Regulated multi-sited practice for physicians in China: incentives and barriers

The multi-sited practices (MSP) policy in China is expected to exert found implications upon uneven distribution of high-quality medical resources,coupled with the widespread phenomenon of physician's informal practices on multiple sites.Since 2009,the Chinese government has upheld a policy that allows medical doctors to take on secondary jobs for the purpose of encouraging talented physicians to work in medical institutions and underdeveloped areas where their expertise is badly needed.This paper focuses on the MSP policy in China by examining how it has been implemented at the national and provincial levels through a review of government documents,statistical information,academic papers,and newspaper accounts.Despite the MSP policy is to offer incentive to physicians at first-tier public hospitals to work in primary care centers or areas where their expertise,the evidence is hard to find.This paper identifies several outstanding challenges to the MSP policy:(1) The importance of the MSP policy which is made by the central government is perceived differently at the provincial level by health officials and hospital administrators;(2) Interest in implementing the policy varies among physicians and hospitals;(3) Concerns about quality control and legal responsibilities for medical doctors to take on secondary jobs are widespread.China's MSP policy differs from the 'dual practice' policy in many countries because of its top-down approach,with its emphasis on government's role and administrative intervention.This paper's findings may be useful for other developing countries where medical expertise is unevenly distributed due to market forces.On the special occasion of the Alma Ata Declaration's 40th anniversary and for the sake of promoting Universal Health Coverage,this paper also aims at sharing with other countries China's experience in trying to develop an adequate force of primary care professionals.At the end of this paper,a four-point proposal is made for policy makers in China.

Assessment of Physicians’ Knowledge, Attitude and Practices of Radiation Safety at Suez Canal University Hospital, Egypt

Doctors who request imaging must be well trained in deciding whether diagnostic imaging is indicated and have an accurate knowledge of the associated risks. Although radiological doses are low and the chance of late effect is minimal, it should be kept as low as reasonably achievable. This cannot be achieved without a proper knowledge and adherence to safe practices. This cross-sectional study investigates the level of physicians’ knowledge about radiation safety and their attitude towards radiation protection. A self-administered questionnaire, for radiation safety was sent to a purposive sample of 120 physicians at Suez Canal University Hospital. Eighty questionnaires were filled by participants (response rate;66.7%). The sample included 22 radiologists, 15 oncologists, 25 surgeons and 18 orthopedists. Most participants did not receive any radiation safety-related training (88.8%). Radiologists and oncologists were exposed to ionizing radiation more frequently;however, their knowledge was as low as that of other physicians. The overall knowledge score ranged from 40% - 60% (mean;56.5 ± 15.2), with a low score among surgeons and orthopedics. The most deficient knowledge was in the dose of background radiation and the radiation dose received by patients in each type of radiation procedure. Adherence to safe radiation practices was violated by most of participants, especially surgeons and orthopedics, but they attributed it to the poor applicability of the protective measures during performing the procedures. This study concluded that physicians at the Suez Canal University Hospital had deficient knowledge, unsafe practices and negative attitude towards radiation safety policies & precautions.

Trust in Clinical Practice: A Systematic Review

Background: The aim of this study is to gain a better understanding of the true importance of trust in clinical practice by looking at how it is formed, how it affects clinical practice, and how to improve it. Methods: Using the PRISMA-ScR checklist, a review of the literature was performed to identify research evaluating the importance of trust in the doctor-patient relationship. After thorough screening and removal of duplicates, 21 articles were used in the literature review. Results: The classifying themes that emerged in the selected articles were What Makes Trust and Effects of Trust. The theme of What Makes Trust garnered two subthemes as well: Impact of Doctor-Patient Relationship on Trust and Impact of Shared Decision-Making on Trust. Further to that, the overarching themes found were slightly more specific. They were Traits of Trust, Mistrust and Barriers to Trust, Positive Effects of Trust and the Effects of a Lack of Trust. We found that the best way to improve trust was to improve communication between the patient and the doctor. Additionally, we found that the biggest barrier to a trusting doctor patient relationship was a stigmatised condition, followed by a perception of a financially-motivated doctor. Finally, we found that a lack of trust can prevent patients from seeking and receiving proper treatment. Conclusions: With a better understanding of how trust is built and the extent of the role it plays in clinical practice, we hope that this growing knowledge can improve the practice of many doctors in the future. It is certain that more research needs to be done in this area, especially focusing on vulnerable and stigmatised populations such as chronic pain patients.

