Educational interventions to ensure provision of doctors in rural areas - a systematic review

Introduction: Recruiting doctors in rural areas is challenging. Various educational interventions have been introduced in many countries. This study aimed to explore undergraduate medical education interventions introduced to recruit doctors to rural areas, and the results of these interventions. Methods: We undertook a systematic search using search words 'rural', 'remote', 'workforce', 'physicians', 'recruitment' and 'retention'. We included articles meeting the following criteria: educational interventions clearly described; study population consisted of medical graduates; and outcome measures included place of work (rural/non-rural) after graduation. Results: The analysis included 58 articles and encompassed educational interventions in ten countries. There were five main types of interventions, often used in combination: preferential admission from rural areas; curriculum relevant to rural medicine; decentralised education; practice-oriented learning in rural areas; and compulsory service periods in rural areas after graduation. The majority of the studies (42) compared place of work (rural/non-rural) of doctors graduated with and without these interventions. In 26 studies, odds ratio for rural place of work was significant at a level of 5%, with odds ratios between 1.5 and 17.2. Significant differences in the proportion with a rural/non-rural place of work were shown in 14 studies, differences ranging from 11 to 55 percentage points. Discussion: Changing focus of undergraduate medical education towards development of knowledge, skills and teaching arenas that equip doctors with competencies to work in rural areas has an impact on the recruitment of doctors in rural areas. Concerning preferential admission from rural areas, we will discuss if national and local contexts makes a difference

Tension between local, regional and national levels in Norway’s handling of COVID-19

Aims: This study aimed to explore the tension between local, regional, and national authorities evoked by some rural municipalities’ decisions to impose local infection-control measures during the first weeks of the COVID-19 pandemic in Norway. Methods: Eight municipal Chief Medical Officers of Health (CMOs) participated in semi-structured interviews, and six crisis management teams participated in focus-group interviews. Data were analysed with systematic text condensation. Boin and Bynander’s interpretation of crisis management and coordination and Nesheim et al.’s framework for nonhierarchical coordination in the state sector inspired the analysis. Results: Uncertainty in the face of a pandemic with unknown damage potential, lack of infection-control equipment, patient transport challenges, vulnerable staff situation and planning of local COVID-19 beds were some of the reasons for rural municipalities imposing local infection-control measures the first weeks of the pandemic. Local CMOs’ engagement, visibility and knowledge contributed to trust and safety. Differences in perspectives between local, regional and national actors created tension. Existing roles and structures were adjusted, and new informal networks arose. Conclusions: Strong municipal responsibility in Norway and the quite unique arrangement with local CMOs in every municipality with the legal right to decide temporary local infection-control measures seemed to facilitate a balance between top-down and bottom-up decision making. Tension between rural, regional and national actors that arose due to local infection-control measures, and the following dialogue and mutual adjustment of perspectives, led to a fruitful balance between national and local measures in Norway’s handling of the COVID-19 pandemic

Evaluering av forsøk med primærhelseteam og alternative finansieringsordninger. Statusrapport V

Source at https://osloeconomics.no/publikasjoner/.Primærhelseteam (PHT) er tverrfaglige team som inkluderer fastlege, sykepleier og helsesekretær. Sentrale målgrupper for PHT er brukere med kronisk sykdom, brukere med psykiske lidelser og rusavhengighet, brukere som omtales som «skrøpelige eldre» og brukere med utviklingshemming og funksjonsnedsettelser, samt «svake etterspørrere». For å finne ut om PHT, med mer systematisk oppfølging av målgruppen, gir et bedre tilbud til listeinnbyggerne enn den vanlige fastlegeordningen, ble forsøk med PHT startet 1. april 2018 på 13 legekontor, mens fire nye legekontor kom til fra 2020. Forsøket prøver ut to ulike finansieringsmodeller; 12 av legekontorene har valgt honorarmodellen og fem har valgt driftstilskuddsmodellen. Evalueringen bygger på analyser av data fra helseregistre og administrative registre, pasientjournaler, spørreundersøkelser, intervjuundersøkelser og dokumenter. I denne rapporten undersøker vi særlig: Pasienters erfaring med PHT Likheter og ulikheter mellom PHT-legekontor med ulike finansieringsmodeller Variasjon i teamarbeid og teameffektivitet ved et utvalg PHT-legekontor Samspill mellom PHT og øvrig helsetjeneste </uli

