a iniciativas como HERMES 9. Otro punto controvertido es el de qué parte de la ciencia y/o la técnica es susceptible de convertirse en una ACE y quién debe proponerlo. Por un lado, existen áreas de conocimiento que dispo-nen con frecuencia de unidades específicas en muchos hospitales, y bien pudieran aspirar a ser consideradas como una subespe-cialización o área específica de conocimiento neumológico. Son, por ejemplo, el asma grave, la patología intersticial, el manejo del tabaquismo, las alteraciones vasculares del pulmón, el trasplante pulmonar o los pacientes semicríticos. Por otra parte, existen áreas que precisan no sólo de conocimientos concretos sino de habilida-des específicas ligadas al soporte instrumental que se debe manejar. Es el caso de algunas de las antes mencionadas, pero también de la neumología intervencionista, y las unidades de alta especiali-zación en pruebas funcionales respiratorias (tanto convencionales como ligadas a la evaluación de la capacidad de esfuerzo), o en el estudio de los trastornos respiratorios del sueño. Creemos que ambas orientaciones pueden ser correctas y que unas necesidades bien definidas por el sistema sanitario y las sociedades científi-cas deben facilitar la priorización. Además, el sistema debe ser lo suficientemente flexible para adaptarse a situaciones inesperadas, como ha sido la pandemia de COVID-19 y la generación en nuestro país de numerosas unidades de cuidados respiratorios interme-dios. Sin embargo, no queda claro de momento en qué orden, bajo qué requisitos y a propuesta de quién se establecerían dichas ACE. Un tercer tema importante es el de en qué lugares podrá rea-lizarse la subespecialización y con qué programa formativo. ¿Será en todas las unidades acreditadas para la formación de residen-tes?, ¿sólo en las de centros terciarios y con unidades específicas previamente acreditadas y con profesionales de reconocido presti-gio? En este último caso, ¿acreditadas por quién? Más aún, ¿podrán todos los residentes de neumología realizar dichas subespecializa-ciones o sólo aquellos con plaza en los centros acreditados al efecto? Respecto del programa formativo pensamos que sería conveniente un desarrollo basado en la adquisición de competencias, probable-mente inspirado en los documentos del programa de Desarrollo Profesional Continuado (DPC) de SEPAR. Esto implica además que deben definirse con precisión los criterios de adquisición de las competencias y titulación de las ACE, que no deben reducirse a seguir simplemente el programa formativo como actualmente sucede con la obtención de las especialidades médicas.
... One of the great attractions of paediatric radiology is the huge variety that one encounters within it. The rise of the subspecialisation has divided the medical profession for many years [1]; however, modern medicine is increasingly becoming a world of genomics, robotic surgery and gene therapy, with a move towards personalised treatment regimens. In this environment, increasing levels of subspecialisation seem inevitable [2]. ...
Article
Full-text available
We present the case for subspecialisation in paediatric gastrointestinal and hepato-pancreatico-biliary radiology. We frame the discussion around a number of questions: What is different about the paediatric patient and paediatric gastrointestinal system? What does the radiologist need to do differently? And finally, what can be translated from these subspecialty areas into everyday practice? We cover conditions that the sub-specialist might encounter, focusing on entities such as inflammatory bowel disease and hepatic vascular anomalies. We also highlight novel imaging techniques that are a focus of research in the subspecialties, including contrast-enhanced ultrasound, MRI motility, magnetisation transfer factor, and magnetic resonance elastography.
... Health includes and is reliant on the support of resilient psychological well-being. Despite this, medicine continues to be increasingly specialised (2) with the focus being biological and narrow (3). In the area of psychiatry, change over time has not led to a similar degree of subspecialisation (4) and there have been some attempts to introduce a more holistic stance, such as through adoption of the biopsychosocial model of care (5,6). ...
Article
Full-text available
Psychiatry has a long tradition of enforcing ‘care’ within mental health settings, through formal and informal coercion, often with little regard to decision-making capacity. Despite scant evidence for the effectiveness of coercive interventions and the wide variation in their application, indicating structural as opposed to health-driven reasons for use, coercive practices continue to be routinely used internationally. This is notwithstanding the recovery model of care that is endorsed on a national public policy level in many countries. Further, the Convention on the Rights of Persons with Disabilities (CRPD) and its Committee make plain that the use of practices of coercion for those who experience disability, including people who experience psychosocial disability, are unacceptable and in breach of their and other international conventions. The CRPD is interpreted as demanding an end to coercion, primarily through substitute decision-making being replaced with supported decision-making. This critical analysis examines the development of coercive practices in psychiatry, how they have become embedded as both common and socially acceptable, and approaches that may help to reduce their use in light of the CRPD. Models of care where changes have been successful in reducing substitute decision-making and promoting supported decision-making are highlighted to challenge some of the inertia to change.
