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1.  PA01.47. Making ayurveda affordable and acceptable to all 
Ancient Science of Life  2012;32(Suppl 1):S97.
Purpose:
Ayurveda is eternal science of life because of its evolution is prior to human being itself. Ayurveda is part of our day to day life as a food & day routine. The study was performed as a survey in Delhi NCR (India) among the common men who use ayurveda or want ayurveda to be their system of medicine. The Aim of this study was to know their opinion that what are the ground realities and how ayurveda can be made more affordable and acceptable to them.
Method:
Sixty individuals were selected randomly comprising equally males and females. Age group was 18 to 70 yrs. All of them have undergone Ayurvedic treatment or have taken ayurvedic medicines as a part of their treatment. They were asked 31 questions about ayurveda under four categories as general questions, questions related to ayurvedic physicians, questions related to ayurvedic retailers and questions related to ayurvedic manufacturers. Their answers were taken on a printed questionnaire as a tick Yes, No and can’t say. Some questions were subjective to get suggestions of patients.
Result:
Result of the survey indicated some valuable points like 90% under study doesn’t know that BAMS are Ayurvedic Physicians. Pure Ayurvedic Retailers are rare; condition of ayurvedic medicines were not good at mixed ones. There was absolute majority for the expiry date on ayurvedic medicines & more research work on Ayurvedic preparations to make them tastier, easily differentiable & patient friendly.
Conclusion:
The results of the study should be addressed by the Ayurvedic Physicians, Ayurvedic manufacturers and retailers community on priority basis. The study also revealed the need of a broad based survey to get further insight of the present ayurvedic scenario in India & abroad and suggestions to make ayurveda more patients friendly and acceptable to all.
PMCID: PMC3800980
2.  Academic career in medicine – requirements and conditions for successful advancement in Switzerland 
Background
Within the framework of a prospective cohort study of Swiss medical school graduates a sample of young physicians aspiring to an academic career were surveyed on their career support and barriers experienced up to their sixth year of postgraduate training.
Methods
Thirty-one junior academics took part in semi-structured telephone interviews in 2007. The interview guideline focused on career paths to date, career support and barriers experienced, and recommendations for junior and senior academics. The qualitatively assessed data were evaluated according to Mayring's content analysis. Furthermore, quantitatively gained data from the total cohort sample on person- and career-related characteristics were analyzed in regard to differences between the junior academics and cohort doctors who aspire to another career in medicine.
Results
Junior academics differ in terms of instrumentality as a person-related factor, and in terms of intrinsic career motivation and mentoring as career-related factors from cohort doctors who follow other career paths in medicine; they also show higher scores in the Career-Success Scale. Four types of career path could be identified in junior academics: (1) focus on basic sciences, (2) strong focus on research (PhD programs) followed by clinical training, (3) one to two years in research followed by clinical training, (4) clinical training and research in parallel. The interview material revealed the following categories of career-supporting experience: making oneself out as a proactive junior physician, research resources provided by superior staff, and social network; statements concerning career barriers encompassed interference between clinical training and research activities, insufficient research coaching, and personality related barriers. Recommendations for junior academics focused on mentoring and professional networking, for senior academics on interest in human resource development and being role models.
Conclusion
The conditions for an academic career in medicine in Switzerland appear to be difficult especially for those physicians combining research with clinical work. For a successful academic career it seems crucial to start with research activities right after graduation, and take up clinical training later in the career. Furthermore, special mentoring programs for junior academics should be implemented at all medical schools to give trainees more goal-oriented guidance in their career.
doi:10.1186/1472-6963-9-70
PMCID: PMC2685793  PMID: 19402885
3.  Study to assess the compensation and skills of medical library professionals relative to information technology professionals* 
Purpose: The study seeks to determine how medical library professionals performing information-technology (IT) roles are compensated and how their positions are designed compared to information technology staff in their institutions.
Methods: 550 medical library directors in hospital and academic medical libraries were surveyed. The data was then compared to survey data from other compensation studies of the IT industry.
Results: There is a gap in compensation between medical library professionals and IT professionals performing similar functions using information technology. Technology-intense library jobs are compensated at higher levels than more traditional jobs.
Conclusions: To compete with IT salaries, managers of medical library professionals will need to be ever more cognizant of the employment practices of IT professionals in nonmedical library disciplines. It is typically in the medical library's best interest to ensure that IT-related jobs, accountabilities, and capabilities of the medical library are known and understood by others, especially in the human resources and information technology staff departments.
PMCID: PMC34558  PMID: 11465684
4.  Academic Institutionalization of Community Health Services: Way Ahead in Medical Education Reforms 
Policy on medical education has a major bearing on the outcome of health care delivery system. Countries plan and execute development of human resource in health, based on the realistic assessments of health system needs. A closer observation of medical education and its impact on the delivery system in India reveals disturbing trends. Primary care forms backbone of any system for health care delivery. One of the major challenges in India has been chronic deficiency of trained human resource eager to work in primary care setting. Attracting talent and employing skilled workforce seems a distant dream. Talking specifically of the medical education, there are large regional variations, urban - rural divide and issues with financing of the infrastructure. The existing design of medical education is not compatible with the health care delivery system of India. Impact is visible at both qualitative as well as quantitative levels. Medical education and the delivery system are working independent of each other, leading outcomes which are inequitable and unjust. Decades of negligence of medical education regulatory mechanism has allowed cropping of multiple monopolies governed by complex set of conflict of interest. Primary care physicians, supposed to be the community based team leaders stand disfranchised academically and professionally. To undo the distorted trajectory, a paradigm shift is required. In this paper, we propose expansion of ownership in medical education with academic institutionalization of community health services.
doi:10.4103/2249-4863.94442
PMCID: PMC3893954  PMID: 24478994
Community based medical education; medical education reforms; family medicine
5.  Expanded carrier screening in reproductive healthcare: perspectives from genetics professionals 
Human Reproduction (Oxford, England)  2013;28(6):1725-1730.
STUDY QUESTION
How do genetics professionals assess the potential benefits and challenges of expanded carrier screening (ECS) in reproductive healthcare?
SUMMARY ANSWER
Genetics professionals believe that current ECS products have major limitations and are not ready for routine use in reproductive healthcare.
WHAT IS KNOWN ALREADY
Non-targeted approaches to carrier screening have been met with uneven enthusiasm from relevant professional organizations. With declining genotyping costs, it is reasonable to expect that the number of genetic conditions evaluated by carrier-screening products will continue to increase. Reproductive healthcare providers will play a critical role in the adoption of ECS and need to be prepared for the potential challenges that lie ahead.
STUDY DESIGN, SIZE, DURATION
Focus groups were convened at six academic medical centers in the USA in March 2011 to examine genetics professionals' views on ECS.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Forty genetic professionals participated in six focus groups for this study. A clinical case report was presented to each focus group to examine participants' opinions about the use of highly multiplexed forms of carrier screening in reproductive healthcare. Focus group transcripts were analyzed for major themes and thematic density across sites using qualitative data analysis software (ATLAS.ti v5.8).
MAIN RESULTS AND THE ROLE OF CHANCE
Participants believed that current ECS products have major limitations pertaining to the analysis of select alleles and genetic mutations. Participants highlighted multiple interpretive and counseling challenges that reproductive healthcare providers may face in communicating ECS results to patients. Participants stressed the importance of communicating these and other limitations to patients before recommending ECS. Participants recommended collaboration with genetic counselors and medical geneticists in providing ECS.
LIMITATIONS, REASONS FOR CAUTION
To the extent that ECS products have not been widely used to date, participants may have had limited familiarity and direct clinical experience with these products. Given that this study was conducted with genetic professionals from academic medical centers in the USA, participant perspectives may not be representative of professional practices and norms in other healthcare settings.
WIDER IMPLICATIONS OF THE FINDINGS
In considering the use of ECS products in their practices, reproductive healthcare providers may find it helpful to consider the perspectives of genetics professionals. These specialists have considerable experience with diverse forms of genetic testing and can provide valuable insights regarding new genomic risk assessment tools such as ECS.
STUDY FUNDING/COMPETING INTEREST(S)
This research was supported by the National Human Genome Research Institute (R01 HG004500 and P50 HG003390). None of the authors have any conflicts of interest to declare.
doi:10.1093/humrep/det091
PMCID: PMC3657126  PMID: 23589535
carrier screening; reproductive healthcare providers; genetics; focus groups
6.  Learning health professionalism at Makerere University: an exploratory study amongst undergraduate students 
BMC Medical Education  2010;10:76.
