Promoting resident wellness: evaluation of a time-off policy to increase residents' utilization of health care services.

PURPOSE: To evaluate awareness and utilization of a new institutional policy to grant residents time off to access personal and family health care. METHOD: In 2012, two years after policy implementation, an electronic survey was sent to all 546 residents and fellows at a tertiary care academic medical center in the United States. Residents were asked questions regarding awareness of the time-off policy, use of the policy, health care status, reasons for policy use, and barriers to use. RESULTS: A total of 490 (90%) residents responded. Eighty-nine percent of those surveyed were aware of the policy. Of those who were aware, 49.7% used the policy to access health care. Top reasons for policy use were for personal routine or preventive health care, dental care, and urgent health care needs. The most commonly reported barrier to policy use was concern about the impact the resident's absence would have on colleagues. CONCLUSIONS: Implementation of policies to prospectively schedule residents' time off during business hours to address health care needs is an important means to promote resident wellness. Such policies remove one commonly cited barrier to residents' access to health care. However, residents still reported concerns about impact on peers and patients as the main reason they were reluctant to take the time off to address their health care needs. More work is needed on both wellness policy implementation practices and on refining the systems that will allow seamless and guiltless transitions of care.

Aligning academic continuing medical education with quality improvement: a model for the 21st century.

The recent health care quality improvement (QI) movement has called for significant changes to the way that health care is delivered and taught in academic medical centers (AMCs). This movement also has affected academic continuing medical education (CME). In January 2011, to better align the CME and QI efforts of AMCs, the Association of American Medical Colleges (AAMC) launched a pilot initiative called Aligning and Educating for Quality (ae4Q). The goal of this pilot was to assist 11 AMCs as they moved to a more integrated model of continuous performance improvement by aligning their quality measurement and improvement with their continuing education endeavors. In this article, the authors describe the development of the ae4Q pilot and the resulting outcomes that have led to ongoing improvements.During the 18-month pilot, AAMC consultants conducted readiness assessments and on-site visits and provided consultation services and Web-based resources based on the AMC's needs. Following these interventions at each site, they then conducted both interviews with participants and postintervention assessment surveys to measure the impact of the pilot. Findings included demonstrated increases in the alignment of CME and QI, a greater use of quality data in CME design and delivery, and a greater use of CME as an intervention for clinical improvement. Two sites also attributed measureable improved clinical outcomes to their participation in the ae4Q pilot. The AAMC has used these findings to create resources and ongoing services to support AMCs as they pursue efforts to align QI and CME.

A comparison between physicians and demographically similar peers in accessing personal health care.

PURPOSE: Residents are a unique subpopulation of physicians, training in a complex work and educational environment that may create barriers to accessing preventive and illness-related health care. This study was designed to investigate residents' utilization of personal health care services and compare with those of demographically similar peers. METHOD: All 675 residents in a large, urban, tertiary care U.S. academic medical center were invited to participate in a confidential, Web-based, cross-sectional survey in January 2008. Survey responses to questions addressing personal health care were compared with those of a demographically similar group using the 2008 survey from the Behavioral Risk Factor Surveillance System (BRFSS). The final weights in BRFSS were used for a post hoc stratified adjustment in analysis. Logistic regression was employed to compare subgroups. RESULTS: Sixty-six percent of residents completed the survey. A significantly lower percentage of residents reported having a primary care provider (44%) or dentist (65%) or having routine health and dental care visits (39% and 53%, respectively) within the past year than those in the demographically similar group of 2008 BRFSS. In that group, 83% reported having a primary care provider, and 63% and 79% reported having routine primary and dental health care visits, respectively. CONCLUSIONS: The residents were significantly less likely than demographically similar peers to have a primary care provider or dentist or to participate in routine health maintenance. Further research into barriers preventing residents from accessing health care, and opportunities to address them, is needed.

Plug the leak: align public spending with public need.

We explore the history behind the current structure of graduate medical education funding and the problems with continuing along the current funding path. We then offer suggestions for change that could potentially manage this health care spill. Some of these changes include attracting more students into primary care, aligning federal graduate medical education spending with future workforce needs, and training physicians with skills they will require to practice in systems of the future.

An appraisal of the quality of published qualitative dental research.

