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Objectives

To evaluate the impact of the Calman reforms of higher specialist training on trainee satisfaction.

Design

Questionnaire surveys using portable electronic survey units, two years apart.

Setting

Postgraduate, teaching, district general, and community NHS trusts in North Thames. North Thames deanery includes London north of the Thames, Essex, and Hertfordshire.

Participants

Trainees in all grades and all specialties: 3078 took part in the first survey and 3517 in the second survey.

Main outcome measures

Trainees' satisfaction with training in their current post, including educational objectives, training agreements, induction, consultant feedback, hands on experience acquired, use of log books, consultant supervision, and overall satisfaction with the post.

Results

In the second survey respondents were more likely to have discussed educational objectives with their consultant, used a log book, and had useful feedback from their consultant. They were more likely to give high ratings to induction, consultant supervision, and hands on experience acquired in the post. Each of these elements was associated with increased satisfaction with the post overall. Improvements were most noticeable at the level of specialist registrar, but changes in the same direction were also seen in more junior grades.

Conclusions

After the reforms of specialist training, trainees in all grades reported greater satisfaction with their current posts. The changes required extra training time and effort from consultants.

Improving education in health promotion and prevention has been identified as a priority for all accredited professional health care training programs, an issue recently addressed by a collaboration of stakeholders in chiropractic education who developed a model course outline for public health education. Using a course evaluation questionnaire, the authors surveyed students in the public health course at the Canadian Memorial Chiropractic College (CMCC) before and after the implementation of new course content based on the model course outline. Following the new course, there were significant improvements in perceived relevance to chiropractic practice and motivation to learn the material as a foundation for clinical practice. Changes made to the content and delivery of the course based on the model course outline were well received in the short term.

As a prelude to more detailed formal contracting, North East Thames Region undertook a review to examine whether the content of postgraduate medical education (PGME) varies according to the type of hospital in which junior doctors are trained. The study covered a sample of 83 trainees at different grades in four types of hospital (postgraduate, university, district general hospital involved in off-site undergraduate medical education, and district general hospital with no formal involvement in undergraduate medical education) and was designed as a qualitative comparative study. The results of the study point to a perceived lack of structure in PGME and indicate that hospital type alone does not determine a trainees' PGME experience. Moreover, different training grades have different educational needs, which will need to be addressed under more formal contracting arrangements. The Region plans to take this work forward by convening one or more consensus conferences to examine how a more structured approach to PGME could be implemented.

Background: Heidelberg Medical School underwent a major curricular change with the implementation of the reform curriculum HeiCuMed (Heidelberg Curriculum Medicinale) in October 2001. It is based on rotational modules with daily cycles of interactive, case-based small-group seminars, PBL tutorials and training of sensomotor and communication skills. For surgical undergraduate training an organisational structure was developed that ensures continuity of medical teachers for student groups and enables their unimpaired engagement for defined periods of time while accounting for the daily clinical routine in a large surgery department of a university hospital. It includes obligatory didactic training, standardising teaching material on the basis of learning objectives and releasing teaching doctors from clinical duties for the duration of a module.

Objective: To compare the effectiveness of the undergraduate surgical reform curriculum with that of the preceding traditional one as reflected by students' evaluations.

Method: The present work analyses student evaluations of the undergraduate surgical training between 1999 and 2008 including three cohorts (~360 students each) in the traditional curriculum and 13 cohorts (~150 students each) in the reform curriculum.

Results: The evaluation of the courses, their organisation, the teaching quality, and the subjective learning was significantly better in HeiCuMed than in the preceding traditional curriculum over the whole study period.

Conclusion: A medical curriculum based on the implementation of interactive didactical methods is more important to successful teaching and the subjective gain of knowledge than knowledge transfer by traditional classroom teaching. The organisational strategy adopted in the surgical training of HeiCuMed has been successful in enabling the maintenance of a complex modern curriculum on a continuously high level within the framework of a busy surgical environment.

Background

Resident education involves didactics and pedagogic strategies using a variety of tools and technologies in order to improve critical thinking skills. Debating is used in educational settings to improve critical thinking skills, but there have been no reports of its use in residency education. The present paper describes the use of debate to teach resident physicians about health care reform.