Background
Anecdotal evidence shows that unprofessional conduct is becoming a common occurrence amongst health workers in Uganda. The development of appropriate professional values, attitudes and behaviors is a continuum that starts when a student joins a health professional training institution and as such health professionals in training need to be exposed to the essence of professionalism. We sought to explore undergraduate health professions students' perceptions and experiences of learning professionalism as a preliminary step in addressing the problem of unprofessional conduct amongst health workers in Uganda.
Methods
Eight focus group discussions were conducted with 49 first to fifth year health professions undergraduate students of the 2008/2009 academic year at Makerere University College of Health Sciences. The focus group discussions were recorded and transcribed, and were analyzed using content analysis with emergent coding.
Results
The difference in the way first and fifth year students of Makerere University College of Health Sciences conceptualized professionalism was suggestive of the decline in attitude that occurs during medical education. The formal curriculum was described as being inadequate while the hidden and informal curricula were found to play a critical role in learning professionalism. Students identified role models as being essential to the development of professionalism and emphasized the need for appropriate role modeling. In our setting, resource constraints present an important, additional challenge to learning universal standards of health professionalism. Furthermore, students described practices that reflect the cultural concept of communalism, which conflicts with the universally accepted standard of individual medical confidentiality. The students questioned the universal applicability of internationally accepted standards of professionalism.
Conclusions
The findings call for a review of the formal professionalism curriculum at Makerere University College of Health Sciences to make it more comprehensive and to meet the needs expressed by the students. Role models need capacity building in professionalism as health professionals and as educators. In our setting, resource constraints present an additional challenge to learning universal standards of health professionalism. There is need for further research and discourse on education in health professionalism in the Sub-Saharan context of resource constraints and cultural challenges.
doi:10.1186/1472-6920-10-76
PMCID: PMC2987936  PMID: 21050457
7.  Improving mental and neurological health research in Latin America: a qualitative study 
BMC Public Health  2009;9:334.
Background
Research evidence is essential to inform policies, interventions and programs, and yet research activities in mental and neurological (MN) health have been largely neglected, particularly in low- and middle-income countries. Many challenges have been identified in the production and utilization of research evidence in Latin American countries, and more work is needed to overcome this disadvantageous situation. This study aims to address the situation by identifying initiatives that could improve MN health research activities and implementation of their results in the Latin American region.
Methods
Thirty-four MN health actors from 13 Latin American countries were interviewed as part of an initiative by the Global Forum for Health Research and the World Health Organization to explore the status of MN health research in low- and middle-income countries in Africa, Asia and Latin-America.
Results
A variety of recommendations to increase MN health research activities and implementation of their results emerged in the interviews. These included increasing skilled human resources in MN health interventions and research, fostering greater participation of stakeholders in the generation of research topics and projects, and engendering the interest of national and international institutions in important MN health issues and research methodologies. In the view of most participants, government agencies should strive to have research results inform the decision-making process in which they are involved. Thus these agencies would play a key role in facilitating and funding research. Participants also pointed to the importance of academic recognition and financial rewards in attracting professionals to primary and translational research in MN health. In addition, they suggested that institutions should create intramural resources to provide researchers with technical support in designing, carrying out and disseminating research, including resources to improve scientific writing skills.
Conclusion
Fulfillment of these recommendations would increase research production in MN health in Latin American countries. This, in turn, will raise the profile of these health problems, and consequently will underscore the need of continued high-quality and relevant research, thus fostering a virtuous cycle in the decision-making process to improve MN health care.
doi:10.1186/1471-2458-9-334
PMCID: PMC2754458  PMID: 19747380
8.  Guidelines, Editors, Pharma And The Biological Paradigm Shift 
Mens Sana Monographs  2007;5(1):27-30.
Private investment in biomedical research has increased over the last few decades. At most places it has been welcomed as the next best thing to technology itself. Much of the intellectual talent from academic institutions is getting absorbed in lucrative positions in industry. Applied research finds willing collaborators in venture capital funded industry, so a symbiotic growth is ensured for both.
There are significant costs involved too. As academia interacts with industry, major areas of conflict of interest especially applicable to biomedical research have arisen. They are related to disputes over patents and royalty, hostile encounters between academia and industry, as also between public and private enterprise, legal tangles, research misconduct of various types, antagonistic press and patient-advocate lobbies and a general atmosphere in which commercial interest get precedence over patient welfare.
Pharma image stinks because of a number of errors of omission and commission. A recent example is suppression of negative findings about Bayer's Trasylol (Aprotinin) and the marketing maneuvers of Eli Lilly's Xigris (rhAPC). Whenever there is a conflict between patient vulnerability and profit motives, pharma often tends to tilt towards the latter. Moreover there are documents that bring to light how companies frequently cross the line between patient welfare and profit seeking behaviour.
A voluntary moratorium over pharma spending to pamper drug prescribers is necessary. A code of conduct adopted recently by OPPI in India to limit pharma company expenses over junkets and trinkets is a welcome step.
Clinical practice guidelines (CPG) are considered important as they guide the diagnostic/therapeutic regimen of a large number of medical professionals and hospitals and provide recommendations on drugs, their dosages and criteria for selection. Along with clinical trials, they are another area of growing influence by the pharmaceutical industry. For example, in a relatively recent survey of 2002, it was found that about 60% of 192 authors of clinical practice guidelines reported they had financial connections with the companies whose drugs were under consideration. There is a strong case for making CPGs based not just on effectivity but cost effectivity. The various ramifications of this need to be spelt out. Work of bodies like the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration and Guidelines Advisory Committee (GAC) are also worth a close look.
Even the actions of Foundations that work for disease amelioration have come under scrutiny. The process of setting up ‘Best Practices’ Guidelines for interactions between the pharmaceutical industry and clinicians has already begun and can have important consequences for patient care. Similarly, Good Publication Practice (GPP) for pharmaceutical companies have also been set up aimed at improving the behaviour of drug companies while reporting drug trials
The rapidly increasing trend toward influence and control by industry has become a concern for many. It is of such importance that the Association of American Medical Colleges has issued two relatively new documents - one, in 2001, on how to deal with individual conflicts of interest; and the other, in 2002, on how to deal with institutional conflicts of interest in the conduct of clinical research. Academic Medical Centers (AMCs), as also medical education and research institutions at other places, have to adopt means that minimize their conflicts of interest.
Both medical associations and research journal editors are getting concerned with individual and institutional conflicts of interest in the conduct of clinical research and documents are now available which address these issues. The 2001 ICMJE revision calls for full disclosure of the sponsor's role in research, as well as assurance that the investigators are independent of the sponsor, are fully accountable for the design and conduct of the trial, have independent access to all trial data and control all editorial and publication decisions. However the findings of a 2002 study suggest that academic institutions routinely participate in clinical research that does not adhere to ICMJE standards of accountability, access to data and control of publication.
There is an inevitable slant to produce not necessarily useful but marketable products which ensure the profitability of industry and research grants outflow to academia. Industry supports new, not traditional, therapies, irrespective of what is effective. Whatever traditional therapy is supported is most probably because the company concerned has a product with a big stake there, which has remained a ‘gold standard’ or which that player thinks has still some ‘juice’ left.
Industry sponsorship is mainly for potential medications, not for trying to determine whether there may be non-pharmacological interventions that may be equally good, if not better. In the paradigm shift towards biological psychiatry, the role of industry sponsorship is not overt but probably more pervasive than many have realised, or the right thinking may consider good, for the health of the branch in the long run.
An issue of major concern is protection of the interests of research subjects. Patients agree to become research subjects not only for personal medical benefit but, as an extension, to benefit the rest of the patient population and also advance medical research.
We all accept that industry profits have to be made, and investment in research and development by the pharma industry is massive. However, we must also accept there is a fundamental difference between marketing strategies for other entities and those for drugs.
The ultimate barometer is patient welfare and no drug that compromises it can stand the test of time. So, how does it make even commercial sense in the long term to market substandard products? The greatest mistake long-term players in industry may make is try to adopt the shady techniques of the upstart new entrant. Secrecy of marketing/sales tactics, of the process of manufacture, of other strategies and plans of business expansion, of strategies to tackle competition are fine business tactics. But it is critical that secrecy as a tactic not extend to reporting of research findings, especially those contrary to one's product.