OBJECTIVES: To appraise the quality of published qualitative research in dentistry and identify aspects of quality, which require attention in future research. METHODS: Qualitative research studies on dental topics were appraised using the critical appraisal skills programme (CASP) appraisal framework for qualitative research. The percentage of CASP criteria fully met during the assessment was used as an indication of the quality of each paper. Individual criteria were not weighted. RESULTS: Forty-three qualitative studies were identified for appraisal of which 48% had a dental public health focus. Deficiencies in detail of reporting, research design, methodological rigour, presentation of findings, reflexivity, credibility of findings and relevance of study were identified. Problems with quality were apparent irrespective of journal impact factor, although papers from low impact factor journals exhibited the most deficiencies. Journals with the highest impact factors published the least qualitative research. CONCLUSIONS: The quality of much of the qualitative research published on dental topics is mediocre. Qualitative methods are underutilized in oral health research. If quality guidelines such as the CASP framework are used in the context of a thorough understanding of qualitative research design and data analysis, they can promote good practice and the systematic assessment of qualitative research.

Personal time off and residents' career satisfaction, attitudes and emotions.

OBJECTIVES: Doctors who are satisfied with their careers have less stress and burnout and are less likely to make medical errors and more likely to provide a higher quality of patient care. In response to reports that residents experienced barriers to taking time off, Oregon Health and Science University designed a survey to evaluate residents' awareness of their programmes' policies for time off, their ability to find time for personal needs, and associations of both with career satisfaction, emotions and training experience. METHODS: All 675 residents in a large, urban, tertiary care academic medical centre located in the USA were invited to participate in a confidential, web-based, cross-sectional survey in 2008; 66% completed the survey. The survey instrument consisted of a variety of items including yes/no, multiple choice, Likert scale and narrative response types. RESULTS: Only 41% of respondents were aware of their programmes' policies regarding time off. Residents who reported awareness of a policy were more able to find time to take care of personal needs (odds ratio=1.553, p=0.026). These respondents reported more positive experiences and emotions, fewer negative experiences and emotions, higher levels of career satisfaction and relatively less perceived stress than those who were unaware of a time-off policy. In addition, these respondents reported, on average, fewer work and more sleep hours. CONCLUSIONS: Our results highlight the importance of ensuring mechanisms for residents to find time to fulfil personal needs in order to enhance resident well-being and career satisfaction. Ensuring resident awareness of time-off policies is one way to do this. Our study demonstrates that ensuring residents are able to find time for personal needs has significant consequences with respect to resident perceptions of well-being and may be an effective strategy to promote career satisfaction and prevent burnout.

Education to return nonpracticing physicians to clinical activity: a case study in physician reentry.

INTRODUCTION: Physician shortages in the United States are estimated to reach as high as 85 000 by 2020. One strategy for addressing the shortage is to encourage physicians who left clinical practice to return to work, but few programs exist to prepare physicians to reenter practice. The Divisions of Continuing Medical Education and Graduate Medical Education (GME), Oregon Health & Science University, collaborated with clinical departments to establish a physician reentry program. METHODS: A case-study of education designed to return nonpracticing physicians to clinical activity was undertaken. RESULTS: Fourteen candidates were accepted into the program. Accepted candidates were appointed special fellows at the university and provided with restricted institutional license and liability coverage. Based on retraining assessment and planned scope of practice, applicants and program directors designed individualized curricula. As trainees demonstrated clinical proficiency, their level of independence increased in a condensed version of the residency training model. Of the 14 accepted candidates, 13 successfully completed the program and are actively engaged in clinical practice. One trainee did not successfully complete the program. DISCUSSION: This reentry program reintroduced clinically inactive physicians into supervised direct patient care. Use of the GME model allowed acceptance of special fellows and provided institutional malpractice coverage for them.

Barriers to innovation in continuing medical education.