Objective

We aimed to describe the method of using a debate in graduate medical education.

Methods

Second-year through fourth-year physical medicine and rehabilitation residents participated in a moderated policy debate in which they deliberated whether the United States has one of the “best health care system(s) in the world.” Following the debate, the participants completed an unvalidated open-ended questionnaire about health care reform.

Results

Although residents expressed initial concerns about participating in a public debate on health care reform, all faculty and residents expressed that the debate was robust, animated, and enjoyed by all. Components of holding a successful debate on health care reform were noted to be: (1) getting “buy-in” from the resident physicians; (2) preparing the debate; and (3) follow-up.

Conclusion

The debate facilitated the study of a large, complex topic like health care reform. It created an active learning process. It encouraged learners to keenly attend to an opposing perspective while enthusiastically defending their position. We conclude that the use of debates as a teaching tool in resident education is valuable and should be explored further.

Background

We investigated the views of newly graduating physicians on their preparedness for postgraduate clinical training, and evaluated the relationship of preparedness with the educational environment and the pass rate on the National Medical Licensure Examination (NMLE).

Methods

Data were obtained from 2429 PGY-1 physicians-in-training (response rate, 36%) using a mailed cross-sectional survey. The Dundee Ready Education Environment Measure (DREEM) inventory was used to assess the learning environment at 80 Japanese medical schools. Preparedness was assessed based on 6 clinical areas related to the Association of American Medical Colleges Graduation Questionnaire.

Results

Only 17% of the physicians-in-training felt prepared in the area of general clinical skills, 29% in basic knowledge of diagnosis and management of common conditions, 48% in communication skills, 19% in skills associated with evidence-based medicine, 54% in professionalism, and 37% in basic skills required for a physical examination. There were substantial differences among the medical schools in the perceived preparedness of their graduates. Significant positive correlations were found between preparedness for all clinical areas and a better educational environment (all p < 0.01), but there were no significant associations between the pass rate on the NMLE and perceived preparedness for any clinical area, as well as pass rate and educational environment (all p > 0.05).

Conclusion

Different educational environments among universities may be partly responsible for the differences in perceived preparedness of medical students for postgraduate clinical training. This study also highlights the poor correlation between self-assessed preparedness for practice and the NMLE.

This paper offers a wide ranging analysis of the drivers that resulted in scrutiny of medical, nursing, and healthcare professional roles. It suggests that what is needed is a coherent vision of the future shape of the health workforce. This requires moving beyond the presumption that reforming working practices primarily involves "delegating doctors" responsibilities to nurses. The paper argues that it is self evident that the implications of changes in healthcare roles and the ability of existing professionals to function effectively in the future will require education, training, and human resource investment supportive of the changes. It suggests a clear definition of competence and a national standard to practice is essential for nurses working in acute and acute critical settings. There should therefore be a correlation between levels of practice, levels of education, and remuneration. Furthermore, education programmes for senior nurses should sit coherently alongside the education programmes required by Modernising Medical Careers. Finally, the realisation of the government's service and modernisation agenda will require a culture change within higher education institutions, postgraduate deaneries, professional organisations, workforce development confederations, and NHS trusts.

Postgraduate medical education and training in many specialties, including Clinical Radiology, is undergoing major changes. In part this is to ensure that shorter training periods maximise the learning opportunities but it is also to bring medical education in line with broader educational theory. Learning outcomes need to be defined so that there is no doubt what knowledge, skills, attitudes and behaviours are expected of those in training. Curricula should be developed into competency or outcome based models and should state the aims, objectives, content, outcomes and processes of a training programme. They should include a description of the methods of learning, teaching, feedback and supervision. Assessment systems must be matched to the curriculum and must be fair, reliable and valid. Workplace based assessments including the use of multisource feedback need to be developed and validated for use during radiology training. These should be used in a formative and developmental way, although the overall results from a series of such assessments can be used in a more summative way to determine progress to the next phase of training. Formal standard setting processes need to be established for ‘high stakes’ summative assessments such as examinations. In addition the unique skills required of a radiologist in terms of image interpretation, pattern recognition, deduction and diagnosis need to be evaluated in robust, reliable and valid ways. Through a combination of these methods we can be assured that decisions about trainees’ progression through training is fair and standardised and that we are protecting patients by establishing national standards for training, curricula and assessment methods.