Pharma has no option but to make a quality product, do comprehensive adverse reaction profiles, and market it only if it passes both tests.
Why does pharma adopt questionable tactics? The reasons are essentially two:
What with all the constraints, a drug comes to the pharmacy after huge investments. There are crippling overheads and infrastructure costs to be recovered. And there are massive profit margins to be maintained. If these were to be dependent only on genuine drug discoveries, that would be taking too great a risk.Industry players have to strike the right balance between profit making and credibility. In profit making, the marketing champions play their role. In credibility ratings, researchers and paid spokes-persons play their role. All is hunky dory till marketing is based on credibility. When there is nothing available to make for credibility, something is projected as one and marketing carried out, in the calculated hope that profits can accrue, since profit making must continue endlessly. That is what makes pharma adopt even questionable means to make profits.
Essentially, there are four types of drugs. First, drugs that work and have minimal side-effects; second, drugs which work but have serious side-effects; third, drugs that do not work and have minimal side-effects; and fourth, drugs which work minimally but have serious side-effects. It is the second and fourth types that create major hassles for industry. Often, industry may try to project the fourth type as the second to escape censure.
The major cat and mouse game being played by conscientious researchers is in exposing the third and fourth for what they are and not allowing industry to palm them off as the first and second type respectively. The other major game is in preventing the second type from being projected as the first. The third type are essentially harmless, so they attract censure all right and some merriment at the antics to market them. But they escape anything more than a light rap on the knuckles, except when they are projected as the first type.
What is necessary for industry captains and long-term players is to realise:
Their major propelling force can only be producing the first type. 2. They accept the second type only till they can lay their hands on the first. 3. The third type can be occasionally played around with to shore up profits, but never by projecting them as the first type. 4. The fourth type are the laggards, real threat to credibility and therefore do not deserve any market hype or promotion.
In finding out why most pharma indulges in questionable tactics, we are lead to some interesting solutions to prevent such tactics with the least amount of hassles for all concerned, even as both profits and credibility are kept intact.
doi:10.4103/0973-1229.32176
PMCID: PMC3192391  PMID: 22058616
Academia; Pharmaceutical Industry; Clinical Practice Guidelines; Best Practice Guidelines; Academic Medical Centers; Medical Associations; Research Journals; Clinical Research; Public Welfare; Pharma Image; Corporate Welfare; Biological Psychiatry; Law Suits Against Industry
9.  Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system 
Background
Malawi has a chronic shortage of human resources for health. This has a significant impact on maternal health, with mortality rates amongst the highest in the world. Mid-level cadres of health workers provide the bulk of emergency obstetric and neonatal care. In this context these cadres are defined as those who undertake roles and tasks that are more usually the province of internationally recognised cadres, such as doctors and nurses. While there have been several studies addressing retention factors for doctors and registered nurses, data and studies addressing the perceptions of these mid-level cadres on the factors that influence their performance and retention within health care systems are scarce.
Methods
This exploratory qualitative study took place in four rural mission hospitals in Malawi. The study population was mid-level providers of emergency obstetric and neonatal care. Focus group discussions took place with nursing and medical cadres. Semi-structured interviews with key human resources, training and administrative personnel were used to provide context and background. Data were analysed using a framework analysis.
Results
Participants confirmed the difficulties of their working conditions and the clear commitment they have to serving the rural Malawian population. Although insufficient financial remuneration had a negative impact on retention and performance, the main factors identified were limited opportunities for career development and further education (particularly for clinical officers) and inadequate or non-existent human resources management systems. The lack of performance-related rewards and recognition were perceived to be particularly demotivating.
Conclusion
Mid-level cadres are being used to stem Africa's brain drain. It is in the interests of both the government and mission organizations to protect their investment in these workers. For optimal performance and quality of care they need to be supported and properly motivated. A structured system of continuing professional development and functioning human resources management would show commitment to these cadres and support them as professionals. Action needs to be taken to prevent staff members from leaving the health sector for less stressful, more financially rewarding alternatives.
doi:10.1186/1478-4491-7-14
PMCID: PMC2657772  PMID: 19228409
10.  Major Infection Events Over 5 Years: How Is Media Coverage Influencing Online Information Needs of Health Care Professionals and the Public? 
Background
The last decade witnessed turbulent events in public health. Emerging infections, increase of antimicrobial resistance, deliberately released threats and ongoing battles with common illnesses were amplified by the spread of disease through increased international travel. The Internet has dramatically changed the availability of information about outbreaks; however, little research has been done in comparing the online behavior of public and professionals around the same events and the effect of media coverage of outbreaks on information needs.
Objective
To investigate professional and public online information needs around major infection outbreaks and correlate these with media coverage. Questions include (1) How do health care professionals’ online needs for public health and infection control information differ from those of the public?, (2) Does dramatic media coverage of outbreaks contribute to the information needs among the public?, and (3) How do incidents of diseases and major policy events relate to the information needs of professionals?
Methods
We used three longitudinal time-based datasets from mid-2006 until end of 2010: (1) a unique record of professional online behavior on UK infection portals: National electronic Library of Infection and National Resource of Infection Control (NeLI/NRIC), (2) equivalent public online information needs (Google Trends), and (3) relevant media coverage (LexisNexis). Analysis of NeLI/NRIC logs identified the highest interest around six major infectious diseases: Clostridium difficile (C difficile)/Methicillin-resistant Staphylococcus aureus (MRSA), tuberculosis, meningitis, norovirus, and influenza. After pre-processing, the datasets were analyzed and triangulated with each other.
Results
Public information needs were more static, following the actual disease occurrence less than those of professionals, whose needs increase with public health events (eg, MRSA/C difficile) and the release of major national policies or important documents. Media coverage of events resulted in major public interest (eg, the 2007/2008 UK outbreak of C difficile/MRSA). An exception was norovirus, showing a seasonal pattern for both public and professionals, which matched the periodic disease occurrence. Meningitis was a clear example of a disease with heightened media coverage tending to focus on individual and celebrity cases. Influenza was a major concern during the 2009 H1N1 outbreak creating massive public interest in line with the spring and autumn peaks in cases; although in autumn 2009, there was no corresponding increase in media coverage. Online resources play an increasing role in fulfilling professionals’ and public information needs.
Conclusions
Significant factors related to a surge of professional interest around a disease were typically key publications and major policy changes. Public interests seem more static and correlate with media influence but to a lesser extent than expected. The only exception was norovirus, exhibiting online public and professional interest correlating with seasonal occurrences of the disease. Public health agencies with responsibility for risk communication of public health events, in particular during outbreaks and emergencies, need to collaborate with media in order to ensure the coverage is high quality and evidence-based, while professionals’ information needs remain mainly fulfilled by online open access to key resources.
doi:10.2196/jmir.2146
PMCID: PMC3713905  PMID: 23856364
information seeking behavior; weblogs analysis; online information needs; data mining; infectious outbreaks
11.  Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study 
PLoS Medicine  2007;4(11):e323.
Background
While ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on “cultural competence,” remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.
Methods and Findings
We conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.
Conclusions
This study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.
From a qualitative study, Joe Kai and colleagues have identified opportunities to empower health professionals to respond more effectively to challenges in their work with patients from diverse ethnic communities.
Editors' Summary
Background.
Communities are increasingly diverse in terms of ethnicity (belonging to a group of people defined by social characteristics such as cultural tradition or national origin) and race (belonging to a group identified by inherited physical characteristics). Although health professionals and governments are striving to ensure that everybody has the same access to health care, there is increasing evidence of ethnic inequalities in health-care outcomes. Some of these inequalities reflect intrinsic differences between groups of people—Ashkenazi Jews, for example, often carry an altered gene that increases their chance of developing aggressive breast cancer. Often, however, these differences reflect inequalities in the health care received by different ethnic groups. To improve this situation, “cultural competence” has been promoted over recent years. Cultural competence is the development of skills by individuals and organizations that allow them to work effectively with people from different cultures. Health professionals are now taught about ethnic differences in health beliefs and practices, religion, and communication styles to help them provide the best service to all their patients.
Why Was This Study Done?