Adjuvant therapy for hormone receptor-positive breast cancer: Perspective from a survey on breast cancer physicians' acceptance of practice-changing data

A cross-sectional online survey was conducted.A high proportion of the Chinese breast cancer(BC)physician respondents(n=77)would prescribe extended adjuvant endocrine therapy(AET)with aromatase inhibitors(AI)beyond 5 years for postmenopausal females with BC,especially those with higher risk.Respondents with≥15 years of clinical experience were more likely to prescribe a longer duration of AET for low-risk patients.Half of the respondents considered intermittent letrozole as an acceptable option.Most respondents would prescribe adjuvant chemotherapy to genomic high-intermediate risk[Oncotype DX recurrence score(RS)21-25]females aged≤50 years regardless of the clinical risk classification.

Physician Perception and Practice of Electroencephalography in Enugu, South East Nigeria

Background: Electroencephalography (EEG) is established for evaluating several acute and chronic medical conditions of neurological basis. In much of Nigeria and Africa, it is largely unavailable and underutilized due to scarcity of neurologists and high costs of the equipment. It offers a relatively simple and efficient way to help manage many encephalopathies if well utilized in trained hands. Aim: This study aimed to determine how physicians practicing in Enugu perceive and utilize electroencephalography routinely. Method: Physicians attending a statewide meeting in Enugu in August 2018 were consecutively recruited and a pretested questionnaire was administered after obtaining prior consent. Sociodemographic data as well as their knowledge, attitude and practice of electroencephalography were documented and analyzed. Results: There were 486 respondents (males 335: females 151) and 345 (71%) were specialists in various disciplines while 141 (29%) were general practitioners. Only 7 doctors (1.4%) claimed ignorance of electroencephalography and 6 (1.2%) stated it was not useful. Majority, 333 doctors (69.1%) believed it had no impact on routine patient management. This perception was highest for Dental Surgery (100%) and lowest for Internal Medicine (23%) specialists. Most doctors (425, 87.4%) agreed that neurologists should analyze recordings. Most physicians had no access to electroencephalography (61.7%) and had no interest in acquiring the machine (50.8%). Conclusion: Electroencephalography is an underappreciated investigative modality amongst physicians in Enugu, despite a high burden of neurological diseases in the population. More education, training and awareness of its utility are needed for medical students and doctors to reverse the trend.

Knowledge and Practice of Fundoscopy among Medical Doctors in Port Harcourt, Nigeria

Background: Many clinical entities manifest early characteristic changes in the fundus of the eye. The value of fundoscopy cannot be overemphasized and every medical doctor is expected to be able to use the ophthalmoscope to detect common pathological changes. However, more often than not fundoscopy is seen as an exclusive specialized skill of the ophthalmologist. Aim: The aim of this study was to evaluate knowledge and practice of fundoscopy among the physicians present at the Ordinary General Meeting of the Nigerian Medical Association (Rivers State branch) held in Port Harcourt on 30th June 2014. Methods: A self administered questionnaire about their knowledge and practice of fundoscopy was administered to 125 medical doctors attending the Ordinary General Meeting of the Nigerian Medical Association (Rivers State branch) held in Port Harcourt on 30th June 2014. Questions asked tested the Knowledge and Practice of the physicians on matters related to fundoscopy. Participants’ knowledge and practice were graded as Good for scores of 75% and above, Fair for 50% - 74% score and Poor for scores less than 50%. Respondents’ demographic data, responses and corresponding scores were entered into computer software—Scientific Package for Social Sciences (SPSS) version 20 and subsequently analyzed. Results: The study participants were 125 physicians;86 males and 39 females (M:F = 2.2:1). Twenty-eight percent of the study participants had good knowledge of fundoscopy while only 15% had good practice. Seventy eight physicians representing 62.4% of the participants could correctly refer patients with the need for fundoscopy to an ophthalmologist, whereas 11 (8.8%) worked in facilities without basic instrument for fundoscopy (ophthalmoscope). Conclusion: Our study demonstrates that knowledge and practice of fundoscopy among medical practitioners in Port Harcourt is poor and far from ideal. Therefore, refresher courses emphasizing the acquisition of the skill in fundoscopy and the provision of ophthalmoscopes in our General Practitioners’ clinics are necessary.