The Postgraduate Medical Education and Training Board (PMETB) is a new organisation set up to develop, establish, and maintain standards and requirements for postgraduate medical education (PGME) and training. First trailed in the NHS Plan,1 its remit covers the UK. As such it aims to be a single, unifying framework for doctors in training.

No course in genetics can prepare the practicing physician to interpret whole-genome data. We argue that genetics is a microcosm of the changing dynamics of the practice of medicine. It illustrates the perfect storm of exponential increases in raw data with undetermined clinical relevance, ease of access to large amounts of data via the internet and shifting expectations of the doctor-patient relationship and the very mechanisms of health care delivery. Educational reform is needed across the continuum of medical education, from the student to the faculty training them, and requires a shift in focus from factual knowledge to data management and interpretation.

Background

Following a situation appraisal in 2001, a six year mental health reform programme (Egymen) 2002-7 was initiated by an Egyptian-Finnish bilateral aid project at the request of a former Egyptian minister of health, and the work was incorporated directly into the Ministry of Health and Population from 2007 onwards. This paper describes the aims, methodology and implementation of the mental health reforms and mental health policy in Egypt 2002-2009.

Methods

A multi-faceted and comprehensive programme which combined situation appraisal to inform planning; establishment of a health sector system for coordination, supervision and training of each level (national, governorate, district and primary care); development workshops; production of toolkits, development of guidelines and standards; encouragement of intersectoral liaison at each level; integration of mental health into health management systems; and dedicated efforts to improve forensic services, rehabilitation services, and child psychiatry services.

Results

The project has achieved detailed situation appraisal, epidemiological needs assessment, inclusion of mental health into the health sector reform plans, and into the National Package of Essential Health Interventions, mental health masterplan (policy guidelines) to accompany the general health policy, updated Egyptian mental health legislation, Code of Practice, adaptation of the WHO primary care guidelines, primary care training, construction of a quality system of roles and responsibilities, availability of medicines at primary care level, public education about mental health, and a research programme to inform future developments. Intersectoral liaison with education, social welfare, police and prisons at national level is underway, but has not yet been established for governorate and district levels, nor mental health training for police, prison staff and teachers.

Conclusions

The bilateral collaboration programme initiated a reform programme which has been sustained beyond the end of the funding. The project has demonstrated the importance of using a multi-faceted and comprehensive programme to promote sustainable system change, key elements of which include a focus on the use of rapid appropriate treatment at primary care level, strengthening the referral system, interministerial and intersectoral liaison, rehabilitation, and media work to mobilize community engagement.

The postgraduate hospitals of London grew up in the nineteenth century and offered a unique national specialist service. Since then specialist services have developed in undergraduate hospitals throughout Britain as well as in London, but the postgraduate hospitals have nevertheless preserved their high levels of staffing. Although numbers of medical posts in the provinces have grown, this has not been by redistribution of London posts but merely differential growth. The fact identified by Tomlinson--that Londoners are not receiving the most appropriate clinical care--is in fact the strongest argument for changing postgraduate medical education. Such education needs to be rooted first in clinical care, though Tomlinson underestimates the importance to education of such care being sited in a shared environment with strong scientific activity.

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Although Canadian health care reform has constrained costs and improved efficiency, it has had a profound and mixed effect on Canadian academic medicine. Teaching hospitals have been reduced in number and size, and in patient programs have shifted to ambulatory and community settings. Specialized care programs are now multi-institutional and multidisciplinary. Furthermore, the influence of regional planning bodies has grown markedly. Although these changes have likely improved clinical service, their impact on the quality of clinical education is uncertain. Within the academic clinical department, recruitment of young faculty has been greatly complicated by constraints on licensing, billing numbers, fee-for-service income and research funding. The departmental practice plan based on university funds and fee-for-service income is being replaced by less favourable funding arrangements. However, emphasis on multidisciplinary programs has rendered these departments more flexible in structure. The future of Canadian academic medicine depends on an effective alliance with government. Academia and government must agree, particularly on human-resource requirements, research objectives and the delivery of clinical and academic programs in regional and community settings. The establishment of focal points for academic health sciences planning within academic health sciences centres and within governments would assist in these developments. Finally, government and the academic health sciences sector must work together to remove the current impediments to the recruitment of highly qualified young faculty.