Numerous guidelines aim to improve cultural competency but little is known about how health professionals experience and perceive their work with patients from diverse ethnic groups. Is their behavior influenced by ethnicity in ways that might contribute to health care disparities? For example, do doctors sometimes avoid medical examinations for fear of causing offence because of cultural differences? If more were known about how health professionals handle ethnic diversity (a term used here to include both ethnicity and race) it might be possible to reduce ethnic inequalities in health care. In this qualitative study, the researchers have explored how health professionals involved in cancer care are affected by working with ethnically diverse patients. A qualitative study is one that collects nonquantitative data such as how doctors “feel” about treating people of different ethnic backgrounds; a quantitative study might compare clinical outcomes in different ethnic groups.
What Did the Researchers Do and Find?
The researchers enrolled 106 doctors, nurses, and other health-related professionals from different health-service settings in the Midlands, an ethnically diverse region of the UK. They organized 18 focus groups in which the health professionals described their experiences of caring for people from ethnic minority backgrounds. The participants were encouraged to recall actual cases and to identify what they saw as problems and strengths in their interactions with these patients. The researchers found that the health professionals wrestled with many challenges when providing health care for patients from diverse ethnic backgrounds. These challenges included problems with language and with general communication (for example, deciding when it was acceptable to touch a patient to show empathy). Health professionals also worried they did not know enough about cultural differences. As a result, they said they often felt uncertain of their ability to avoid causing affront or appearing racist. This uncertainty, the researchers report, disempowered the health professionals, sometimes making them hesitate or fail to do what was best for their patient.
What Do These Findings Mean?
These findings reveal that health professionals often experience considerable uncertainty when caring for ethnically diverse patients, even after training in cultural competency. They also show that this uncertainty can lead to hesitancy and inertia, which might contribute to ethnic health care inequalities. Because the study participants were probably already interested in ethnic diversity and health care, interviews with other health professionals (and investigations of patient experiences) are needed to confirm these findings. Nevertheless, the researchers suggest several interventions that might reduce health care inequalities caused by ethnic diversity. For example, health professionals should be encouraged to recognize their uncertainty and should have access to more information and training about ethnic differences. In addition, there should be a shift in emphasis away from relying on knowledge-based cultural information towards taking an “ethnographic” approach. In other words, health professionals should be helped to feel able to ask their patients about what matters most to them as individuals about their illness and treatment.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040323.
Information on cultural competence and health care is available from the US National Center for Cultural Competence (in English and Spanish) and DiversityRx
PROCEED (Professionals Responding to Cancer in Ethnic Diversity) is a multimedia training tool for educators within the health and allied professions developed from the results of this study; a press release on PROCEED is available from the University of Nottingham
Transcultural Health Care Practice: An educational resource for nurses and health care practitioners is available on the web site of the UK Royal College of Nursing
doi:10.1371/journal.pmed.0040323
PMCID: PMC2071935  PMID: 18001148
12.  Medical student interest in academic medical careers: a multi-institutional study 
Perspectives on Medical Education  2013;2(5-6):298-316.
Little is known about how medical students view academic medicine. This multi-institutional study explored student perceptions of this career path. During 2009–2010, third- and fourth-year students at three United States medical schools completed a 30-item online survey. In total, 239 students completed the questionnaire (37 % response rate). Significant predictors of students’ desires for academic medical careers included interest in teaching (γ = 0.74), research (γ = 0.53), interprofessional practice (γ = 0.34), administration (γ = 0.27), and community service opportunities (γ = 0.16). A positive correlation existed between accumulated debt and interest in academic medicine (γ = 0.20). Student descriptions of the least and most appealing aspects of academic medicine were classified into five categories: professional, research, personal, teaching and mentoring, and patients/patient care. Students are more likely to be interested in a career in academic medicine if they have participated in research or were influenced by a mentor. Factors that may also influence a medical student’s decision to pursue a career in academic medicine include age and debt accumulated prior to medical school. Professional aspects of academic medicine (cutting edge environment, resources) and the opportunity to teach were the most appealing aspects.
doi:10.1007/s40037-013-0051-6
PMCID: PMC3824757  PMID: 23670688
Medical students; Career; Academic medicine
13.  How hyper are we? A look at hypermedia management in academic health sciences libraries. 
Advances in instruction-delivery technology have a direct impact on academic media centers. New technology challenges librarians philosophically, financially, and ethically to provide access to information and instructional systems. Each institution has a unique set of circumstances governing decisions to provide access to hypermedia. If patron needs are met satisfactorily through labs outside the library, it may not be necessary for the library to incorporate hypermedia into its collection. Other library media centers may serve as a main point of access, or a substantial alternative computing resource may exist in departments or professional schools. Regardless of which route is taken, hypermedia is a viable instructional delivery system and can coexist with traditional services. Future studies on various aspects of hypermedia and multimedia management should be encouraged. Academic health sciences librarians would benefit from the study of hypermedia and multimedia collection-development policies, equipment, and personnel management. As computer networking of multimedia and image databases becomes available, it will be interesting to see the role academic health sciences libraries assume in integrating these data-bases with traditional information-delivery systems. Changing technology and instructional methods will affect budgets as well as library relationships with academic departments and computing centers.
PMCID: PMC225732  PMID: 8428192
14.  The College of Medicine in the Republic of Malawi: towards sustainable staff development 
Background
Malawi has a critical human resources problem particularly in the health sector. There is a severe shortage of doctors; there are only few medical specialists. The College of Medicine (COM) is the only medical school and was founded in 1991. For senior staff it heavily depends on expatriates. In 2004 the COM started its own postgraduate training programme (Master of Medicine) in the clinical specialties.
Methods
We explore to what extent a brain drain took place among the COM graduates by investigating their professional development and geographical distribution. Using current experience with the postgraduate programme, we estimate at what point all senior academic positions in the clinical departments could be filled by Malawians. We demonstrate the need for expatriate staff for its most senior academic positions in the interim period and how this can be phased out. Lastly we reflect on measures that may influence the retention of Malawian doctors.
Results
Since the start of the COM 254 students have graduated with an average of 17 students per year. Most (60%) are working in Malawi. Of those working abroad, 60% are in various postgraduate training programmes.
In 2015, adequate numbers of Malawi senior academics should be available to fill most senior positions in the clinical departments, taking into account a 65% increase in staff to cope with increasing numbers of students.
Conclusion
There seems to be no significant brain drain among graduates of the COM. The postgraduate programme is in place to train graduates to become senior academic staff. In the interim, the COM depends heavily upon expatriate input for its most senior academic positions. This will be necessary at least until 2015 when sufficient numbers of well trained and experienced Malawian specialists may be expected to be available. Improved pay structure and career development perspectives will be essential to consolidate the trend that most doctors will remain in the country.
doi:10.1186/1478-4491-5-10
PMCID: PMC1863431  PMID: 17433100
15.  19A. Practical Strategies for Integrating Ayurvedic Therapies Into the Integrative Medicine Clinical Encounter 
Focus Area: Experiential Workshop
The 3 Ayurvedic clinicians presenting this experiential session have delivered Ayurvedic medicine in diverse settings, including: a conventional managed care network using a group clinic format; with research participants at an academic medicine center; and in private practice. The 3 presenting Ayurvedic clinicians have approximately 50 years' combined experience practicing Ayurvedic medicine and have developed strategies for overcoming logistical and cultural challenges in working with patients. Ayurveda can be accessed for both acute and chronic conditions and includes multitarget therapies tailored to the unique constitution/imbalance profile of each patient, while accounting for any biomedical diagnoses. The focus of Ayurveda goes beyond symptom alleviation to the identification of the root cause of the imbalance and eventual resolution of the disorder. Ayurveda has a primary focus on modification of the diet and daily routine of the individual in an effort to create sustainable lifestyle change to promote overall health and prevent comorbid conditions. Ayurvedic clinicians also use herbal supplements, medicated oils, and hands-on manual therapies, as well as detoxification and rejuvenation therapies, to enhance healing holistically and synergistically and to create a state of durable well-being.