Intraoperative Nerve Monitoring in Otolaryngology: A Survey of Clinical Practice Patterns

Introduction: Intraoperative nerve monitoring is used in otolaryngology to assist in identification of nerves at risk. It is hoped that this will lead to lower rates of nerve injury. The objective of this study was to quantify the use of monitoring technology in current clinical practice. Method: An electronic survey was distributed to 376 registered fellows of the Australian Society of Head and Neck Surgery. Results: One-hundred and twenty-five responses were obtained. The majority of respondents report using monitoring at least some of the time during thyroid, parotid, and mastoid surgery (80%, 87%, and 73% respectively). Predictors of use include experience with intraoperative monitoring during training, and high caseloads in parotid surgery. Practice setting did not predict use. Conclusion: Despite equivocal evidence that intraoperative nerve monitoring is associated with a reduction in nerve injuries, this study demonstrates that the technology is widely used amongst otolaryngologists.

Treating chronic hepatitis B virus:Chinese physicians' awareness of the 2010 guidelines

AIM: To investigate Chinese physicians' awareness of the 2010 guidelines on the treatment of chronic hepatitis B virus(HBV) infection.METHODS: This was a quantitative survey that investigated the characteristics and practices of physicians who were treating patients with hepatitis B, the profile of their patients and physician practices regarding the diagnosis and treatment of HBV at the time of the survey. Participants were randomly selected from available databases of Chinese physicians and requested to complete either an online or paper-based survey. Data from the survey responses were analysed. For data validation and interpretation, qualitative in-depth interviews were conducted with 39 of the respondents.RESULTS: Five-hundred completed surveys, from 663 physicians were available for analysis. A mean of 175 chronic hepatitis B(CHB) patients was seen by each physician every month, of whom 85(49%) were treated in line with therapeutic indications stated in the 2010 guidelines. A total of 444(89%) physicians often(> 60% of the time) adhered to the guidelines. Most physicians used antiviral medications as recommended. For patients with compensated and decompensated cirrhosis, 342(68%) and 336(67%) of physicians, respectively, often followed the recommendation to use potent nucleos(t)ide analogues with a high genetic barrier to resistance, using the appropriate treatment more than 60% of the time. Physicians from infectious disease or liver disease departments were better informed than those from gastrointestinal or other departments.CONCLUSION: The majority of Chinese physicians often adhere to Chinese 2010 CHB guidelines and are well-informed about the use of antiviral medications for hepatitis B.

Referring Physicians’ Knowledge on Justification of Medical Exposure in Diagnostic Imaging in a Sub-Saharan African Country, Cameroon

Background: Justification is the process of weighing the potential benefit of the exposure against potential detriment for that individual. Its role has been largely delegated to imaging professionals. Nevertheless, justification process involves referring physicians, radiographers and radiologists. Objective: To assess the knowledge of referring physicians regarding justification of irradiating examinations in medical imaging at the university-affiliated hospitals in Yaoundé Cameroon. Materials and Methods: A questionnaire (18 questions) based on the French guide for the proper use of medical imaging tests in relation to the justification of irradiating examinations, was self-administered to 151 referring physicians in Yaounde (Cameroon) between October 2012 and January 2013. The pre-tested questionnaire was completed in the presence of the investigator. A scoring system was then adopted with a total of 15 points from the level of knowledge on justification which could be classified as satisfactory or not. Results: Referring physicians were 75 (49.7%) GPs, 53 (35.1%) residents and 23 (15.2%) specialists. Knowledge on justification was unsatisfactory for 79.5% of referring physicians with no significant difference in terms of professional experience (p = 0.95) or specialty (p = 0.119). The concepts of “useful exam” and “justified exam” were not known by 113 (74.8%) and 95 (62.9%) practitioners. MRI was selected as irradiating by 62 (41.1%), SPECT and PET-scan as non-radiating examinations by 98 (64.9%) and 115 (76.1%) participants. The main reasons for repeating a giving radiology exam were: unsatisfactory interpretation, unknown of where it was performing and poor quality exam respectively for 23 (15.2%), 37 (24.5%) and 43 (28.5%) referring physicians. Justification was the responsibility of the referring physician alone for 57% of respondent. Only 11 clinicians knew the reference of “Justification-Optimization-Limitation” to radiation protection. Conclusion: The knowledge of physicians on radiating medical procedures and justification of requests for these procedures is inadequate. Training in radiation protection and the introduction of guidelines for the proper use of imaging tests could improve physicians’ justification of radiating examinations.