Background

In Bangladesh, widespread dissatisfaction with government health services did not improve during the Health and Population Sector Programme (HPSP) reforms from 1998-2003. A 2003 national household survey documented public and health service users' views and experience. Attitudes and behaviour of health workers are central to quality of health services. To investigate whether the views of health workers influenced the reforms, we surveyed local health workers and held evidence-based discussions with local service managers and professional bodies.

Methods

Some 1866 government health workers in facilities serving the household survey clusters completed a questionnaire about their views, experience, and problems as workers. Field teams discussed the findings from the household and health workers' surveys with local health service managers in five upazilas (administrative sub-districts) and with the Bangladesh Medical Association (BMA) and Bangladesh Nurses Association (BNA).

Results

Nearly one half of the health workers (45%) reported difficulties fulfilling their duties, especially doctors, women, and younger workers. They cited inadequate supplies and infrastructure, bad behaviour of patients, and administrative problems. Many, especially doctors (74%), considered they were badly treated as employees. Nearly all said lack of medicines in government facilities was due to inadequate supply, not improved during the HPSP. Two thirds of doctors and nurses complained of bad behaviour of patients. A quarter of respondents thought quality of service had improved as a result of the HPSP.

Local service managers and the BMA and BNA accepted patients had negative views and experiences, blaming inadequate resources, high patient loads, and patients' unrealistic expectations. They said doctors and nurses were demotivated by poor working conditions, unfair treatment, and lack of career progression; private and unqualified practitioners sought to please patients instead of giving medically appropriate care. The BMA considered it would be dangerous to attempt to train and register unqualified practitioners.

Conclusions

The continuing dissatisfaction of health workers may have undermined the effectiveness of the HPSP. Presenting the views of the public and service users to health managers helped to focus discussions about quality of services. It is important to involve health workers in health services reforms.

Background

The educational climate is crucial in postgraduate medical education. Although leaders are in the position to influence the educational climate, the relationship between leadership skills and educational climate is unknown. This study investigates the relationship between the educational climate in clinical departments and the leadership skills of clinical consultants responsible for education.

Methods

The study was a trans-sectional correlation study. The educational climate was investigated by a survey among all doctors (specialists and trainees) in the departments. Leadership skills of the consultants responsible for education were measured by multi-source feedback scores from heads of departments, peer consultants, and trainees.

Results

Doctors from 42 clinical departments representing 21 specialties participated. The response rate of the educational climate investigation was moderate 52% (420/811), Response rate was high in the multisource-feedback process 84.3% (420/498). The educational climate was scored quite high mean 3.9 (SD 0.3) on a five-point Likert scale. Likewise the leadership skills of the clinical consultants responsible for education were considered good, mean 5.4 (SD 0.6) on a seven-point Likert scale. There was no significant correlation between the scores concerning the educational climate and the scores on leadership skills, r = 0.17 (p = 0.29).

Conclusions

This study found no relation between the educational climate and the leadership skills of the clinical consultants responsible for postgraduate medical education in clinical departments with the instruments used. Our results indicate that consultants responsible for education are in a weak position to influence the educational climate in the clinical department. Further studies are needed to explore, how heads of departments and other factors related to the clinical organisation could influence the educational climate.

Little is known about African-American physicians' health system experience or their opinions on health reform. In an attempt to obtain socioculturally relevant data quantifying these experiences and opinions, the National Medical Association administered a 38-question, 80-item survey instrument in August 1993. The questionnaire was completed by 236 physicians. The results indicate that African-American physicians feel health care is a right and that the health system needs fundamental change. Although there was no consensus on the type of health reform needed, approximately 35% cited availability and access to care to be the greatest problem facing the system with high costs of care (18.2%) ranking second. Unique findings in the survey indicated respondents felt that the needs and concerns of most African Americans will not be fairly addressed in the reform of the health-care system, that African-African physicians are not included in the formation of health-care policies, and that African-American physicians are facing high levels of professional and healthcare system racial discrimination. More than 99% of African-American physicians reported some degree of racial discrimination in the practice of medicine including peer review, obtaining practice privileges at hospitals, hospital staff promotions, Medicaid and Medicare reimbursements, malpractice suits, private insurance oversight and reimbursements, and referral practices of white colleagues. These findings have profound health policy, health financing, and health service delivery implications and should be included in debates and deliberations on health reform.