Article
Healthcare systems in Canada are under pressure and require change—the status quo is no longer fit for purpose, if it ever was. Innovation is often held up as a cure for what ails us, but shiny new things or novel technologies alone have not been enough. This article will explore the concepts of differentiation and integration as being important drivers in the evolution of living organisms, ecosystems, and complex human organizations. The implications of this deep pattern of systems change are essential to understanding the roles of specialization in medicine, and optionality in primary care. Specifically, overspecialization without attention to the principles of healthcare integration can lead to fragmentation of care and worse patient outcomes. Finally, this article will describe some practical examples of system integration as innovation in the form of better public health and care delivery connections, health homes, and community care coordination centres.
Article
Full-text available
Chronic liver disease is a global health issue. Patients with chronic liver disease require a fresh approach that focuses on the genetic and environmental factors that contribute to disease initiation and progression. Emerging knowledge in the fields of Genomic Medicine and Genomic Nutrition demonstrates differences between countries in terms of genetics and lifestyle risk factors such as diet, physical activity, and mental health in chronic liver disease, which serves as the foundation for the implementation of Personalized Medicine and Nutrition (PerMed-Nut) strategies. Most of the world’s populations have descended from various ethnic groupings. Mexico’s population has a tripartite ancestral background, consisting of Amerindian, European, and African lineages, which is common across Latin America’s regional countries. The purpose of this review is to discuss the genetic and environmental components that could be incorporated into a PerMed-Nut model for metabolic-associated liver disease, viral hepatitis B and C, and hepatocellular carcinoma in Mexico. Additionally, the implementation of the PerMed-Nut approach will require updated medicine and nutrition education curricula. Training and equipping future health professionals and researchers with new clinical and investigative abilities focused on preventing liver illnesses in the field of genomic hepatology globally is a vision that clinicians and nutritionists should be concerned about.
Article
Introduction Patients who present to hospital with an acute non‐critical illness or injury, which is considered outside the capability framework of that hospital to treat, will require inter‐hospital transfer (IHT) to a hospital with a higher level of capability for that condition. Delays in IHT can negatively impact patient care and patient outcomes. Objective To review and synthesis academic evidence, practitioner insights and patient perspectives on ways to improve IHT from regional to metro hospitals. Design A rapid review methodology identified one review and 14 primary studies. Twelve practitioner interviews identified insights into practice and implementation, and the patient perspectives were explored through a citizen panel with 15 participants. Findings The rapid review found evidence relating to clinician and patient decision factors, protocols, communication practices and telemedicine. Practitioner interviews revealed challenges in making the initial decision, determining appropriate destinations and dealing with pushback. Adequate support and communication were raised as important to improve IHT. The citizen panel found that the main concern with IHT was delays. Citizen panel participants suggested dedicated transfer teams, education and information transfer systems to improve IHT. Discussion and Conclusion Common challenges in IHT include making the initial decision to transfer and communicating with other health services and patients and families. In identifying the appropriateness of transferring acute non‐critical patients, clear and effective communication is central to appropriate and timely IHT; this evidence review indicates that education, protocols and information management could make IHT processes smoother.
Article
Meaningful improvements to graduate medical education (GME) have been achieved in recent decades, yet many GME improvement pilots have been small trials without rigorous outcome measures and with limited generalizability. Thus, lack of access to large-scale data is a key barrier to generating empiric evidence to improve GME. In this article, the authors examine the potential of a national GME data infrastructure to improve GME, review the output of 2 national workshops on this topic, and propose a path toward achieving this goal. The authors envision a future where medical education is shaped by evidence from rigorous research powered by comprehensive, multi-institutional data. To achieve this goal, premedical education, undergraduate medical education, GME, and practicing physician data must be collected using a common data dictionary and standards and longitudinally linked using unique individual identifiers. The envisioned data infrastructure could provide a foundation for evidence-based decisions across all aspects of GME and help optimize the education of individual residents. Two workshops hosted by the National Academies of Sciences, Engineering, and Medicine (NASEM) Board on Health Care Services explored the prospect of better using GME data to improve education and its outcomes. There was broad consensus about the potential value of a longitudinal data infrastructure to improve GME. Significant obstacles were also noted. Suggested next steps outlined by the authors include producing a more complete inventory of data already being collected and managed by key medical education leadership organizations, pursuing a grass-roots data sharing pilot among GME-sponsoring institutions, and formulating the technical and governance frameworks needed to aggregate data across organizations. The power and potential of big data is evident across many disciplines, and the authors believe that harnessing the power of big data in GME is the best next step toward advancing evidence-based physician education.