The presenters of this workshop will focus on 3 key areas of Ayurvedic clinical practice: (1) Ayurvedic diet, daily routine, and yoga therapy (JR); (2) herbal therapies and home detoxification regimens (CE); and (3) manual therapies and Ayurvedic acupressure points (PV). Participants in the workshop will have the opportunity to (1) sample some simple medicinal teas and experience Ayurvedic dietary theory according to food qualities; (2) experience the effects of simple Ayurvedic breathing techniques and therapeutic yoga poses; and (3) participate in a basic demonstration of Ayurvedic manual therapies and acupressure.
doi:10.7453/gahmj.2013.097CP.S19A
PMCID: PMC3875039
16.  A survey of the 16 Canadian child and youth protection programs: A threadbare patchwork quilt 
Paediatrics & Child Health  2007;12(3):205-209.
BACKGROUND
Child abuse and neglect (CAN) represents an international public health and societal problem, the extent and nature of which are inadequately understood. Child and youth protection programs (CYPPs), based in 16 Canadian paediatric academic health science centres, identify, manage, treat and prevent cases of CAN.
OBJECTIVES
To ascertain the structure, resources and functioning of Canadian CYPPs.
METHODS
Telephone interviews were conducted with the directors of the 16 CYPPs.
RESULTS
Full-time equivalent staffing ranged from 0.25 to 18.7 people. All programs were staffed with physicians. The majority of programs had social workers (14 of 16) and administrative staff (12 of 16), while fewer programs had a dedicated nurse (nine of 16) or psychologists (six of 16). All CYPPs provided medical examinations and psychosocial assessments, consultation and coordination of CAN cases within the hospital and with community professionals, expert medico-legal opinions and representation in court, and hospital in-service and community outreach education and advocacy. Nine centres participated in regular multi-agency reviews of cases. Fourteen centres had specialized teams for acute sexual assault. Academic activities include lectures to medical students (16 of 16), undergraduate clinical electives (11 of 16), mandatory clinical rotations for paediatric residents (10 of 16) and/or electives (15 of 16), a fellowship (one of 16) and research on CAN-related issues (11 of 16). CAN documentation was inconsistent and limited, underestimating the number of cases assessed within the CYPPs.
CONCLUSION
CYPPs appear to need further resources to care for maltreated children and their families. A national, standardized database to document CAN cases would aid in the allocation of resources to help develop policies and programs that effectively address the needs of CAN victims and their families, and to prevent CAN.
PMCID: PMC2528694  PMID: 19030360
Abuse; Child; Documentation; Neglect; Programs
17.  A Binational Model of Collaboration for Enhancing Cross-border ID Surveillance 
Objective
The purpose of this demonstration is to describe the cross-border collaborative processes used for the development of a transparent methodology to identify and prioritize zoonotic infectious disease agents in the California-Baja California border region.
Introduction
International borders present unique challenges for the surveillance of infectious disease. Border communities represent locations with vast differences in cultures and languages, governing institutions, healthcare access, and priorities for the collection and surveillance of disease data. Pathogens and the health and security risks they create do not respect geographical and political boundaries. However, the organizations responsible for the surveillance and control of these agents must function within the borders of their respective governments. One Border One Health (OBOH) is a binational, multidisciplinary initiative aimed at engaging partners in the US and Mexico to identify and implement methods for successful communication and collaboration to enhance health capacity and disease surveillance within the border region. The advancements of international initiatives such as OBOH will help to develop the types of multi-country networks necessary for the effective monitoring of disease patterns and risks.
Methods
One Border One Health Surveillance Committee participants represent multi-disciplinary professionals working together for the advancement of One Health principles in the California/Baja California border region. This showcase documents the identification and prioritization of zoonotic infectious disease agents along the US-Mexico border, by use of a transparent methodology which engaged public and private partners from both countries. Preliminary research and input from collaborators in government, academic, and private sectors in the US and Mexico allowed for review and discussion of current methodologies available for prioritizing infectious agents. The DISCONTOOLS Work Package 2 Prioritization Scoring Model was selected as the basis for scoring and weighting various zoonotic diseases of concern within border region. Subject matter experts were then asked to review and score an initial list of diseases, in order to produce a final ranked list of pathogens. The intent is that these prioritized pathogens will be used by government agencies to make informed decisions, integrating priorities from both nations with regards to infectious disease surveillance. This collaboration provides insight into the binational cooperation needed for the selection of diseases to be considered in a regional, integrated disease surveillance system. To the authors’ knowledge this is the first transparent scientific-based approach to pathogen prioritization in the US-Mexico border region.
Conclusions
OBOH is the first binational regional network of its kind along the US-Mexico border recognizing the interconnectivity between human, animal, and environmental health. Given the limited resources in the current economic climate, the use of regional integrated surveillance systems provide an opportunity to protect and improve border health and security by moving away from species-specific surveillance programs. The process showcased here for the transparent review and prioritization of pathogens along the California-Baja California border can be used as a model along the entire US-Mexico Border. The ultimate aim is to protect border communities through the creation of a binational, early warning surveillance system which would allow for actionable and timely interventions to limit emergence, mitigate spread, provide gap analysis, and enhance prevention and control for several emergent and re-emergent diseases. Ultimately, this will decrease negative health and environmental impacts while improving agricultural and economic outcomes in both nations. However, obstacles such as continued sustainability, identification of new multi-disciplinary collaborators, cooperation between government agencies, and identifying funding for advancement of integrated regional surveillance systems remain challenges.
PMCID: PMC3692861
One Health; disease surveillance; cross-border collaborative
18.  Variables Impacting an Academic Pharmacy Career Choice 
Objectives
To identify the variables associated with an academic pharmacy career choice among the following groups: final professional-year doctor of pharmacy (PharmD) students, pharmacy residents, pharmacy faculty members within the first 5 years of academic employment, and clinical pharmacy practitioners.
Methods
A cross-sectional design Web-based survey instrument was developed using the online tool SurveyMonkey. The survey link was distributed via e-mail and postcards, and data were collected anonymously. Quantitative analyses were used to describe the 2,494 survey respondents and compare their responses to 25 variables associated with an academic pharmacy career choice. Logistic regression models were used to predict the motivators/deterrents associated with an academic pharmacy career choice for each participant group.
Results
Across all participant groups, the potential need to generate one's salary was the primary deterrent and autonomy, flexibility, and the ability to shape the future of the profession were the primary motivators. Final-year pharmacy students who considered a career in academic pharmacy were significantly deterred by grant writing. The overall sample of participants who considered an academic pharmacy career was more likely to be motivated by the academic environment and opportunities to teach, conduct professional writing and reviews, and participate in course design and/or assessment.
Conclusions
This study demonstrates specific areas to consider for improved recruitment and retention of pharmacy faculty. For example, providing experiences related to pharmacy academia, such as allowing student participation in teaching and research, may stimulate those individuals' interest in pursuing an academic pharmacy career.
PMCID: PMC2508718  PMID: 18698388
academia; faculty; career; motivating factors
19.  “A Good Personal Scientific Relationship”: Philip Morris Scientists and the Chulabhorn Research Institute, Bangkok 
PLoS Medicine  2008;5(12):e238.
Background
This paper examines the efforts of consultants affiliated with Philip Morris (PM), the world's leading transnational tobacco corporation, to influence scientific research and training in Thailand via the Chulabhorn Research Institute (CRI). A leading Southeast Asian institute for environmental health science, the CRI is headed by Professor Dr. Her Royal Highness Princess Chulabhorn, the daughter of the King of Thailand, and it has assumed international significance via its designation as a World Health Organization (WHO) Collaborating Centre in December 2005.
Methods and Findings
This paper analyses previously confidential tobacco industry documents that were made publicly available following litigation in the United States. PM documents reveal that ostensibly independent overseas scientists, now identified as industry consultants, were able to gain access to the Thai scientific community. Most significantly, PM scientist Roger Walk has established close connections with the CRI. Documents indicate that Walk was able to use such links to influence the study and teaching of environmental toxicology in the institute and to develop relations with key officials and local scientists so as to advance the interests of PM within Thailand and across Asia. While sensitivities surrounding royal patronage of the CRI make public criticism extremely difficult, indications of ongoing involvement by tobacco industry consultants suggest the need for detailed scrutiny of such relationships.
Conclusions
The establishment of close links with the CRI advances industry strategies to influence scientific research and debate around tobacco and health, particularly regarding secondhand smoke, to link with academic institutions, and to build relationships with national elites. Such strategies assume particular significance in the national and regional contexts presented here amid the globalisation of the tobacco pandemic. From an international perspective, particular concern is raised by the CRI's recently awarded status as a WHO Collaborating Centre. Since the network of WHO Collaborating Centres rests on the principle of “using national institutions for international purposes,” the documents presented below suggest that more rigorous safeguards are required to ensure that such use advances public health goals rather than the objectives of transnational corporations.