The last major change in medical education occurred almost 100 years ago following an independent investigation conducted by Dr. Abraham Flexner in 1910. Although individual institutions have implemented drastic changes in their own curriculum and the accrediting agencies have mandated other initiatives intended to maintain medical education at the cutting edge of science and technology, many facets of medical education, from the premedical requirements through medical school and residency training, have not changed in nearly half a century. There are areas that are completely lacking in the process of training physicians, and perhaps the assumption was that physicians were intelligent enough to figure this out on their own. While that may have been true in the past when things were less complicated, this approach offers too many opportunities for misadventure, ultimately to the detriment of physicians and patients. Perhaps what is needed is a more rigorous, didactic training program and more thought put into areas where judgment, morality and ethics converge to create potential hazards that can defeat the finest training, equipment and intent. Although American residency programs produce physicians fully capable of independent practice after their prescribed periods of training, there are elements of these training programs that are outdated, costly and perhaps not the best way to get to the desired endpoint. Perhaps these can be revised to more accurately reflect the changing times. This manuscript addresses some of these issues at all levels of training with recommendations for corrective action.

In this article, we examine the financing mechanisms for graduate medical education (GME) in the United States. In so doing, we identify Medicare as the single largest contributor to GME and the most important barrier to producing a physician workforce that is appropriately sized, balanced, and skilled. Until passage of the 1997 Budget Reconciliation Agreement, the structure of Medicare payments promoted overproduction and skewed production toward training specialists in tertiary settings. We then examine the various reform proposals put forward by major health care organizations and policy bodies. These organizations generally agree on seven policy objectives: Remove incentives that promote expanded resident production; Base the GME subsidy on actual costs and distribute it more uniformly; Focus reductions on specialty residency positions; Provide GME payments for training provided in ambulatory, community, and managed care sites; Decouple Medicare GME reimbursement from payments to health maintenance organizations for patient care; Require all health insurers to contribute to GME; and Ensure that reductions in the GME subsidy do not reduce access to care for low-income persons. A myriad of different mechanisms for achieving these objectives have been recommended, many of which could be melded together to form a comprehensive approach to GME reform. The prospects for meaningful GME reform are dim in the absence of broader Medicare reform. The costs to stake-holders are too concentrated while the benefits to the public are too diffuse for GME reform to stand alone. But the political imperative to deal with the federal budget's short-term deficit and Medicare's long-term solvency will likely create an opportunity for GME reform. An addendum has been added that shows how the 1997 Budget Reconciliation Agreement addresses most of the major reform objectives identified but that several important issues remain unresolved.

AIM: To compare the opinions and recommendations of imaging specialists from United States (USA) and non-USA developed nations for USA health care reform.

METHODS: A survey was emailed out to 18 imaging specialists from 17 non-USA developed nation countries and 14 radiologists within the USA regarding health care reform. The questionnaire contained the following questions: what are the strengths of your health care system, what problems are present in your nation’s health care system, and what recommendations do you have for health care reform in the USA. USA and non-USA radiologists received the same questionnaire.

RESULTS: Strengths of the USA health care system include high quality care, autonomy, and access to timely care. Twelve of 14 (86%) USA radiologists identified medicolegal action as a major problem in their health care system and felt that medicolegal reform was a critical aspect of health care reform. None of the non-USA radiologists identified medicolegal aspects as a problem in their own country nor identified it as a subject for USA health care reform. Eleven of 14 (79%) USA radiologists and 16/18 (89%) non-USA radiologists identified universal health care coverage as an important recommendation for reform.

CONCLUSION: Without full universal coverage, meaningful health care reform will likely require medicolegal reform as an early and important aspect of improved and efficient health care.