Article
Aims: This work aimed to review patients discharged from Spanish hospitals with a principal diagnosis of infection during a 5-year period, including the first year of the SARS-CoV-2 pandemic. Materials and method: This work analyzed the Basic Minimum Data Set (CMBD) of patients discharged during the 2016-2020 period from hospitals in the Spanish National Health Service in order to identify cases with a principal diagnosis of an infectious disease according to the ICD-10-S code. All patients older than 14 years of age admitted to a conventional ward or intensive care unit, excluding labor and delivery, were included in the analysis and were evaluated based on the discharging department. Results: Patients discharged with infectious diseases as the principal diagnosis have increased from 10% to 19% in recent years. A large part of the growth is due to the SARS-CoV-2 pandemic. Internal medicine departments cared for more than 50% of these patients, followed by pulmonology (9%) and surgery (5%). In 2020, 57% of patients with a principal diagnosis of infection were discharged by internists, who cared for 67% of patients with SARS CoV-2. Conclusions: At present, more than half of patients admitted with a principal diagnosis of infection are discharged from internal medicine departments. Given the growing complexity of infections, the authors advocate for an approach in which training allows for specialization, but within a generalist context, for the better management of these patients.
Article
Background: Nursing home residents face many barriers to accessing specialist physician outpatient care. However, little data exists on how specialty care use changes when individuals transition to a nursing home in the US. Methods: We studied specialist outpatient visits for new long-term care (LTC) residents within 1 year before and after their transition to nursing home residence using the Minimum Data Set v3.0 (MDS) and a 20% sample of Medicare fee-for-service claims in 2014-2018. To focus on residents requiring specialty care at baseline, we limited the cohort to residents with specialty care in the 13-24 months before LTC transition. We then measured the proportion of residents receiving at least one visit in the 12 months before the transition and the 12 months after the transition. We also examined subgroups of residents with a prior diagnosis likely requiring long-term specialty care (e.g., multiple sclerosis). Finally, we examined whether there was continuity of care within the same specialty care provider. Results: Among 39,288 new LTC transitions identified in 2016-2017, 17,877 (45.5%) residents had a prior specialist visit 13-24 months before the transition. Among them, the proportion of residents with specialty visits decreased consistently in all specialties in the 12 months after the transition, ranging from a relative decrease of 14.4% for orthopedics to 67.9% for psychiatry. The relative decrease among patients with a diagnosis likely requiring specialty care ranged from 0.9% for neurology in patients with multiple sclerosis to 67.1% for psychiatry in patients with severe mental illness. Among residents who continued visiting a specialist, 78.9% saw the same provider as before the transition. Conclusions: The use of specialty care falls significantly after patients transition to a nursing home. Further research is needed to understand what drives this drop in use and whether interventions, such as telemedicine can ameliorate potential barriers to specialty care.
Article
Full-text available
Aim. The aim of this study is to determine the factors affecting the preferences of specialization in the field of medicine. Materials and Methods. Mixed research and exploratory sequential research design were used. In the exploratory phase, data were collected from specialist physicians (n=14) and findings were analyzed by descriptive and content analysis. In the light of qualitative findings, a measurement tool was developed and applied to medical school students and the physicians who prepared specialty exams (n = 502). Results. Qualitative findings were structured under 3 themes: individual, occupational and systemic factors. The measurement tool, which was named “Physicians' Preference Tendencies of Specialty Branch” was structured as 42 items and 7 dimensions: risk, comfort, health problems, status, emotional interest, gender, and marital status emerged. Conclusions. Although there are many factors that affect preferences of the medical field, it is concluded that personality traits and idealism of individuals and mortality rates associated with branch or field of medicine are the most significant professional factors, while the risks and the exposure to violence and the application of the additional payment based on the performance of candidates are the systemic factors that affect selections and preferences. Also, it was concluded that qualitative data obtained in the research were supported with quantitative data.
