The Role of Relationships in the Professional Formation of Physicians

BACKGROUND: Studies of the professional development of physicians highlight the important effect that the learning environment, or \"hidden curriculum,\" has in shaping student attitudes, behaviors, and values. We conducted this study to better understand the role that relationships have in mediating these effects of the hidden curriculum. [See PDF for complete abstract]

Policy analysis of Texas Senate Bill 532 and the regulation of nurse practitioners in the convenience care model

Background. Retail clinics, also called convenience care clinics, have become a rapidly growing trend since their initial development in 2000. These clinics are coupled within a larger retail operation and are generally located in "big-box" discount stores such as Wal-mart or Target, grocery stores such as Publix or H-E-B, or in retail pharmacies such as CVS or Walgreen's (Deloitte Center for Health Solutions, 2008). Care is typically provided by nurse practitioners. Research indicates that this new health care delivery system reduces cost, raises quality, and provides a means of access to the uninsured population (e.g., Deloitte Center for Health Solutions, 2008; Convenient Care Association, 2008a, 2008b, 2008c; Hansen-Turton, Miller, Nash, Ryan, Counts, 2007; Salinsky, 2009; Scott, 2006; Ahmed & Fincham, 2010). Some healthcare analysts even suggest that retail clinics offer a feasible solution to the shortage of primary care physicians facing the nation (AHRQ Health Care Innovations Exchange, 2010). ^ The development and performance of retail clinics is heavily dependent upon individual state policies regulating NPs. Texas currently has one of the most highly regulated practice environments for NPs (Stout & Elton, 2007; Hammonds, 2008). In September 2009, Texas passed Senate Bill 532 addressing the scope of practice of nurse practitioners in the convenience care model. In comparison to other states, this law still heavily regulates nurse practitioners. However, little research has been conducted to evaluate the impact of state laws regulating nurse practitioners on the development and performance of retail clinics. ^ Objectives. (1). To describe the potential impact that SB 532 has on retail clinic performance. (2). To discuss the effectiveness, efficiency, and equity of the convenience care model. (3). To describe possible alternatives to Texas' nurse practitioner scope of practice guidelines as delineated in Texas Senate Bill 532. (4). To describe the type of nurse practitioner state regulation (i.e. independent, light, moderate, or heavy) that best promotes the convenience care model. ^ Methods. State regulations governing nurse practitioners can be characterized as independent, light, moderate, and heavy. Four state NP regulatory types and retail clinic performance were compared and contrasted to that of Texas regulations using Dunn and Aday's theoretical models for conducting policy analysis and evaluating healthcare systems. Criteria for measurement included effectiveness, efficiency, and equity. Comparison states were Arizona (Independent), Minnesota (Light), Massachusetts (Moderate), and Florida (Heavy). ^ Results. A comparative states analysis of Texas SB 532 and alternative NP scope of practice guidelines among the four states: Arizona, Florida, Massachusetts, and Minnesota, indicated that SB 532 has minimal potential to affect the shortage of primary care providers in the state. Although SB 532 may increase the number of NPs a physician may supervise, NPs are still heavily restricted in their scope of practice and limited in their ability to act as primary care providers. Arizona's example of independent NP practice provided the best alternative to affect the shortage of PCPs in Texas as evidenced by a lower uninsured rate and less ED visits per 1,000 population. A survey of comparison states suggests that retail clinics thrive in states that more heavily restrict NP scope of practice as opposed to those that are more permissive, with the exception of Arizona. An analysis of effectiveness, efficiency, and equity of the convenience care model indicates that retail clinics perform well in the areas of effectiveness and efficiency; but, fall short in the area of equity. ^ Conclusion. Texas Senate 532 represents an incremental step towards addressing the problem of a shortage of PCPs in the state. A comparative policy analysis of the other four states with varying degrees of NP scope of practice indicate that a more aggressive policy allowing for independent NP practice will be needed to achieve positive changes in health outcomes. Retail clinics pose a temporary solution to the shortage of PCPs and will need to expand their locations to poorer regions and incorporate some chronic care to obtain measurable health outcomes. ^

The public health applications of law enforcement medical direction: A practical experience with the Dallas Police Department

In 2008, 132 law enforcement officers were killed in the line of duty in The United States. Additionally, some have explored both the public health implications of interactions with law enforcement as well as the potential benefits of the use of law enforcement officers as public health and emergency healthcare providers. By virtue of these novel analyses and techniques, professional medical direction of the emerging specialty of law enforcement medicine is needed. This paper, an analysis of law enforcement medical direction through a look at the Dallas Police Medical Direction Program, seeks to examine origins of law enforcement medicine through a comprehensive literature review, as well as begin to define to core competencies of law enforcement medical direction. ^ The unique intersection of public health, medicine and law enforcement, and the subsequent specialty that is developing to manage this interface, is in its relative infancy. An analysis of this nature is in order to begin to lay down the foundations necessary for future study and improvements in the field. ^

Development of a standard sign-out procedure for clinicians in a pediatric intensive care unit

Background: Poor communication among health care providers is cited as the most common cause of sentinel events involving patients. Sign-out of patient data at the change of clinician shifts is a component of communication that is especially vulnerable to errors. Sign-outs are particularly extensive and complex in intensive care units (ICUs). There is a paucity of validated tools to assess ICU sign-outs. ^ Objective: To design a valid and reliable survey tool to assess the perceptions of Pediatric ICU (PICU) clinicians about sign-out. ^ Design: Cross-sectional, web-based survey ^ Setting: Academic hospital, 31-bed PICU ^ Subjects: Attending faculty, fellows, nurse practitioners and physician assistants. ^ Interventions: A survey was designed with input from a focus group and administered to PICU clinicians. Test-retest reliability, internal consistency and validity of the survey tool were assessed. ^ Measurements and Main Results: Forty-eight PICU clinicians agreed to participate. We had 42(88%) and 40(83%) responses in the test and retest phases. The mean scores for the ten survey items ranged from 2.79 to 3.67 on a five point Likert scale with no significant test-retest difference and a Pearson correlation between pre and post answers of 0.65. The survey item scores showed internal consistency with a Cronbach's Alpha of 0.85. Exploratory factor analysis revealed three constructs: efficacy of sign-out process, recipient satisfaction and content applicability. Seventy eight % clinicians affirmed the need for improvement of the sign-out process and 83% confirmed the need for face- to-face verbal sign-out. A system-based sign-out format was favored by fellows and advanced level practitioners while attendings preferred a problem-based format (p=0.003). ^ Conclusions: We developed a valid and reliable survey to assess clinician perceptions about the ICU sign-out process. These results can be used to design a verbal template to improve and standardize the sign-out process.^