Jeff Collin and Ross MacKenzie analyze tobacco industry documents and find that Philip Morris consultants were able to gain access to a Thai research institute that is a WHO Collaborating Centre.
Editors' Summary
Background.
Tobacco use kills 5.4 million people a year (one person every six seconds) and accounts for one in ten adult deaths worldwide. Globally, the use of tobacco is on the rise, especially in developing countries, which have become a major target for tobacco industry marketing. The tobacco industry has worked hard to try and influence public perceptions about the risks of smoking and the risk of inhaling secondhand smoke (passive smoking). The industry has used a variety of tactics to downplay the health hazards of smoking or inhaling secondhand smoke—two examples are publishing articles casting doubts about the health hazards of tobacco and funding research that is biased toward giving pro-industry results. Another tactic is for tobacco industry consultants to try and gain entry to universities and other academic centers to see if they can influence research and teaching activities.
Why Was This Study Done?
The researchers were concerned that consultants from the tobacco company Philip Morris had gained access to an academic research center in Thailand called the Chulabhorn Research Institute (CRI). The CRI is an internationally renowned teaching institution for a variety of scientific disciplines, including environmental toxicology (the study of how chemicals in the environment, such as tobacco smoke, can affect human health), biomedicine, and biotechnology. The institute has secured funding from the Thai government, the Association of Southeast Nations and the United Nations Development Programme. In 2005 the institute's environmental toxicology unit was designated a World Health Organization (WHO) Collaborating Centre. WHO Collaborating Centres are “institutions such as research institutes, parts of universities or academies, that are designated by the Director-General of the WHO to carry out activities in support of the WHO's programs” (http://www.who.int/collaboratingcentres/en/). The researchers were concerned that Philip Morris consultants had been able to develop relationships with the CRI to help advance the company's interests.
What Did the Researchers Do and Find?
The researchers analyzed previously confidential tobacco industry documents that were made publicly available online following litigation in the United States. They searched two online collections of industry documents—the Legacy Tobacco Documents Library and Tobacco Documents Online—as well as the online collections operated by US-based tobacco companies. They found that consultants to Philip Morris were able to gain access to the scientific community in Thailand. A Philip Morris scientist named Roger Walk was able to establish close connections to the CRI, and he used these connections to influence research and teaching activities at the CRI on environmental toxicology. Walk was also able to build relationships with government officials and scientists in Thailand to help advance the interests of Philip Morris in the country and across Asia.
What Do these Findings Mean?
This study provides evidence that the tobacco industry has established close links with a research institute in Thailand that collaborates with the WHO, and has been able to influence the institute's teaching curriculum and research. Such links are of great concern to the public health community, which is working hard to reduce deaths and disease due to tobacco. These links raise the possibility that the tobacco industry is managing to influence medical research and teaching at academic institutions. The WHO has stated that a firewall is in place between itself and the tobacco industry—but the study authors argue, based on their findings, that “this firewall is not impenetrable.” The study findings, they conclude, highlight a challenge posed to international tobacco control efforts, especially with respect to Article 5.3 of an international treaty called the WHO Framework Convention on Tobacco Control; Article 5.3 addresses the need to protect public health policies from the vested interests of the tobacco industry. The authors say that better safeguards must be put in place to prevent tobacco companies from thwarting public health goals.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050238.
The Legacy Tobacco Documents Library contains over 9.7 million documents created by tobacco companies
Tobacco Documents Online contains over 4 million tobacco industry documents
Over 900 WHO Collaborating Centres are at work in 99 Member States on many health disciplines
The WHO held an inquiry in 2000 into possible tobacco industry influence over the organization (and over other UN agencies), and has published its recommendations in response to this inquiry
The WHO Framework Convention on Tobacco Control is an international treaty on controlling tobacco
doi:10.1371/journal.pmed.0050238
PMCID: PMC2605886  PMID: 19108600
20.  Primary Care Research Team Assessment (PCRTA): development and evaluation. 
BACKGROUND: Since the early 1990s the United Kingdom (UK) Department of Health has explicitly promoted a research and development (R&D) strategy for the National Health Service (NHS). General practitioners (GPs) and other members of the primary care team are in a unique position to undertake research activity that will complement and inform the research undertaken by basic scientists and hospital-based colleagues and lead directly to a better evidence base for decision making by primary care professionals. Opportunities to engage in R&D in primary care are growing and the scope for those wishing to become involved is finally widening. Infrastructure funding for research-active practices and the establishment of a range of support networks have helped to improve the research capacity and blur some of the boundaries between academic departments and clinical practice. This is leading to a supportive environment for primary care research. There is thus a need to develop and validate nationally accepted quality standards and accreditation of performance to ensure that funders, collaborators and primary care professionals can deliver high quality primary care research. Several strategies have been described in national policy documents in order to achieve an improvement in teaching and clinical care, as well as enhancing research capacity in primary care. The development of both research practices and primary care research networks has been recognised as having an important contribution to make in enabling health professionals to devote more protected time to undertake research methods training and to undertake research in a service setting. The recognition and development of primary care research has also brought with it an emphasis on quality and standards, including an approach to the new research governance framework. PRIMARY CARE RESEARCH TEAM ASSESSMENT: In 1998, the NHS Executive South and West, and later the London Research and Development Directorate, provided funding for a pilot project based at the Royal College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. EVALUATION: A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent researcher (FM). This was supplemented with feedback from the assessment team members. The qualitative aspect of the evaluation, which included face-to-face and telephone interviews with assessors, lead researchers and other practice staff within the pilot research practices, as well as members of the project management group, demonstrated a positive view of the pilot scheme. Several key areas were identified in relation to particular strengths of research practices and areas for development including: Strengths Level II practices were found to have a strong primary care team ethos in research. Level II practices tended to have a greater degree of strategic thinking in relation to research. Development areas Level I practices were found to lack a clear and explicit research strategy. Practices at both levels had scope to develop their communication processes for dissemination of research and also for patient involvement. Practices at both levels needed mechanisms for supporting professional development in research methodology. The evaluation demonstrated that practices felt that they had gained from their participation and assessors felt that the scheme had worked well. Some specific issues were raised by different respondents within the qualitative evaluation relating to consistency of interpretation of standards and also the possible overlap of the assessment scheme with other RCGP quality initiatives. NATIONAL IMPLEMENTATION OF THE PRIMARY CARE RESEARCH TEAM ASSESSMENT: The pilot project has been very successful and recommendations have been made to progress to a UK scheme. Management and review of the scheme will remain largely the same, with a few changes focusing on the assessment process and support for practices entering the scheme. Specific changes include: development of the support and mentoring role of the primary care research networks increased peer and external support and mentoring for research practices undergoing assessment development of assessor training in line with other schemes within the RCGP Assessment Network work to ensure consistency across RCGP accreditation schemes in relation to key criteria, thereby facilitating comparable assessment processes refinement of the definition of the two groups, with Level I practices referred to as Collaborators and Level II practices as Investigator-Led. The project has continued to generate much enthusiasm and support and continues to reflect current policy. Indeed, recent developments include the proposed new funding arrangements for primary care R&D, which refer to the RCGP assessment scheme and recognise it as a key component in the future R&D agenda. The assessment scheme will help primary care trusts (PCTs) and individual practices to prepare and demonstrate their approach to research governance in a systematic way. It will also provide a more explicit avenue for primary care trusts to explore local service and development priorities identified within health improvement programmes and the research priorities set nationally for the NHS.