INTRODUCTION: Criteria for maintenance of certification (MOC) emphasize the importance of competencies such as communication, professionalism, systems-based care, and practice performance in addition to medical knowledge. Success of this new competency paradigm is dependent on physicians' willingness to engage in activities that focus on less traditional competencies. We undertook this analysis to determine whether physicians' preferences for CME are barriers to participation in innovative programs. METHODS: A geographically stratified, random sample of 755 licensed, practicing physicians in the state of Oregon were surveyed regarding their preferences for type of CME offering and instructional method and plans to recertify. RESULTS: Three hundred seventy-six of 755 surveys were returned for +/-5% margin of error at 95% confidence level; 91% of respondents were board certified. Traditional types of CME offerings and instructional methods were preferred by the majority of physicians. Academic physicians were less likely than clinical physicians to prefer nontraditional types of CME offerings and instructional methods. Multiple regression analyses did not reveal any significant differences based on demography, practice location, or physician practice type. DISCUSSION: Physicians who participate in CME select educational opportunities that appeal to them. There is little attraction to competency-based educational activities despite their requirement for MOC. The apparent disparity between the instructional methods a learner prefers and those that are the most effective in changing physician behavior may represent a barrier to participating in more innovative CME offerings and instructional methods. These findings are important for medical educators and CME program planners developing programs that integrate studied and effective educational methods into CME programs that are attractive to physicians.

Awareness of and participation in maintenance of professional certification: a prospective study.

INTRODUCTION: National health care concerns have led to the emergence of maintenance of certification (MOC) as a means to ensure the competence of practicing physicians. Little is known about physician perceptions of the barriers and/or benefits of MOC or proportions of physicians who participate in MOC programs. The purposes of this study were to assess physicians' plans for participating in MOC and to identify influences on decisions to participate. METHODS: A geographically stratified, random sample of 755 licensed practicing physicians in the state of Oregon were surveyed regarding certification status, awareness of MOC requirements, influences on decision to participate in MOC, and resources available and/or desired to assist with MOC. RESULTS: Three hundred seventy-six of 755 surveys were returned for +/-5% margin of error at 95% confidence level. Of the respondents 91% were board certified; 95% with time-limited certificates planned to recertify. Factors rated "extremely important" in decisions to recertify were to "demonstrate expertise in my specialty" (50%), to "demonstrate my medical knowledge is up to date" (52%), and to "demonstrate my competency to provide patient care in my specialty" (51%). Practice groups provided physicians with few resources for MOC; 29% report that their practices provided no resources for the MOC process. DISCUSSION: These results are important for hospitals, medical institutions, medical educators, and CME program planners. Although the large majority of physicians with time-limited certificates plan to participate in maintenance of certification, lack of some resources (time, money, and administrative support) and reluctance to utilize others (systems-based care) are identified as barriers to the success of MOC.

Inequalities in the provision of NHS primary care dental services in Scotland in 2004.

OBJECTIVE: To assess inequalities in the provision of National Health Service (NHS) primary care dental services between Health Boards and the four provider groups (General Dental Service [GDS] non-specialist, GDS salaried, specialist working in primary care, Community Dental Service [CDS]) in Scotland. METHODS: A postal questionnaire survey of all dentists (N=2852) registered with the General Dental Council at an address in Scotland was undertaken. The following were assessed: the proportion of primary care dentists not accepting new children/adults for NHS care or using a waiting list, the proportion of dentists working in wheelchair-accessible surgeries, furthest distance travelled by patients to primary care surgery in an average week, waiting time for routine NHS treatment, and the proportion of dentists offering weekend or evening appointments to NHS patients. Data were analysed by Health Board and the four provider groups. RESULTS: A total of 2134 (74.8%) completed questionnaires were returned. One thousand, five hundred and seventy-seven dentists (73.9%) of the respondents were providing NHS primary care dental services for at least part of each week. There was a wide variation in the provision of NHS primary care dental services between Health Boards. Borders, Dumfries and Galloway, and Grampian performed poorly on most indicators, whereas Lanarkshire, Greater Glasgow, and Argyll and Clyde generally performed well. The CDS scored well on most indicators of service provision. There were problems with the provision of specialist dental services in primary care, and GDS services provided by Health Boards. CONCLUSIONS: Because the problem issues differed between Health Boards and the four provider groups, it is likely that both local and national solutions are required to improve the provision of services. Further research on service demand is required to confirm the apparent inequalities in provision suggested by the study.

The contributions of qualitative research towards dental public health practice.