Family physicians’ perception on environmental influences in promoting physical activity in their obese patients

Although many obese patients do not engage in adequate physical activity (PA), little is known about whether physicians discuss environmental barriers in promoting PA. We conducted this study to describe physicians’ views about discussing environmental barriers in promoting PA with obese patients and determine whether counseling varies by years of practice. We conducted an online survey of family physicians practicing in 17 clinics in Central Texas. We performed descriptive analysis on barriers to PA, counseling on meeting PA recommendation, and written prescription for exercise and bivariate analysis by years of practice. Statistical significance was set at p < 0.05. Of 96 physicians invited, 57 (59.4%) completed the survey. Majority reported their obese patients brought up the environment as a barrier to walking (89.3%) or PA (91.2%). Majority (80.7%) also reported asking about environmental barriers to walking, with 84.2% giving specific examples to overcome these barriers. While 96.5% reported advising their obese patients about meeting the PA recommendation, only 26.3% reported giving them a written prescription for exercise. These did not vary significantly by years of practice. Physicians felt having more time with their patients and knowing specific strategies to overcome environmental barriers, safe places in patients’ neighborhoods, and what environmental factors influence PA may help discuss environmental issues with their obese patients. Physicians want and counsel their obese patients to be physically active, but do not generally give prescriptions for exercise irrespective of years of practice. They also want tools to enhance their abilities to better assist these patients.

全科住院医师规范化培训师资开展教学门诊的意愿及影响因素研究

背景全科住院医师规范化培训(以下简称住培)师资开展规范的教学门诊是培养合格全科医生的关键环节,2021年7月中国医师协会组织专家修订了《全科专业住院医师规范化培训全科教学门诊规范(试行)》,全国各全科住培基地均参照此规范开展教学门诊。然而现阶段各住培基地教学门诊的实施仍处于探索阶段,且重视程度不足,教学门诊质量不高、开展形式不规范现象普遍存在。目的了解全科住培师资开展教学门诊的意愿和影响因素,并分析开展教学门诊的难点与困惑,提出思考与建议。方法于2021年10月—2023年11月,以参加广东省省级全科住培普通师资培训班、骨干师资培训班的全科住培师资为调查对象(n=1003)。采用自行设计的问卷对纳入师资进行调查,内容涉及师资的基本情况、工作情况及全科教学门诊带教情况。通过“问卷星”平台制作电子问卷,并实现问卷的线上发放和回收。结果全科师资的平均年龄为(40.7±14.1)岁,724名(72.18%)师资所在机构开设了全科教学门诊,792名(78.96%)有带教意愿,710名(70.79%)无带教经验,904名(90.13%)自评带教能力为60~89分,583名(58.13%)未接受过全科教学门诊师资培训,462名(46.06%)期望以多种类型培训相结合的形式开展师资培训,分别有417名(41.58%)和309名(30.81%)认为全科教学门诊的教学难点是指导全科住院医师在全科门诊独立接诊患者和分层教学,377名(37.59%)认为最难实现的教学目的是指导全科住院医师掌握全科临床思维、提高其临床决策能力,216名(21.54%)认为全科住院医师最需要的培训内容是问诊技巧,456名(45.46%)认为所在机构未开展/不愿意开展教学门诊的原因为缺乏时间。多因素Logistic回归分析结果显示,所在机构开设全科教学门诊情况、带教经验、自评带教能力、接受全科教学门诊师资培训情况是全科师资教学门诊带教意愿的影响因素(P<0.05)。结论大部分全科住培师资愿意开展全科教学门诊,但存在带教经验、带教培训、带教能力不足等困难。建议优化和规范全科教学门诊、加强全科教学门诊师资的全科理念培训、强化带教激励措施、完善住培师资监督和反馈机制,以提升全科教学门诊质量。

