The health transition in developing countries: a role for internists from the developed world.

Demographic and epidemiologic changes that have occurred in the past five decades in many developing countries provide new opportunities for internists from developed countries to contribute to improvements in international health. These changes, called the "health transition," are characterized by major growth in the number and proportion of middle-aged and elderly persons and in the frequency of the chronic diseases that occur in these age groups. The health transition is the result of concentrated national and international efforts to improve maternal and child health by emphasizing primary care and community-organized outreach services. In many developing countries, such efforts have been responsible for a decrease in the birth rate; reduced maternal mortality; improved preventive services; and a vigorous therapeutic approach to infantile diarrhea and respiratory infection, which, in turn, have resulted in the reduced infant mortality and the increased life expectancy that defines the health transition. These changes, often accompanied by increasing urbanization and industrialization, are creating health problems similar to those seen in the "developed" world but are occurring in countries that have far fewer resources. Internists interested in working in developing countries can therefore bring their skills, experience, and perspective to bear on these problems, primarily by working within well-structured programs, the aim of which is to strengthen the capacity of the organizations and institutions within these countries to cope with the rising tide of chronic adult diseases.

A bi-national perspective on continuing medical education.

This paper presents a review and comparison of qualitative improvements in the organization, needs assessment, educational methodology, evaluation, and research in continuing medical education (CME) in the United States and Canada. Although accreditation now establishes minimal standards for CME and reduces the chances of irresponsible programs, some organizational issues (such as commercial sponsorship) and educational issues (how to "accredit" journal reading) remain unresolved. There are many examples of excellent, innovative CME programs offered by medical schools, and specialty societies have been instrumental in upgrading CME by serving as sponsors of accreditation and special projects. There is some evidence that the national health system of Canada has influenced the organization and content of Canadian CME, and these changes may soon affect U.S. programs as well. CME research has grown, with two types of research evident: the biomedical model, which assesses the efficacy of CME interventions by quantitative methods; and a model that uses grounded, ethnographic, methods to assess physician learning and performance change. Given the improvements of the past 20 years, the criticisms that focus exclusively on the lack of ideal educational planning for all CME programs are not so much wrong as dated and perhaps irrelevant. In developing their programs, CME leaders can begin to emphasize the physician learner and the clinical and social environment in which learning occurs.

A physician retraining program. Assessment update.

The Medical College of Pennsylvania, Philadelphia, has sponsored a retraining program for clinically inactive physicians since 1968. A previous study examined return to clinical medicine of retrainees from 1968 to 1975. The present study tracked changes in physician characteristics from 1976 to 1981 and compared return to clinical medicine of retrainees in the two time periods. Although important shifts in gender, nature of inactivity, status of licensure, and geographic distribution occurred during the past five years, the number of retrainees returning to clinical activity after the program was comparable for the two time periods (85% and 83%). Women inactive because of family responsibilities and non-clinically active physicians made more career changes than non-primary care clinical specialists. This study demonstrated that a retraining program is an effective method for reintroducing inactive physicians to clinical medicine.

Priorities and practices of continuing medical education program directors.

A survey of program directors in continuing medical education (CME) was conducted to determine the priorities and practices of the persons who develop CME programs. Respondents from community hospitals, medical schools, specialty societies, state medical societies, and other organizations thought that the most important issues related to the measurement of educational needs and outcomes. A high degree of congruence between program directors' ideal priorities and those they thought were actually being attained in their organizations was notes. Differences between groups of CME providers were infrequent, but medical schools were significantly more concerned than other groups about funding and accountability; community hospitals, about needs assessment and training for program directors; and specialty societies, about methods for adult learning. The majority of directors thought that CME credits, recertification, and relicensure (but not reexamination) should be mandatory.

The effects of mandatory quality assurance: a review of hospital medical audit processes.

A study of 17 hospitals in the Greater Delaware Valley region was undertaken in order to determine if those hospitals which had participated in an early voluntary effort to initiate medical audit differed qualitatively or quantitatively from a matched group of hospitals which had not participated in the previous project. The study also provided the opportunity to analyze the current status of medical audit in a group of hospitals which varied significantly in size, location, and educational responsibilities. Data regarding audit administrative organization, number of audits performed, type of system used, quality of audit criteria, and utilization of audit findings were gathered and analyzed. For these variables, no discernible differences were found between hospitals which had participated in the early voluntary project and those which had not. Wide variations were found among the hospitals in the extent to which medical audit processes were formalized and implemented. There were also variations in the quality of criteria formulated by the hospitals, but they generally did not receive a high rating. The implications of audit findings were generally not followed up in an organized and appropriate manner. Many hospitals which had received PSRO delegated status were given a low rating by the reviewers. The implications of these findings are discussed.

A comparative study of physicians' and nurses' conceptions of the role of the nurse practitioner.

Attempts to define the role of the nurse practitioner as a new health care provider raise questions about the traditional health care division of labor. In order to determine nurses' and physicians' conceptions of the NP's role, parallel surveys were conducted among registered nurses and primary care physicians in southeastern Pennsylvania (including Philadelphia). Respondents (679 nurses and 597 physicians) indicated their opinions on the issue of autonomy for NPs and on the issue of specific tasks appropriate to the NP's role. There were significant differences between nurses and physicians with respect to both of the issues under consideration, but there were also important differences within each of these groups. Nurses were more likely to assert that an NP might practice independently, and also had a higher conception of the NP's capabilities. Physicians who were interested in employing a nurse practitioner had opinions which were closest to those of nurses. These findings suggest that conflict between nurses and physicians might be minimal as long as the nurse practitioner movement remains relatively small, but that there may be latent conflict inherent in any large scale attempt to change the health care division of labor at the present time.

Retraining inactive physicians. A seven-year experience.

In 1969 the Medical College of Pennsylvania began a program to retrain clinically inactive physicians. Originally designed for women physicians who had discontinued their clinical training or practice in response to family responsibilities, the program has expanded its goals to encompass physicians in nonclinical careers who wish to reenter clinical practice. An eight week program, which provides didactic and clinical experience, has been designed as a first step or catalyst for these physicians. Since the program began, 102 physicians have matriculated to the program, and of these physicians, 78 have returned to clinical activity. Criteria have been developed in selecting those physicians most likely to return to clinical activity. There is a potential continued need for programs whose unique attributes and liabilities of retraining are a form of continuing medical education.

The mandate project: institutionalizing a system of patient care quality assurance.

In 1970, prior to present-day requirements for quality assurance programs, a project was undertaken to institute such a program voluntarily in ten hospitals. Five hospitals succeeded in fully implementing the program which was based on the "Bi-Cycle Process" and each documented improvements in desired patient care behaviors. Two hospitals partially implemented the process and demonstrated no significant changes in desired patient care behaviors. Two hospitals failed to provide the data upon which assessments could be made and one hospital never got beyond preliminary efforts at instituting the process. The project demonstrates that a voluntary quality assurance program is feasible and has important implications for PSROs and continuing medical education. It also provides evidence that attention to psychosocial factors is essential in the institutionalization of programs designed to produce desired changes in patient care behaviors.