Labor Unionization Among Physicians in Training.

This study examines the number of unique unions and characteristics of unionization elections among physicians in training in the US.

As Laws Restricting Health Care Surge, Some US Physicians Choose Between Fight or Flight.

In this Medical News article, 13 physicians and health care experts spoke with JAMA about the increasing efforts to criminalize evidence-based medical care in the US.

A statewide quality improvement collaborative significantly improves quality metric adherence and physician engagement in vascular surgery.

BACKGROUND: Quality improvement national registries provide structured, clinically relevant outcome and process-of-care data to practitioners-with regional meetings to disseminate best practices. However, whether a quality improvement collaborative affects processes of care is less clear. We examined the effects of a statewide hospital collaborative on the adherence rates to best practice guidelines in vascular surgery. METHODS: A large statewide retrospective quality improvement database was reviewed for 2013 to 2019. Hospitals participating in the quality improvement collaborative were required to submit adherence and outcomes data and meet semiannually. They received an incentive through a pay for participation model. The aggregate adherence rates among all hospitals were calculated and compared. RESULTS: A total of 39 hospitals participated in the collaborative, with attendance of surgeon champions at face-to-face meetings of >85%. Statewide, the hospital systems improved every year of participation in the collaborative across most "best practice" domains, including adherence to preoperative skin preparation recommendations (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.76-1.79; P < .001), intraoperative antibiotic redosing (OR, 1.09; 95% CI, 1.02-1.17; P = .018), statin use at discharge for appropriate patients (OR, 1.18; 95% CI, 1.16-1.2; P < .001), and reducing transfusions for asymptomatic patients with hemoglobin >8 mg/dL (OR, 0.66; 95% CI, 0.66-0.66; P < .001). The use of antiplatelet therapy at discharge remained high and did not change significantly during the study period. Teaching hospital and urban or rural status did not affect adherence. The adherence rates exceeded the professional society mean rates for guideline adherence. CONCLUSIONS: The use of a statewide hospital collaborative with incentivized semiannual meetings resulted in significant improvements in adherence to "best practice" guidelines across a large, heterogeneous group of hospitals.

Supporting the Next Generation of Scientists to Lead Cancer Immunology Research.

Recent success in the use of immunotherapy for a broad range of cancers has propelled the field of cancer immunology to the forefront of cancer research. As more and more young investigators join the community of cancer immunologists, the Arthur L. Irving Family Foundation Cancer Immunology Symposium provided a platform to bring this expanding and vibrant community together and support the development of the future leaders in the field. This commentary outlines the lessons that emerged from the inaugural symposium highlighting the areas of scientific and career development that are essential for professional growth in the field of cancer immunology and beyond. Leading scientists and clinicians in the field provided their experience on the topics of scientific trajectory, career trajectory, publishing, fundraising, leadership, mentoring, and collaboration. Herein, we provide a conceptual and practical framework for career development to the broader scientific community.

Task-sharing with artificial intelligence: a design hypothesis for an Emergency Unit in sub-Saharan Africa.

In sub-Saharan Africa, there is a significant unmet need for emergency care, with a shortage of trained providers. One model to increase the number of providers is to task-share: roles traditionally filled by clinicians are shared with lay workers who have received task-specific training. Separately, there has been much recent interest in the possible implications of artificial intelligence (AI) on healthcare. This paper proposes that, by combining the task-sharing model with AI, it is possible to design an Emergency Unit (EU) that shares the tasks currently undertaken by physicians and nurses with lay providers, with the activities of lay providers guided and supervised by AI. The proposed model would free emergency care clinicians to focus on higher-acuity and complex cases while AI-supervised routine care is provided by lay providers. The paper outlines the model for such an implementation and considers the potential benefits to patient care, as well as considering the risks, costs, effect on providers, and ethical questions. The paper concludes that AI and healthcare workers can operate as a team, with significant potential to augment human resources for health in sub-Saharan Africa.

Do Not Waste a Crisis: Physician Engagement during the COVID-19 Pandemic.

Physician engagement is an important factor in improving care quality and patient safety, but engaging physicians is not easy. Winston Churchill's famous assertion about never wasting a crisis has defined the approach taken by many leaders during the COVID-19 pandemic. This paper describes three case studies of successful physician engagement across the continuum of acute care, chronic care and primary care settings during the pandemic. These examples offer insights on physician engagement within unique settings by leveraging intrinsic motivators and Spurgeon's model of medical engagement.

Letter on an iceberg.

In the public sphere, issues are like icebergs. This somewhat hackneyed metaphor illustrates that, while one facet of an issue is perceived, what is not seen is the hidden substructure of power and culture that form and reinforce it, buoying the issue to prominence above the surface.

Effects of a physician- and pharmacist-managed clinic on pain management in cancer patients in China.

