Competency, board certification, credentialing, and specialization: who benefits?
Pharmacists are concerned with the rapid changes in the healthcare system and what the requirements will be for a pharmacist in the near future. The emergence of board certification, credentialing, and other certification programs for pharmacists are causing significant concern among pharmacists. Pharmacists must assess certification programs and decide on the value of certification to their careers and to the patients they serve. Employers of pharmacists and those paying for healthcare and pharmacy services must also evaluate the value of pharmacists certification. Perhaps the most direct and significant benefit of pharmacist certification lies in the ability of the pharmacist to provide better and more comprehensive care to patients or selected groups of patients (eg, diabetic patients). Better and more comprehensive care provided by a pharmacist benefits the patient, other healthcare professionals, the healthcare system generally, and payers of healthcare and pharmacy services. Demonstrated competence of the pharmacist to provide pharmaceutical care is essential to achieving this benefit. Board certification of pharmacists in current board-recognized specialty areas of nutrition support pharmacy, pharmacotherapy, psychiatric pharmacy, nuclear pharmacy, and oncology pharmacy totaled 2075 board certified pharmacists in the United States as of January 1997. (+info
The importance of surgeon volume and training in outcomes for vascular surgical procedures.
PURPOSE: Mortality and morbidity rates after vascular surgical procedures have been related to hospital volume. Hospitals in which greater volumes of vascular surgical procedures are performed tend to have statistically lower mortality rates than those hospitals in which fewer procedures are performed. Only a few studies have directly assessed the impact of the surgeon's volume on outcome. Therefore, the purpose of this study was to review a large state data set to determine the impact of surgeon volume on outcome after carotid endarterectomy (CEA), lower extremity bypass grafting (LEAB), and abdominal aortic aneurysm repair (AAA). METHODS: The Florida Agency for Health Care Administration state admission data from 1992 to 1996 were obtained. The data included all nonfederal hospital admissions. Frequencies were calculated from first-listed International Classification of Diseases-9 codes. Multiple logistic regression was used to test the significance on outcome of surgeon volume, American Board of Surgery certification for added qualifications in general vascular surgery, hospital size, hospital volume, patient age, and gender. RESULTS: During this interval, there were 31,172 LEABs, 45,744 CEAs, and 13,415 AAAs performed. The in-hospital mortality rate increased with age. A doubling of surgeon volume was associated with a 4% reduction in risk for adverse outcome for CEA (P =.006), an 8% reduction for LEAB, and an 11% reduction for AAA ( P =.0002). However, although hospital volume was significant in predicting better outcomes for CEA and AAA procedures, it was not associated with better outcomes for LEAB. Certification for added qualifications in general vascular surgery was a significant predictor of better outcomes for CEA and AAA. Certified vascular surgeons had a 15% lower risk rate of death or complications after CEA (P =.002) and a 24% lower risk rate of a similar outcome after AAA (P =.009). However, for LEAB, certification was not significant. CONCLUSION: Surgeon volume and certification are significantly related to better patient outcomes for patients who undergo CEA and AAA. In addition, surgeons with high volumes demonstrated consistently lower mortality and morbidity rates than did surgeons with low volumes. Hospital volume for a given procedure also is correlated with better outcomes. (+info
Characteristics of nurse-midwife patients and visits, 1991.
OBJECTIVES: This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States. METHODS: Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling. RESULTS: We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits. CONCLUSIONS: Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations. (+info
Consistency, inter-rater reliability, and validity of 441 consecutive mock oral examinations in anesthesiology: implications for use as a tool for assessment of residents.
BACKGROUND: Oral practice examinations (OPEs) are used extensively in many anesthesiology programs for various reasons, including assessment of clinical judgment. Yet oral examinations have been criticized for their subjectivity. The authors studied the reliability, consistency, and validity of their OPE program to determine if it was a useful assessment tool. METHODS: From 1989 through 1993, we prospectively studied 441 OPEs given to 190 residents. The examination format closely approximated that used by the American Board of Anesthesiology. Pass-fail grade and an overall numerical score were the OPE results of interest. Internal consistency and inter-rater reliability were determined using agreement measures. To assess their validity in describing competence, OPE results were correlated with in-training examination results and faculty evaluations. Furthermore, we analyzed the relationship of OPE with implicit indicators of resident preparation such as length of training. RESULTS: The internal consistency coefficient for the overall numerical score was 0.82, indicating good correlation among component scores. The interexaminer agreement was 0.68, indicating moderate or good agreement beyond that expected by chance. The actual agreement among examiners on pass-fail was 84%. Correlation of overall numerical score with in-training examination scores and faculty evaluations was moderate (r = 0.47 and 0.41, respectively; P < 0.01). OPE results were significantly (P < 0.01) associated with training duration, previous OPE experience, trainee preparedness, and trainee anxiety. CONCLUSION: Our results show the substantial internal consistency and reliability of OPE results at a single institution. The positive correlation of OPE scores with in-training examination scores, faculty evaluations, and other indicators of preparation suggest that OPEs are a reasonably valid tool for assessment of resident performance. (+info
The American Society of Tropical Medicine and Hygiene initiative to stimulate educational programs to enhance medical expertise in tropical diseases.