Article
Background & Aims Follow-up of abdominal computed tomography (CT) and magnetic resonance imaging (MRI) findings suspicious for pancreatic cancer may be delayed if documentation is unclear. We evaluated whether standardized reporting and follow-up of imaging results reduced time to diagnosis of pancreatic cancer. Methods We used a quasi-experimental stepped-wedge cluster design to evaluate the effectiveness of newly implemented radiology reporting system. The system standardizes the reporting of CT and MRI reports using hashtags that classify pancreatic findings. The system also automates referral of patients with findings suspicious for pancreatic cancer to a multidisciplinary care team for rapid review and follow-up. The study examined 318,331 patients who underwent CT or MRI that included the abdomen during 2016 through 2019 who had not had an eligible CT or MRI in the preceding 24 months. We evaluated the association of the intervention with incidence of pancreatic cancer within 60 days and 120 days after imaging. Results 38% of patients received the intervention and 1,523 (0.48%) patients were diagnosed with pancreatic cancer. In multivariable analysis accounting for age, race/ethnicity, sex, Charlson comorbidity, history of cancer, diabetes, and 4-month calendar period, the intervention was associated with nearly 50% greater odds of diagnosing pancreatic cancer within 60 days (adjusted OR, 1.47, 95% CI, 1.05-2.06) and 120 days (adjusted OR, 1.46, 95% CI, 1.04-2.06). Conclusions In this large quasi-experimental community-based observational study, implementation standardized reporting of abdominal CT and MRI reports with clinical navigation was effective for increasing the detection and diagnosis of pancreatic cancer.
Article
Full-text available
Objective: To describe trends in healthcare system use over time between onset of classic ovarian cancer symptoms and ovarian cancer diagnosis in the United States. Methods: A population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted on patients aged ≥66 years with stage II-IV epithelial ovarian cancer between 1992 and 2015 with at least one of the following diagnosis codes: abdominal pain, bloating, difficulty eating, and/or urinary symptoms. The outcomes were frequency of visit type, frequency of diagnostic modality, and Medicare reimbursement between first symptomatic claim and cancer diagnosis. Jonckheere-Terpstra and Cochran-Armitage tests were used to evaluate trends over time. Results: Among 13 872 women, 13 541 (97.6%) had outpatient, 6466 (46.6%) had inpatient, and 4906 (35.4%) had emergency room visits. The frequency of outpatient (p<0.001) and emergency room visits (p<0.001) increased while the frequency of inpatient visits (p<0.001) decreased between 1992 and 2015. The median number of outpatient visits (p<0.001) and physician specialties seen (p<0.001) increased over time. The median hospital length of stay decreased from 10 days in 1992 to 5 days in 2015 (p<0.001). Between 1992 and 2015, the frequency of ultrasound decreased (p<0.001) while the frequency of computed tomography, magnetic resonance imaging, positron emission tomography imaging, and cancer antigen 125 tumor immunoassay increased (p<0.001). Median monthly total (p<0.001), inpatient (p<0.001), and outpatient (p=0.006) reimbursements decreased while emergency room reimbursements increased (p<0.001) over time. Conclusion: Healthcare reimbursement between symptomatic presentation and ovarian cancer diagnosis has decreased over time and may reflect the trends in fewer and shorter hospitalizations and increased use of emergency and outpatient management during the evaluation of symptoms of women with ovarian cancer.
Chapter
Strategies for health services need to take into account the complex nature and contexts of healthcare. Key contextual factors that need to be considered include norms and values, macroeconomics, demographic pressures, changing disease patterns, technological changes, the quest for quality and reducing waste, and rising patient expectations. Healthcare systems have responded to the evolving environment by reassessing the relationship between the state and the market, the way health services are organized and financed, and the involvement of patients in their own care. These developments bring new opportunities to reorient health services towards the maximization of health gain. This chapter discusses strategies where public health professionals can play a potentially vital role in translating these opportunities into reality. It starts by looking at the needs assessment and priority-setting process to ensure that the health services provided reflect the health needs of the population that they serve. Following that, it reviews the design and organization of health services to enhance the efficiency with which services are delivered. It concludes by discussing the enablers (i.e. intelligent purchasing, a workforce with the appropriate capacity and capability, and a robust information and knowledge management system) that are necessary to implement, sustain, and enhance these services.