Despite the political and economic reforms that have swept Eastern Europe in the past 5 years, there has been little change in Poland's health care system. The Ministry of Health and Social Welfare has targeted preventive care as a priority, yet the enactment of legislation to meet this goal has been slow. The process of reform has been hindered by political stagnation, economic crisis, and a lack of delineation of responsibility for implementing the reforms. Despite the delays in reform, recent developments indicate that a realistic, sustainable restructuring of the health care system is possible, with a focus on preventive services. Recent proposals for change have centered on applying national goals to limited geographic areas, with both local and international support. Regional pilot projects to restructure health care delivery at a community level, local health education and disease prevention initiatives, and a national training program for primary care and family physicians and nurses are being planned. Through regionalization, an increase in responsibility for both the physician and the patient, and redefinition of primary health care and the role of family physicians, isolated local movements and pilot projects have shown promise in achieving these goals, even under the current budgetary constraints.

Background

In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of regulations that mandated a reduction in the number of hours that medical residents can work. These requirements have generated controversy among medical educators, with some expressing concern that reducing resident hours may limit clinical exposure and competency, particularly in surgical specialties.

Objective

This study examines the impact of duty hour restrictions on resident operative experience in residents in 2 surgical subspecialties since the implementation of the ACGME duty hour limits.

Method

We examined operative log data for vascular surgery and pediatric surgery, using the academic year immediately preceding the duty hour restrictions, 2002 to 2003, as a baseline for comparison to subsequent academic years through 2006 to 2007 for vascular surgery and 2007 to 2008 for pediatric surgery.

Results

Graduating fellows in pediatric surgery showed no change in their total operative volume following duty hour restrictions. The pediatric-defined category of neonate procedures showed an increase following duty hour restrictions. Graduating fellows in vascular surgery showed an increase in total major procedures as surgeon. The vascular-defined categories of endovascular-diagnostic, endovascular-therapeutic, and endovascular-graft procedures also increased.

Conclusions

The reduction of duty hours has not resulted in a decrease in operative volume as some have predicted. Operative volume in pediatric surgery remained mainly unchanged, whereas operative volume in vascular surgery increased. We explore possible explanations for the observed findings.

It has been more than a decade since the Royal College of Physicians and Surgeons of Canada implemented the Canadian Medical Education Directives for Specialists (CanMEDS) project. Despite frequent and widespread correspondence to Canadian practitioners and educators, the adoption of the 7 core competencies espoused by CanMEDS has been slow. Barriers to the teaching and acquisition of these skills include a lack of understanding of what they actually represent, a paucity of tools to teach them and an inability to quantify performance. It is essential to translate the goals of the CanMEDS project into clinically relevant concepts. We define the current status of the CanMEDS competencies with respect to urological training and provide some context to what has been, until now, a poorly defined and abstract educational construct.

OBJECTIVE: To identify what changes should be made in the University of British Columbia's rural family practice training program curriculum to help graduates be better prepared to practice. DESIGN: Two cross-sectional surveys via mailed questionnaires: one designed to measure physicians' self-reported preparedness for practice and the other to measure the importance of various rural family medicine components. SETTING: Rural training program graduates and preceptors representing rural communities in British Columbia. PARTICIPANTS: Thirty-nine graduates of the rural training program between 1982 and 1991 and 14 community-based rural training program preceptors representing eight communities throughout the province participated in this study. MAIN OUTCOME MEASURES: Percentage of graduates of the rural program who reported themselves to be underprepared on each family practice item and preceptors' mean scores for the attributed importance to rural practice of each item on this questionnaire. RESULTS: A list of curriculum areas most in need of reform was created. This list included trauma, counseling skills, radiology, vacuum extraction, fracture care, exercising community leadership, cost-effective use of diagnostic tests, using community health resources, obtaining hospital privileges, ophthalmology, dermatology, otolaryngology, personal and professional growth, relationships with other physicians, and personnel issues. CONCLUSIONS: Using both the level of graduates' self-reported underpreparedness and the attributed importance of elements of rural practice, as indicated by the preceptor survey, we developed a list of the areas of the rural training program curriculum most in need of reform.

The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.

The medical component of workers' compensation programs-now costing over $24 billion annually-and the rest of the nation's medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers' compensation and traditional health insurance. What is the relationship of the workers' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?

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