Dental public health (DPH) researchers have traditionally relied on quantitative methods for scientific enquiry. This paper argues that qualitative methodology can make a significant contribution to DPH knowledge and practice because it allows researchers to answer important questions of relevance to procedure and policy that are difficult to answer satisfactorily using quantitative methods alone. Qualitative research can also challenge the norms and assumptions of DPH practice. There are tensions in the relationship between qualitative research and the prevailing paradigm of evidence-based practice (EBP) which potentially influence the utility of DPH-related qualitative research. However, the relevance of qualitative research is increasing as the scope of EBP enquiry extends beyond questions of effectiveness, and methods are developed for incorporating qualitative research into systematic reviews.

Area deprivation and oral health in Scottish adults: a multilevel study.

OBJECTIVES: To explore the association between area deprivation and adult oral health. METHODS: Multilevel regression analysis of data taken from the 1998 Adult Dental Health Survey in the UK comprising 632 participants living in 346 households located in 31 postcode sectors in Scotland. Three oral health outcomes were investigated: number of sound (including restored) teeth; has one or more unsound teeth; has periodontal pocketing 4 mm or more in one or more teeth. RESULTS: In the most deprived areas, individuals had a mean of 4.6 fewer sound teeth than those in the least deprived areas. The difference in normalised number of sound teeth between least and most deprived areas was -0.707 (95% CI -1.164, -0.250), P = 0.024. After adjusting for age, sex, qualification status, head of household social class and household income, the estimated difference was -0.238 (-0.591 to 0.115) (P = 0.164). Area deprivation was not associated with having one or more unsound teeth or periodontal pocketing 4 mm or more in one or more teeth. CONCLUSIONS: There is a univariate association of area deprivation with the number of sound teeth. This association is largely explained by household and individual level socioeconomic variables. A small area deprivation effect cannot be excluded in these data. The findings challenge current understanding of the relationship between area deprivation and oral health. Further multilevel research exploring the relationship between area deprivation and oral health is required using a larger sample and a prospective longitudinal design.

The management of abuse: 4. Abuse of vulnerable adults.

Vulnerable adults include those who, for reasons of age or illness, are unable to protect themselves from significant harm. The role of the GDP and the dental team in the recognition and management of abuse of vulnerable adults is discussed. Information on the current legislation and protocols for referral are provided.

The management of abuse: 3. Domestic violence.

UNLABELLED: The role of the GDP and the dental team in the recognition and management of domestic violence is discussed. Information on the current legislation and protocols for referral are provided. CLINICAL RELEVANCE: This paper discusses domestic violence and offers information and practical advice for the dental team.

The management of abuse: 2. Child abuse.

UNLABELLED: The role of the GDP and the dental team in the recognition and management of child abuse is discussed. Information on the current legislation and protocols for referral are provided. CLINICAL RELEVANCE: This paper discusses child abuse and offers information and practical advice for the dental team.

The management of abuse: 1. Setting the scene.

UNLABELLED: This series of articles has been developed to provide all members of the dental team with an understanding of the different forms of abuse, and the political, social and legal context of safeguarding patients. It also aims to assist the dental team in recognizing and managing abuse effectively, by outlining processes whereby dental practitioners can provide a safe environment for their patients to disclose abuse, and identifying protocols for reporting abuse. CLINICAL RELEVANCE: The GDP and dental team have an important role to play in dealing with patients who are being abused.

The social determinants of oral health: new approaches to conceptualizing and researching complex causal networks.

Oral epidemiological research into the social determinants of oral health has been limited by the absence of a theoretical framework which reflects the complexity of real life social processes and the network of causal pathways between social structure and oral health and disease. In the absence of such a framework, social determinants are treated as isolated risk factors, attributable to the individual, having a direct impact on oral health. There is little sense of how such factors interrelate over time and place and the pathways between the factors and oral health. Features of social life which impact on individuals' oral health but are not reducible to the individual remain under-researched. A conceptual framework informing mainstream epidemiological research into the social determinants of health is applied to oral epidemiology. The framework suggests complex causal pathways between social structure and health via interlinking material, psychosocial and behavioural pathways. Methodological implications for oral epidemiological research informed by the framework, such as the use of multilevel modelling, path analysis and structural equation modelling, combining qualitative and quantitative research methods, and collaborative research, are discussed.