Article
Background: Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care. Objective: To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination. Design: Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time. Setting: Traditional fee-for-service Medicare. Patients: 20% sample of Medicare beneficiaries. Measurements: Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients. Results: The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019. Limitation: Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel. Conclusion: Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs. Primary funding source: National Institute on Aging.
Article
Full-text available
Introdução: O Hospital das Clínicas da Universidade de São Paulo (HCFMUSP) exerce importante papel na formação de médicos especialistas. Contudo, o perfil dos residentes do maior complexo médico da América Latina ainda é pouco estudado. Objetivo: Buscou-se descrever as características gerais e a distribuição geográfica dos médicos residentes HCFMUSP, bem como comparar aqueles graduados na Faculdade de Medicina da Universidade de São Paulo (FMUSP) e os que se graduaram em outras instituições de ensino. Metodologia: Trata-se de um estudo transversal descritivo baseado em dados secundários de registros profissionais e de formação dos médicos. Para analisar a localização e a distribuição geográfica dos médicos foram utilizados mapas de pontos e as tabulações apresentadas foram realizadas com o Software IBM 24.0 SPSS ®. Para comparações entre grupos distintos de médicos foi usado o teste de qui-quadrado para variáveis categóricas e o teste de t para variáveis contínuas. Um valor de p inferior a 0,05 foi considerado significativo. Resultados: O estudo considerou 8468 médicos que cursavam ou haviam concluído a Residência Médica no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre os anos de 1999 e 2019. Desses, 47,5% eram mulheres. A média de idade de ingresso foi de 26,8 anos. 77,1% dos médicos residentes foram graduados em escolas públicas. As especialidades mais escolhidas foram Clínica Médica (11,2%), Cirurgia geral (8,7%) e Pediatria (7,7%). A maioria dos residentes nasceu (58,0%) e reside (71,9%) no estado de São Paulo. Além disso, observa-se que os residentes, estavam, em 2019, concentrados principalmente nas capitais. Quanto à escola de graduação dos Residentes, 66,2% graduaram-se em outras escolas (não FMUSP). Neste grupo, 65%, graduaram-se em escolas médicas públicas e aproximadamente 25% vieram da região Nordeste. Discussão: Nos programas de Residência Médica devem ser consideradas a oferta de vagas, mas também as características, perfis e trajetórias dos médicos, assim como a origem e a escola de graduação, fatores que podem ser determinantes nas escolhas de especialidades e nas decisões futuras sobre inserção e localização do exercício profissional. Conclusão: O estudo mostrou que características sociodemográficas e informações sobre trajetórias e escolhas dos médicos Residentes são relevantes para a avaliação da instituição formadora e para subsidiar políticas de planejamento sobre força de trabalho médico.
Article
Purpose: To describe the career choices of newly practicing ophthalmologists and explore factors influencing career decisions and satisfaction. Methods: A cross-sectional study was conducted using data from an electronic survey of ophthalmologists who completed training within the prior 5 years. The survey included questions about demographic information, medical education, current practice, factors affecting career choices, and career satisfaction. Statistical comparisons were made based on gender, type of practice, subspecialty training, and practice area. Results: Surveys were completed by 696 (32%) newly practicing ophthalmologists, including 276 (40%) women, 179 (29%) academicians, and 465 (67%) subspecialists. A higher proportion of female respondents entered academics than male respondents (36% vs 26%, P = .009). Female and male respondents pursued fellowship training with similar frequency (64% vs 68%, P = .32), but men were more likely to seek vitreoretinal fellowships (30% vs 11%, P < .001) and women were more likely to undertake fellowships in pediatric ophthalmology (21% vs 8%, P < .001), uveitis (10% vs 2%, P = .002), and neuro-ophthalmology (6% vs 2%, P = .042). A total of 514 (83%) respondents reported being happy with work life. Conclusions: The career choices of newly practicing ophthalmologists differ based on gender, type of practice, subspecialty training, and practice area. Many factors affect career decisions, and they have varying influence on subgroups within ophthalmology. Ophthalmologists have high levels of career satisfaction. This information may prove useful when developing workforce strategies to meet future eye care needs.