In China, pharmacists have started to manage cancer pain at outpatient clinics. This retrospective study performed at a tertiary teaching hospital was aimed to evaluate the effects of a physician-pharmacist joint clinic for cancer pain management. The study was performed between December 2016 and August 2019 and included 113 outpatients with moderate to severe cancer-related pain. Patients were divided into two groups according to the clinic each patient visited: the physician-pharmacist joint clinic (joint group, n = 59) or physician-only clinic (usual group, n = 54). Brief Pain Inventory (BPI) and Morisky Medication Adherence Measure (MMAM) were used to collect data on pain intensity, interference and medication adherence. Pain Management Index (PMI) was also calculated. BPI, MMAM and PMI were assessed at baseline (patients' first visit, week 0) and week 4 follow-up. The Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) was used to assess patients' health-related quality of life (HRQoL) at week 4. The primary outcomes were the improvement in pain intensity, adequacy of pain management and medication adherence. The secondary outcome was the improvement in HRQoL. At week 4, compared to the usual group, the BPI pain intensity categories except the pain right now were significantly lower in the joint group: worst pain, 4 (3-7) vs 6 (4-8), P = .020; least pain, 1 (0-2) vs 2 (1-3), P = .010; average pain, 3 (2-4) vs 4 (2-5), P = .023; pain right now, 2 (1-3) vs 2 (0-4), P = .796. For the seven pain interference categories, there were no significant improvements in the joint group (P > .05). Significantly more patients achieved adequate pain control in the joint group than the usual group ((P = .002). There was also a significant difference in medication adherence between the two groups (P = .001). There were no significant differences in HRQoL between the two groups. The study suggests that pharmacist participation in outpatient cancer pain management is associated with improvement of patients' pain control and medication adherence.

Medicine, Machines, and Medical Education.

While advances in science and technology continue to be at the forefront of the evolution of medical practice, the 21st century is also undergoing a unique and profound cultural shift that is changing the very nature of what it means to be a medical professional, namely humankind's transition to an information-based internet society. Medical care will increasingly depend on computer-generated probabilities guided and supported by a growing variety of individuals in health care-related professions, including statisticians, technologists, and information managers. Perhaps the biggest challenge to the profession will come from the erosion of professional autonomy, driven by smart machines, social networks, and internet search engines. As a result of these and other changes, physicians are facing a systematic loss of control, often without the direct input and leadership of the profession itself. In this commentary, the author urges the profession to adopt several strategies, including shifting its focus from reimbursement to the care patients value most, meaningfully addressing critical issues in health policy, becoming the definitive source for publicly available medical information, reimagining medical education, and overhauling the existing accreditation and licensing systems. Medical education must go beyond a focus on physicians whose professional identity revolves around being the exclusive source of medical knowledge. In the digitized 21st century, medical education should emphasize the centrality of the humanistic interface with patients such that the doctor-patient relationship is paramount in the complex medical world of machines and social media. Removing the roadblocks to successful professional reform is no small task, but the process can begin with a grassroots movement that empowers physicians and facilitates organizational and behavioral change. Failure to take action may well hasten the diminishment of patient care and the profession's trusted role in society.

Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review.

BACKGROUND: This study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician-paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention. METHODS: A retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician-paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km2. RESULTS: Over 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate 'primary' cricothyroidotomy was performed in 17 patients (23.6%), and 'rescue' cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%). CONCLUSIONS: This study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service.

A qualitative study on the development of pharmacist-managed clinics in Taiwan.

WHAT IS KNOWN AND OBJECTIVE: Pharmacist-managed clinics (PMCs) are established to solve drug-related problems and enhance the quality of care of ambulatory patients. Although the benefits of such services have been demonstrated, little is known about PMC operations, especially outside the United States. The aim of this study was to explore how PMCs were established and to discuss implementation issues of PMCs in Taiwan. METHODS: A purposive sample of pharmacists, pharmacy administrators and physicians involved with PMCs was recruited from hospitals of varying scales across Taiwan. Semi-structured, individual interviews were conducted to understand the perceptions of the clinical service of PMCs. Interviews were transcribed verbatim and analysed by thematic analysis to find underlying themes. RESULTS: A total of 12 pharmacists, 5 pharmacy administrators and 3 physicians from 8 institutions were interviewed. Pharmacists spent 4 to 20 h per week at PMCs, and the practice experiences of PMC ranged from 1 to 6 years. PMCs have been provided in these institutions for 4 to 11 years with an average volume of 28 h and 25 patient visits weekly. Study participants described influential factors in establishing PMCs, including clinical expertise, attitude towards patient care and trust building with collaborating physicians. Operational concerns in implementing PMCs included role clarifications, manpower shortage, inadequate advanced training or certification, regulatory issues and a lack of service promotion. WHAT IS NEW AND CONCLUSION: This research broadens the understanding of operating PMC services and reveals key requirements and concerns regarding the care model, which can be useful for other countries. Resolving perceived barriers and collecting other stakeholders' perspectives may reinforce the integration of PMCs into patient care in the future.

Machine Learning: The Next Paradigm Shift in Medical Education.

Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.