More than a decade ago, at a time when current and emerging tropical diseases posed growing threats to the United States, expert panels convened by the Institute of Medicine of the U.S. National Academy of Sciences concluded that medical expertise within the United States competent to address diseases of the tropics had declined. Recognizing a national need to encourage and enhance such, The American Society of Tropical Medicine and Hygiene developed a program to stimulate new postgraduate medical education in diseases of the tropics. The Society formally requested academic institutions within the United States and Canada to propose new postgraduate programs. To assure the quality of these new curricular offerings, the Society developed an outline of key areas of competency and agreed to offer an examination that would grant physicians a Certificate of Knowledge in Clinical Tropical Medicine and Travelers Health. The certifying examination was to be an integral component of a program to stimulate academic institutions to provide instructional programs in tropical diseases and to encourage physicians to become trained, evaluated, and recognized for their knowledge of clinical tropical diseases and travelers' health. The Society's initiative to stimulate educational programs in tropical medicine is reviewed. (+info
Experiences of ethnic minority primary care physicians with managed care: a national survey.
OBJECTIVES: To determine if ethnic minority physicians experience more barriers in acquiring and maintaining managed care contracts than white physicians, and to determine if the physician's perceptions of his or her ability to provide appropriate care to patients varies with physician ethnicity. STUDY DESIGN: Using a national sample, we identified 4 research areas germane to this topic and analyzed them by physician ethnic group. METHODS: Analysis involved a pre-existing data set from a national survey that employed a random sampling approach to achieve reasonably accurate national population estimates with acceptable margins of error (95% CI = +/- 2). RESULTS: A total of 1032 primary care physicians completed the survey (response rate of 48%). After controlling for confounding variables, we found that Asian physicians have the most difficulty keeping managed care contracts. Type of practice varies with physician ethnicity, and solo practitioners have more problems securing contracts than physicians in other types of practices. Board-certified physicians are more likely to have managed care contracts than those who are not. Latino physicians have significantly fewer managed care patients than primary care physicians who are white, African American, or Asian. The perceptions of the physicians of their ability to deliver appropriate care overall did not vary by ethnicity, but 2 major subcategories of this item did vary by physician ethnicity: quality of care, and limitations to providing care. CONCLUSIONS: Although we did not find overwhelming evidence of discrimination against ethnic minority physicians, differences in rates of termination, type of practice, board certification rates, and managed care affiliation were related to physician ethnicity. (+info
Differences between generalists and specialists in characteristics of patients receiving gastrointestinal procedures.
BACKGROUND: As a result of market forces and maturing technology, generalists are currently providing services, such as colonoscopy, that in the past were deemed the realm of specialists. OBJECTIVE: To determine whether there were differences in patient characteristics, procedure complexity, and clinical indications when gastrointestinal endoscopic procedures were provided by generalists versus specialists. DESIGN: Retrospective cohort study. PATIENTS: A random 5% sample of aged Medicare beneficiaries who underwent rigid and flexible sigmoidoscopy, colonoscopy, and esophagogastroduodenoscopy (EGD) performed by specialists (gastroenterologists, general surgeons, and colorectal surgeons) or generalists (general practitioners, family practitioners, and general internists). MEASUREMENTS: Characteristics of patients, indications for the procedure, procedural complexity, and place of service were compared between generalists and specialists using descriptive statistics and logistic regression. MAIN RESULTS: Our sample population had 167,347 gastrointestinal endoscopies. Generalists performed 7.7% of the 57, 221 colonoscopies, 8.7% of the 62,469 EGDs, 42.7% of the 38,261 flexible sigmoidoscopies, and 35.2% of the 9,396 rigid sigmoidoscopies. Age and gender of patients were similar between generalists and specialists, but white patients were more likely to receive complex endoscopy from specialists. After adjusting for patient differences in age, race, and gender, generalists were more likely to have provided a simple diagnostic procedure (odds ratio [OR] 4.2; 95% confidence interval [95% CI] 4.0, 4.4), perform the procedure for examination and screening purposes (OR 4.9; 95% CI, 4. 3 to 5.6), and provide these procedures in rural areas (OR 1.5; 95% CI 1.4 to 1.6). CONCLUSIONS: Although generalists perform the full spectrum of gastrointestinal endoscopies, their procedures are often of lower complexity and less likely to have been performed for investigating severe morbidities. (+info
Physician-nutrition-specialist track: if we build it, will they come? Intersociety Professional Nutrition Education Consortium.
The Intersociety Professional Nutrition Education Consortium (IPNEC) has made substantial progress in its first 2 y. With support from 9 participating nutrition societies and certification organizations and with funding from the National Institutes of Health and several nutrition industry partners, a sustained, functioning consortium has been established. The consortium's 2 principal aims are to establish educational standards for fellowship training of physician nutrition specialists (PNSs) and to create a unified mechanism for certifying physicians who are so trained. Its long-term goals are to increase the pool of PNSs to enable every US medical school to have at least one PNS on its faculty and to surmount obstacles that currently impede the incorporation of nutrition education into the curricula of medical schools and residency programs. The consortium formulated and refined a paradigm for PNSs, conducted a national role delineation survey to define the scope of the discipline of clinical nutrition, and developed a preliminary curriculum template for training PNSs that can be completed in a minimum of 6 mo. IPNEC and its sponsoring societies are strategically positioned to play an important long-term role in nutrition education for physicians. We intend to continue soliciting broad input, especially from directors of fellowship training programs in nutrition and closely related subspecialties; to develop the core content for fellowships in nutrition and related subspecialties; and to initiate a unified PNS certification examination. (+info