Article
Background The first-line treatment for intussusception is radiologic reduction with either air-contrast enema (AE) or liquid-contrast enema (LE). The purpose of this study was to explore relationships between self-reported institutional AE or LE intussusception reduction preferences and rates of operative intervention and bowel resection. Methods Pediatric Health Information System (PHIS) hospitals were contacted to assess institutional enema practices for intussusception. A retrospective study using 2009-2018 PHIS data was conducted for patients aged 0-5 y to evaluate outcomes. Chi-squared tests were used to test for differences in the distribution of surgical patients by hospital management approach. Results Of the 45 hospitals, 20 (44%) exclusively used AE, 4 (9%) exclusively used LE, and 21 (46%) used a mixed practice. Of 24,688 patients identified from PHIS, 13,231 (54%) were at exclusive AE/LE hospitals and 11,457 (46%) were at mixed practice hospitals. Patients at AE/LE hospitals underwent operative procedures at lower rates than at mixed practice hospitals (14.8% versus 16.5%, P< 0.001) and were more likely to undergo bowel resection (31.1% versus 27.1%, P= 0.02). Conclusions Practice variation exists in hospital-level approaches to radiologic reduction of intussusception and mixed practices may impact outcomes.
Chapter
Why does the human body sometimes defend against harmless stimuli, even foods—the very source of the body’s basic requirements? These reactions are errors and can even be fatal. A dramatic increase in food allergies in recent decades has prompted a global research effort. However, even with advances in research, data are conflicting and have not brought medical researchers any closer to a consensus nor explained why many cases occur without immune-mediated processes. While the field of immunology has established that allergies are an inappropriate defense reaction of the immune system, this chapter argues that errant defense is a universal physiological phenomenon that can occur with any system in the body; it is not exclusive to the immune system and, significantly, may be contributing to a vast number of conditions. Errant defense results from dysfunctional signaling processes which alter stimulus interpretation, leading to erroneous perception of threat. The pervasive role of errant defense in pathology can be explained through a biosemiotic framework.
Article
Purpose Narrowly focused surgical practice has become increasingly common in ophthalmology and may have an effect on surgical outcomes. Previous research evaluating the influence of surgical focus on cataract surgical outcomes has been lacking. This study aimed to evaluate whether surgeons’ exclusive surgical focus on cataract surgery influences the risk of cataract surgical adverse events. Design Population-based cohort study. Participants All patients 66 years of age or older undergoing cataract surgery in Ontario, Canada, between January 1, 2002, and December 31, 2013. Methods Outcomes of isolated cataract surgery performed by exclusive cataract surgeons (no other types of surgery performed), moderately diversified cataract surgeons (1%–50% noncataract procedures), and highly diversified cataract surgeons (>50% noncataract procedures) were evaluated using linked healthcare databases and controlling for patient-, surgeon-, and institution-level covariates. Surgeon-level covariates included both surgeon experience and surgical volume. Main Outcome Measures Composite outcome incorporating 4 adverse events: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. Results The study included 1 101 864 cataract operations. Patients had a median age of 76 years, and 60.2% were female. Patients treated by the 3 groups of surgeons were similar at baseline. Adverse events occurred in 0.73%, 0.78%, and 2.31% of cases performed by exclusive cataract surgeons, moderately diversified surgeons, and highly diversified surgeons, respectively. The risk of cataract surgical adverse events for patients operated on by moderately diversified surgeons was not different than for patients operated on by exclusive cataract surgeons (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00–1.18). Patients operated on by highly diversified surgeons had a higher risk of adverse events than patients operated on by exclusive cataract surgeons (OR, 1.52; 95% CI, 1.09–2.14). This resulted in an absolute risk difference of 0.016 (95% CI, 0.012–0.020) and a number needed to harm of 64 (95% CI, 50–87). Conclusions Exclusive surgical focus did not affect the safety of cataract surgery when compared with moderate levels of surgical diversification. The risk of cataract surgical adverse events was higher among surgeons whose practice was dedicated mainly to noncataract surgery.