PMCID: PMC2560501  PMID: 12049028
21.  The Need for Veterinarians in Biomedical Research 
The number of veterinarians in the United States is inadequate to meet societal needs in biomedical research and public health. Areas of greatest need include translational medical research, veterinary pathology, laboratory-animal medicine, emerging infectious diseases, public health, academic medicine, and production-animal medicine. Veterinarians have unique skill sets that enable them to serve as leaders or members of interdisciplinary research teams involved in basic science and biomedical research with applications to animal or human health. There are too few graduate veterinarians to serve broad national needs in private practice; academia; local, state, and federal government agencies; and private industry. There are no easy solutions to the problem of increasing the number of veterinarians in biomedical research. Progress will require creativity, modification of priorities, broad-based communication, support from faculty and professional organizations, effective mentoring, education in research and alternative careers as part of the veterinary professional curriculum, and recognition of the value of research experience among professional schools’ admissions committees. New resources should be identified to improve communication and education, professional and graduate student programs in biomedical research, and support to junior faculty. These actions are necessary for the profession to sustain its viability as an integral part of biomedical research.
doi:10.3138/jvme.36.1.70
PMCID: PMC2852242  PMID: 19435992
biomedical research; veterinarian; laboratory animal; pathology; public health
22.  Developing the educational needs of Telehealthcare support staff at SCQF/QCF level 6 
Background
The use, monitoring and care of individuals through the use of technology have played a key role in the delivery of health and social care services for decades (Wooton et al. 2006). Contemporary changes in how health and social care is provided in Scotland have focussed on using Telehealthcare as a medium to improve access, efficiency and equity of services across the country for a range of service users and the management of a range of conditions (JIT 2011). The Scottish Government Joint Improvement Team (JIT) and the Scottish Centre for Telehealth (SCT) published an Education and Training Strategy for Telehealthcare in Scotland in March 2010. The Strategy acknowledged that the provision of education and training to support unqualified staff working in telehealthcare service delivery was limited to locally developed, non-accredited training delivered in-house by telehealthcare service providers. It identified that although accredited frameworks do exist in Higher Education at SCQF/QCF 9, 10 and 11, the context, content and academic level was not appropriate for support staff. To meet the education and training needs of unqualified staff working in telehealthcare, the Strategy Action Plan included a workstream to develop a Competency Framework for Telehealthcare Support Staff. A subsequent workstream within the Action Plan focussed on the design and development of an academic award based on the competencies identified within the new Framework. This involved setting up a Qualification Design Team (QDT) made up of telehealthcare and education service providers and specialists. The Qualification Design Team worked with the Scottish Qualifications Authority (SQA) to design and accredit a Professional Development Award (PDA) in Telehealthcare at SCQF/QCF level 6. This paper outlines the design and development of the Professional Development Award.
Project objectives
To design a Professional Development Award in Telehealthcare to meet the educational needs of unqualified support staff working in telehealthcare service delivery.
To achieve National accreditation of a Professional Development Award in Telehealthcare at SCQF/QCF level 6.
Proposed next stage objectives
To evaluate the telehealthcare support staff experience of undertaking the Professional Development Award.
To evaluate the modes of delivery and geographical contexts in which the Professional Development Award is delivered.
To describe the impact the educational experience has on the candidates personal and professional development.
Proposed design/method
A mixed method research design will be used to evaluate the candidate’s experiences of undertaking the Professional Development Award in Telehealthcare. Structured interviews and surveys will be used to gather information to analyse the candidate’s experience. A random sample of candidates will be drawn from all SQA approved sites to deliver the Professional Development Award.
Findings and points of interest
It is anticipated that a positive outcome will be achieved from the project evaluation as this award was driven and led by Telehealthcare staff working in the field. Further awards and specific modules are likely to emerge from this work to underpin advancements in career pathways and to address innovations and developments in telehealthcare.
PMCID: PMC3571146
education; telehealthcare staff development; competency framework
23.  Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile 
PLoS Medicine  2013;10(9):e1001513.
Siankam Tankwanchi and colleagues used the AMA Physician Masterfile and the WHO Global Health Workforce Statistics on physicians in sub-Saharan Africa to determine trends in physician emigration to the United States.
Please see later in the article for the Editors' Summary
Background
The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.
Methods and Findings
We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.
Conclusion
Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Population growth and aging and increasingly complex health care interventions, as well as existing policies and market forces, mean that many countries are facing a shortage of health care professionals. High-income countries are addressing this problem in part by encouraging the immigration of foreign health care professionals from low- and middle-income countries. In the US, for example, international medical graduates (IMGs) can secure visas and permanent residency by passing examinations provided by the Educational Commission of Foreign Medical Graduates and by agreeing to provide care in areas that are underserved by US physicians. Inevitably, the emigration of physicians from low- and middle-income countries undermines health service delivery in the emigrating physicians' country of origin because physician supply is already inadequate in those countries. Physician emigration from sub-Saharan Africa, which has only 2% of the global physician workforce but a quarter of the global burden of disease, is particularly worrying. Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in sub-Saharan Africa. In Liberia, for example, in 1973, there were 7.76 physicians per 100,000 people but by 2008 there were only 1.37 physicians per 100,000 people; in the US, there are 250 physicians per 100,000 people.
Why Was This Study Done?
Before policy proposals can be formulated to address global inequities in physician distribution, a clear picture of the patterns of physician emigration from resource-limited countries is needed. In this study, the researchers use data from the 2011 American Medical Association Physician Masterfile (AMA-PM) to investigate the “brain drain” of physicians from sub-Saharan Africa to the US. The AMA-PM collects annual demographic, academic, and professional data on all residents (physicians undergoing training in a medical specialty) and licensed physicians who practice in the US.
What Did the Researchers Do and Find?
The researchers used data from the World Health Organization (WHO) Global Health Workforce Statistics and graduation and residency data from the 2011 AMA-PM to estimate physician emigration rates from sub-Saharan African countries, year of US entry, years of service provided before emigration to the US, and length of time in the US. There were 10,819 physicians who were born or trained in 28 sub-Saharan African countries in the 2011 AMA-PM. By using a published analysis of the 2002 AMA-PM, the researchers estimated that US immigration among sub-Saharan African-trained physicians had increased over the past decade for all the countries examined except South Africa, where physician emigration had decreased by 8%. Overall, the number of sub-Saharan African IMGs in the US had increased by 38% since 2002. More than half of this increase was accounted for by Nigerian IMGs. Liberia was the country most affected by migration of its physicians to the US—77% of its estimated 226 physicians were in the 2011 AMA-PM. On average, sub-Saharan African IMGs had been in the US for 18 years and had practiced for 6.5 years before emigration. Finally, nearly half of the sub-Saharan African IMGs had migrated to US between 1984 and 1995, years during which structural adjustment programs, which resulted in deep cuts to public health care services, were implemented in developing countries by international financial institutions as conditions for refinancing.
What Do These Findings Mean?
Although the sub-Saharan African IMGs in the 2011 AMA-PM only represent about 1% of all the physicians and less than 5% of the IMGs in the AMA-PM, these findings reveal a major loss of physicians from sub-Saharan Africa. They also suggest that emigration of physicians from sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the AMA-PM only lists physicians who qualify for a US residency position, more physicians may have moved from sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees (“brain waste”). The researchers suggest that physician emigration from sub-Saharan Africa to the US reflects the complexities in the labor markets for health care professionals in both Africa and the US and can be seen as low- and middle-income nations subsidizing the education of physicians in high-income countries. Policy proposals to address global inequities in physician distribution will therefore need both to encourage the recruitment, training, and retention of health care professionals in resource-limited countries and to persuade high-income countries to train more home-grown physicians to meet the needs of their own populations.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001513.
The Foundation for Advancement of International Medical Education and Research is a non-profit foundation committed to improving world health through education that was established in 2000 by the Educational Commission for Foreign Medical Graduates
The Global Health Workforce Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators, and professional associations dedicated to identifying, implementing and advocating for solutions to the chronic global shortage of health care professionals (available in several languages)
Information on the American Medical Association Physician Masterfile and the providers of physician data lists is available via the American Medical Associations website
The World Health Organization (WHO) annual World Health Statistics reports present the most recent health statistics for the WHO Member States
The Medical Education Partnership Initiative is a US-sponsored initiative that supports medical education and research in sub-Saharan African institutions, aiming to increase the quantity, quality, and retention of graduates with specific skills addressing the health needs of their national populations
CapacityPlus is the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals
Seed Global Health cultivates the next generation of health professionals by allying medical and nursing volunteers with their peers in resource-limited settings
"America is Stealing the Worlds Doctors", a 2012 New York Times article by Matt McAllester, describes the personal experience of a young doctor who emigrated from Zambia to the US
Path to United States Practice Is Long Slog to Foreign Doctors, a 2013 New York Times article by Catherine Rampell, describes the hurdles that immigrant physicians face in practicing in the US
doi:10.1371/journal.pmed.1001513
PMCID: PMC3775724  PMID: 24068894
24.  A Population-Based Evaluation of a Publicly Funded, School-Based HPV Vaccine Program in British Columbia, Canada: Parental Factors Associated with HPV Vaccine Receipt 
PLoS Medicine  2010;7(5):e1000270.