浅谈住院医师规范化培训的心电图实践教学

住院医师规范化培训(简称住培)是目前较受认可的培养合格临床医师的方式,而心电图作为一项重要的临床常规检查,是临床医生必须掌握的基本技能之一,也是住培中要求掌握的重要内容。昆明医科大学第二附属医院心功能科在不断完善和改进中摸索出了一套更适合住培学员的教学方式,利用多元化的教学形式增强学员学习兴趣,保证学习质量,从而使其更好地将所学知识和技能应用于临床。

ISO9000融入中医类别医师资格实践技能考试考务质量管理的设计与实践

考务质量管理是中医类别医师资格实践技能考试质量管理的重要内容。本研究以ISO9000族质量管理体系要求为基准,借助服务蓝图技术将ISO9000标准理念引入中医类别医师资格实践技能考试基地考务管理,分析中医类别医师资格实践技能考试考务质量管理过程、剖析质量管理过程要素、识别考务组织潜在风险,并开展了考务质量管理实践,为规范中医类别医师资格实践技能考试基地考务管理、提升考试质量、防范考试风险、强化考试的公平公正性提供借鉴和帮助。

基于OBE理念的“四梯度、三维度”方剂学教学改革与实践

[目的]阐述基于学习产出教育(outcomes-based education,OBE)理念的“四梯度、三维度”方剂学教学改革模式与成效,以期助力中医药教育事业的发展。[方法]基于OBE理念,根据存在的问题,有针对性地从教学目的、教学内容、教学资源、教学方法、考核评价等角度开展“知方-识方-辨方-制方”四梯度、“精勤医方-精进医技-精湛医术”三维度教学实践,并以医师资格考试作为中长期的衡量指标。[结果]基于OBE理念进行教学改革,主要包括明确教学目的,调整教学内容,运用线上资源,创新教学方法,探索考核评价等方面。对中医类别医师资格考试本科全日制考生的方剂学成绩进行数据分析,浙江中医药大学方剂学掌握率2012至2021年连续十年均高于全国;浙江中医药大学方剂学被评为2021年度浙江省一流课程,线上课程“寻方问药纵横谈”被评为2022年度浙江省一流课程,方剂学被评为2023年度国家级一流课程。[结论]基于OBE理念的“四梯度、三维度”方剂学教学改革模式,能够提升学生成绩,改善课程评价,有助于中医药教育事业的发展。

基于中医执业医师分阶段考试的中医学专业成绩分析与策略研究

[目的]总结和分析浙江中医药大学中医学专业学生的培养质量和存在问题,为中医药院校提高教学质量和学生临床知识及技能提供参考。[方法]以该校2018至2020年参加中医执业医师分阶段考试(第一阶段)实证研究的中医学专业学生为研究对象,采用方差分析和χ^(2)检验进行数据分析,比较分阶段考试成绩与在校学习成绩的相关性、考试通过率、掌握率。[结果]分阶段考试成绩能够较好地反映学生在校学习成绩情况,理论考试平均通过率为68.64%,技能考试平均通过率95.27%。理论考试平均总掌握率为65.06%,其中西医(基础医学类)55.57%、西医(临床医学类)52.12%,与理论考试总掌握率比较,差异有统计学意义(P<0.05);技能考试总掌握率为76.57%,第3~4站(体格检查)的平均掌握率分别为71.24%、72.24%。可以通过制定考试激励机制来提高学生考试内驱力,通过强化西医课程培训来提升理论考试通过率,通过反复临床技能训练来补齐技能考核的短板等改进措施和策略,从而提高学生的临床知识和技能,可为中医药院校提高教学质量作参考。[结论]中医药院校可以通过制定考试激励机制、强化西医课程培训、反复临床技能训练来提高学生的临床知识和技能,从而提高中医学专业学生的培养质量。