Article
Full-text available
The Institute of Medicine's reports and discussions on quality of medical care have focused on a systems-based approach to quality improvement. Our objective is to summarize evidence and theory about the role of a physician's current board certification status in quality improvement. The first body of evidence includes the validity of board certification demonstrated by the testing process, the relationship of examination scores with other measures of physician competence, and the relationship between certification status and clinical outcomes. The second body of evidence involves the adaptation of error prevention theory to medical care. Patient safety is enhanced when problem-solving uses readily accessed habits of behavior, the same behavior necessary to achieve board certification. The third body of evidence, obtained through a Gallup poll, demonstrates that certification and maintenance of certification are highly valued by the public. The majority of respondents thought it important for physicians to be reevaluated on their qualifications every few years and that physicians should do more to demonstrate ongoing competence than is currently required by the profession. We conclude that a physician's current certification status should be among the evidence-based measures used in the quality movement.
Article
Full-text available
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. To study U.S. internists' perceptions about the forces driving them to maintain certification. Mail survey. A nationally representative sample of certified internists in the United States. Physicians originally certified in internal medicine, a subspecialty, or an area of added qualifications in 1990, 1991, or 1992. 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. 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. 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.
Article
Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre–managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized by the primary care physician or managed care organization. Financial incentives would be needed, eg, to encourage PCPs to provide management of complex cases and discourage both overreferral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care.
Article
This article has no abstract; the first 100 words appear below. IN 1865,¹ the first meeting of the American Medical Association after any war was held in Boston and was a happy occasion. The official point of assembly for the delegates was the chamber of the House of Representatives at the State House (Fig. 1); there were welcoming speeches by His Excellency the Governor and His Honor the Mayor, a program of serious medical papers and a great deal of enjoyable entertainment with accompanying collations, balls and concerts. The final event was an evening trip along Boston Harbor on the steamship Rose Standish, concluded by a clambake and a triumphal . . . Source Information BOSTON *Assistant dean, Harvard Medical School; consultant, Peter Bent Brigham Hospital.
Article
This interactive feature allows readers to make a decision on the basis of a vignette that is followed by specific options, none of which can be considered either correct or incorrect. In short essays, experts in thefield then arguefor each of the options. In the online version of this feature, available at NEJM.org, readers can participate in forming community opinion by choosing one of the options and, if they like, providing their reasons.
Article
This article has no abstract; the first 100 words appear below. The American Board of Internal Medicine appreciates more than most the "dilemma" in which internal medicine finds itself.¹ In setting standards for subspecialists the Board was responding to a trend set in motion 20 years earlier. Its erstwhile Chairman, Dr. Petersdorf, articulate and well informed, accepts on behalf of the Board more guilt for subspecialization than other emeriti and current members do. But the Board does not challenge his facts. Also convinced that too many positions are offered in the United States for the training of clinical subspecialists in internal medicine, the Board has repeatedly and exhaustively re-examined its policies . . . Richard J. Reitemeier, M.D. Chairman John A. Benson, Jr., M.D. President, American Board of Internal Medicine Portland, OR 97201
Article
Primary care gatekeeping, in which the goal of the primary care physician (PCP) is to reduce patient referrals to specialists and thereby reduce costs, is not an adequate system in which to practice medicine. However, returning to the pre-managed care model of uncoordinated open access to specialists is a poor solution. The primary care model should be retained, but PCPs should be transformed from gatekeepers into coordinators of care, in which the goal of the PCP is to integrate both primary and specialty care to improve quality. Changes in the PCP's daily work process, as well as the referral and payment processes, need to be implemented to reach this goal. This model would eliminate the requirement that referrals to specialists be authorized by the primary care physician or managed care organization. Financial incentives would be needed, eg, to encourage PCPs to provide management of complex cases and discourage both over-referral and underreferral to specialists. Budgeting specialists should control excess costs that might be created by the elimination of the primary care gatekeeper. Pilot projects are needed to test and refine this model of PCP as coordinator of care.
Article
RIMARY CARE MEDICINE IS IN SEARCH OF REDEFINItion. Prevalent payment modes have undermined traditional models and reduced workforce interest while some functions of primary care are emerging in new incarnations. Payers find physicians “too expensive” for basic primary care services, and young physicians find their earnings expectations greater than primary care careers can offer. Understanding these market forces could lead to better understanding of required physician expertise within the larger framework of primary care. A more explicit definition of that expertise could lead to more appropriate market valuation of physician services. Fee-for-service reimbursement has undermined good pri
American Board of Internal Medicine maintenance of certification program
  • Levinson K
  • King TE Jr
  • Goldman L
  • Goroll AH
  • Kessler B
3 The certification of specialists