Analysis of a telephone survey by Gina Ogilvie and colleagues identifies the parental factors associated with HPV vaccine uptake in a school-based program in Canada.
Background
Information on factors that influence parental decisions for actual human papillomavirus (HPV) vaccine receipt in publicly funded, school-based HPV vaccine programs for girls is limited. We report on the level of uptake of the first dose of the HPV vaccine, and determine parental factors associated with receipt of the HPV vaccine, in a publicly funded school-based HPV vaccine program in British Columbia, Canada.
Methods and Findings
All parents of girls enrolled in grade 6 during the academic year of September 2008–June 2009 in the province of British Columbia were eligible to participate. Eligible households identified through the provincial public health information system were randomly selected and those who consented completed a validated survey exploring factors associated with HPV vaccine uptake. Bivariate and multivariate analyses were conducted to calculate adjusted odds ratios to identify the factors that were associated with parents' decision to vaccinate their daughter(s) against HPV. 2,025 parents agreed to complete the survey, and 65.1% (95% confidence interval [CI] 63.1–67.1) of parents in the survey reported that their daughters received the first dose of the HPV vaccine. In the same school-based vaccine program, 88.4% (95% CI 87.1–89.7) consented to the hepatitis B vaccine, and 86.5% (95% CI 85.1–87.9) consented to the meningococcal C vaccine. The main reasons for having a daughter receive the HPV vaccine were the effectiveness of the vaccine (47.9%), advice from a physician (8.7%), and concerns about daughter's health (8.4%). The main reasons for not having a daughter receive the HPV vaccine were concerns about HPV vaccine safety (29.2%), preference to wait until the daughter is older (15.6%), and not enough information to make an informed decision (12.6%). In multivariate analysis, overall attitudes to vaccines, the impact of the HPV vaccine on sexual practices, and childhood vaccine history were predictive of parents having a daughter receive the HPV vaccine in a publicly funded school-based HPV vaccine program. By contrast, having a family with two parents, having three or more children, and having more education was associated with a decreased likelihood of having a daughter receive the HPV vaccine.
Conclusions
This study is, to our knowledge, one of the first population-based assessments of factors associated with HPV vaccine uptake in a publicly funded school-based program worldwide. Policy makers need to consider that even with the removal of financial and health care barriers, parents, who are key decision makers in the uptake of this vaccine, are still hesitant to have their daughters receive the HPV vaccine, and strategies to ensure optimal HPV vaccine uptake need to be employed.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
About 10% of cancers in women occur in the cervix, the structure that connects the womb to the vagina. Every year, globally, more than a quarter of a million women die because of cervical cancer, which only occurs after the cervix has been infected with a human papillomavirus (HPV) through sexual intercourse. There are many types of HPV, a virus that infects the skin and the mucosa (the moist membranes that line various parts of the body, including the cervix). Although most people become infected with HPV at some time in their life, most never know they are infected. However, some HPV types cause harmless warts on the skin or around the genital area and several—in particular, HPV 16 and HPV 18, so-called high-risk HPVs—can cause cervical cancer. HPV infections are usually cleared by the immune system, but about 10% of women infected with a high-risk HPV develop a long-term infection that puts them at risk of developing cervical cancer.
Why Was This Study Done?
Screening programs have greatly reduced cervical cancer deaths in developed countries in recent decades by detecting the cancer early when it can be treated; but it would be better to prevent cervical cancer ever developing. Because HPV is necessary for the development of cervical cancer, vaccination of girls against HPV infection before the onset of sexual activity might be one way to do this. Scientists recently developed a vaccine that prevents infection with HPV 16 and HPV 18 (and with two HPVs that cause genital warts) and that should, therefore, reduce the incidence of cervical cancer. Publicly funded HPV vaccination programs are now planned or underway in several countries; but before girls can receive the HPV vaccine, parental consent is usually needed, so it is important to know what influences parental decisions about HPV vaccination. In this study, the researchers undertake a telephone survey to determine the uptake of the HPV vaccine by 11-year-old girls (grade 6) in British Columbia, Canada, and to determine the parental factors associated with vaccine uptake; British Columbia started a voluntary school-based HPV vaccine program in September 2008.
What Did the Researchers Do and Find?
In early 2009, the researchers contacted randomly selected parents of girls enrolled in grade 6 during the 2008–2009 academic year and asked them to complete a telephone survey that explored factors associated with HPV vaccine uptake. 65.1% of the 2,025 parents who completed the survey had consented to their daughter receiving the first dose of HPV vaccine. By contrast, more than 85% of the parents had consented to hepatitis B and meningitis C vaccination of their daughters. Nearly half of the parents surveyed said their main reason for consenting to HPV vaccination was the effectiveness of the vaccine. Conversely, nearly a third of the parents said concern about the vaccine's safety was their main reason for not consenting to vaccination and one in eight said they had been given insufficient information to make an informed decision. In a statistical analysis of the survey data, the researchers found that a positive parental attitude towards vaccination, a parental belief that HPV vaccination had limited impact on sexual practices, and completed childhood vaccination increased the likelihood of a daughter receiving the HPV vaccine. Having a family with two parents or three or more children and having well-educated parents decreased the likelihood of a daughter receiving the vaccine.
What Do These Findings Mean?
These findings provide one of the first population-based assessments of the factors that affect HPV vaccine uptake in a setting where there are no financial or health care barriers to vaccination. By identifying the factors associated with parental reluctance to agree to HPV vaccination for their daughters, these findings should help public-health officials design strategies to ensure optimal HPV vaccine uptake, although further studies are needed to discover why, for example, parents with more education are less likely to agree to vaccination than parents with less education. Importantly, the findings of this study, which are likely to be generalizable to other high-income countries, indicate that there is a continued need to ensure that the public receives credible, clear information about both the benefits and long-term safety of HPV vaccination.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000270.
The US National Cancer Institute provides information about cervical cancer for patients and for health professionals, including information on HPV vaccines (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about cervical cancer and about HPV
The UK National Health Service Choices website has pages on cervical cancer and on HPV vaccination
More information about cervical cancer and HPV vaccination is available from the Macmillan cancer charity
ImmunizeBC provides general information about vaccination and information about HPV vaccination in British Columbia
MedlinePlus provides links to additional resources about cervical cancer (in English and Spanish)
doi:10.1371/journal.pmed.1000270
PMCID: PMC2864299  PMID: 20454567
25.  A case report of adult lead toxicity following use of Ayurvedic herbal medication 
Introduction
Ayurvedic medications consist of herbs that may be intentionally combined with metals, such as lead, mercury, iron, and zinc. Ayurvedic practitioners and their patients believe that the toxic properties of the metals are reduced or eliminated during preparation and processing.
Case report
A 69 year old Caucasian male retired professional with a prior history of stroke presented for evaluation of new onset depression, fatigue, generalized weakness, constipation, anorexia, and weight loss. History revealed that his symptoms were temporally related to initiation of an Ayurvedic herbal medication. The patient had been previously admitted to another hospital for these symptoms and was found to have a severe anemia for which no etiology was found. Laboratory tests revealed an elevated blood lead level and a diagnosis of symptomatic lead toxicity was made. The patient was treated with intramuscular, intravenous, and oral chelation therapy to promote lead excretion. Because of complaints of continued poor mental function, neuropsychological tests were administered before and after one of the chelation treatments and showed improvement in measures of attention and other cognitive domains. In addition, the patient was able to discontinue use of antidepressant medication after chelation.
Discussion
A high index of suspicion of metal toxicity is necessary among persons with characteristic symptoms and signs in the absence of occupational exposure. Despite limited evidence for chelation in adults and in those with modest blood lead levels, this patient appeared to benefit from repeated chelation therapy. Both allopathic and alternative medicine practitioners and public health specialists need to be aware of the potential for contamination of and side effects from alternative pharmacologic and herbal therapies.
doi:10.1186/1745-6673-8-26
PMCID: PMC3850721  PMID: 24083830
Lead poisoning; Clinical toxicity; Ayurvedic medicine; Metals; Chelation

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