医患沟通模拟教学在内科住培医师临床实践中的应用研究

目的探究医患沟通模拟教学在内科住院医师规范化培训(住培)医生临床实践中的应用价值。方法选取2022年1月—2023年1月潍坊医学院附属医院临床内科住培医生共54名,采用随机抽签法分为模拟组(n=27)及对照组(n=27),模拟组构建医患沟通场景,进行情景设计,给予模拟实验;对照组仅给予传统临床教学。比较两组患者技能考试成绩、医患沟通能力、临床患者满意度及综合能力评分。结果模拟组准备、信息收集、信息给予、理解患者等维度评分均高于对照组,差异有统计学意义(P均<0.05);模拟组体格检查、专业理论、临床思维和表达能力、处理危重疑难解患者能力等部分评分及总分均显著高于对照组,差异有统计学意义(P均<0.05);模拟组基本技能操作、模拟场景进行医患沟通、临床接诊等3个部分评分均显著高于对照组,差异有统计学意义(P均<0.05)。结论运用医患沟通模拟教学能有效提高内科住培医生的临床沟通能力,为下一步疾病诊治和患者随访构建良好的协作基础。

高职公共卫生人才实践技能教学提升探究——基于公共卫生执业(助理)医师考试

为了探讨提升高职预防医学专业公共卫生实践技能的方法,帮助学生提升公共卫生实践能力,提高公共卫生执业医师资格证的考试通过率,采用文献查阅、学生调研等方法,找出实训教学困境,并提出优化课程设置、加强实践教学、创新教学方法以及加强“双师型”教师制度等提升措施,进行教学改革实践。经过教学改革后,学生反映公共卫生各项技能掌握程度比较好,对公共卫生执业(助理)医师考试实践部分更有信心。由此可知,预防医学专业学生公共卫生实践技能培养对学生的意义重大,既可以提高学生的实践操作能力,让学生对实习阶段的学习更加游刃有余,也能提升公共卫生执业医师资格证的考试通过率,值得进一步推广。

一分钟诊间教学在规范床旁教学中的应用探索

目的探讨一分钟诊间教学(one minute preceptor,OMP)在规范床旁教学中的应用效果。方法选取2021年10月—2022年1月深圳市儿童医院的14个亚专科科室的21位带教老师及38位住院医师进行临床OMP教学法带教,分析实施效果。结果认为OMP教学法有显著效果的带教老师占68.42%,认为效果不显著人数占28.57%;建议开展OMP频率为5次以下的带教老师占比52.38%,5~10次占比28.57%,14.29%认为开展次数越多越好。61.9%带教老师对自身专业知识及能力肯定,28.57%认为需要继续积累经验。71.43%带教老师认为能够提高住院医生临床思维能力,28.57%觉得可以提高病史采集和人文沟通能力;3名住院医师对诊间教学无法理解,35名住院医师表示有帮助。结论OMP模型为临床教学工作者提供一个系统的教学框架,为住院医师提供指导和反馈,有利于规范日常带教过程,从而起到规范和量化床旁教学过程的作用,模式可行有效。

整形美容专科医师继续医学教育的探索

随着广大人民群众对美的需求不断增加,整形美容市场急剧扩大,存在大量医疗隐患,对整形美容专科医师进行继续医学教育已成为社会所需。整形美容专科医师继续医学教育既可为规范整形美容市场打下坚实的基础,也可为基层医院整形美容外科的建立提供有力保障。此次教学实践对整形美容专科医师继续医学教育中的理论知识、临床能力、科研能力、美学修养、医学人文素质的培养及考核制度等方面进行了初步探索。文章就整形美容专科医师继续医学教育中积累的宝贵临床教学经验进行了归纳总结,同时对遇到的问题进行了深刻反思,旨在更好地开展整形美容专科医师继续医学教育工作,使继续医学教育更加人性化、科学化、正规化,帮助专科培训医师由外科向整形外科顺利转型,进一步提高整形美容专科医师的医疗专业水平和医疗服务质量,使其更好地服务于美容医疗行业、服务于社会。

多点远程执业模式对医师注意义务认定的挑战及其回应

多点远程执业模式以医师为主体,通过互联网技术为注册医师多点、线上执业提供了可能,但也对医师注意义务的认定带来挑战。在多点远程执业模式下,法律关系由简单变得复杂,诊疗场景由单一转向多变,主观医疗过错的判定由相对容易变得较为困难。在这种情况下,医患关系的成立节点、医师在不同情境下的具体诊疗义务以及各主体之间的责任分配规则等问题需要重新思考。医患关系是否存在之认定应以是否接受诊疗为关键判断因素,远程诊疗下应扩张解释医师的亲自诊查义务。各主体之间的责任分配以合同作为主要判断依据,如果不存在合同,则需要根据民法典中相关规定进行确定。