Livets slutt i sykehjem. Pasientens ønsker og legens rolle

In Norway, nearly fifty percent of all deaths occur in nursing homes. The last period of life in other high-income countries is also increasingly spent in nursing homes. The nursing home doctor is responsible for medical care in the last phase of life. Together with nursing personnel, the nursing home doctor is expected to preserve patients’ dignity as they approach death. To achieve this the doctor needs to know something about what patients and their relatives need and expect, medical education must furnish doctors with the skills and tools to meet these expectations, and organisation of nursing home services must facilitate a dignity conserving care. In this dissertation I have explored conditions for doctors’ delivery of dignity conserving care to nursing home patients in the last period of life. My analysis is funded on three studies about the following topics: 1) What does previous research tell about patients’ and relatives’ expectations and experiences on how nursing home doctors can contribute to high quality end-of-life-care in nursing homes? 2) What are the learning experiences with end-of-life care in nursing homes for newly qualified doctors, especially concerning dialogues about death? and 3) Nursing home doctors’ perspectives on barriers and strategies for providing end-of-life care in nursing home in Norway and in the Netherlands. The first study was a metasynthesis of 14 qualitative studies about nursing home patients’ and relatives’ expectations and experiences with end-of-life care, with special focus on their perception of nursing home doctors’ work. We used the seven steps procedure for metaethnography from Noblit and Hare in our analysis. In the second study we used material from three focus group interviews with 16 newly qualified doctors serving as house officers in nursing homes in Northern Norway, exploring their learning experiences with end-of-life care in nursing home with special focus on dialogues about death. Analysis was performed with systematic text condensation, supported by Lave and Wenger’s theory about situated learning and legitimate peripheral participation. The third study was a survey among 435 Norwegian and 244 Dutch nursing home doctors on barriers and strategies for end-of-life care. We used SPSS for analysis, and differences between countries were compared using chi-square-test and t-test. The metasynthesis revealed that patients and their relatives expect nursing home personnel to anticipate illness trajectories and recognize their needs for palliation and information. Worries about staff shortage and competence was common, and they expected the doctor to be available and participating. Patients’ ability to consent was often not recognized by family and health personnel. In the focus group study we found that newly qualified doctors discovered new aspects of their role as a doctor when attending dying patients as part of the interdisciplinary team in the nursing home. They experienced how challenging dialogues and medical decisions could become less difficult through personal knowledge of patients’ life story. The survey showed more similarities than differences between Norwegian and Dutch nursing home doctors in spite of educational and organizational differences. Most prominent barriers reported were inadequate staffing, lack of skills among personnel and heavy time commitment for nursing home doctors. Preferred strategies for enhancing endof- life care were routines for involving family, monitoring protocols for pain and symptoms, routines for advance care planning and better education of doctors and nursing personnel. This dissertation points to how doctors can avoid violation of patients’ dignity through dialogues about end-of-life focusing on the patients’ perspective more than on procedures. Having the courage to become involved with the patient as a person in combination with the ability to sound appraisal of medical, ethical and resource conditions, the doctor can adjust medical care to the individual patient. Time, competence and interest are key elements in improving end-of-life care in nursing homes. Medical education should emphasize reflection on death and dying in order to make doctors capable of enduring existential and medical dilemmas in the last phase of life. Nursing homes are interdisciplinary, practice based learning arenas offering expanded insight into doctors’ role in end-of-life care. In this dissertation I have explored nursing home doctors’ role, but my analysis is applicable to all doctors’ relation to death and dying and performance in end-of-life care

How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway

Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk. Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis. Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs’ proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs’ medical judgement. Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload. Key points Task shifting between different levels of health care is a relevant and legitimate strategy for planning and policy. GPs in Norway report adverse events related to task shifting from specialist colleagues without proper resource allocation. Patient safety may be put at risk by hazardous delay, overdiagnosis, endangered accountability and potential malpractice. Planning and implementation of task shifting must involve all system levels and relevant stakeholders to ensure patient safety.</li

How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway

Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk. Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis. Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs’ proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs’ medical judgement. Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload

Tiltak i grunnutdanningen for å sikre legertil distrikt – en systematisk oversikt

BAKGRUNN - Rekruttering av leger til distrikt er utfordrende. Ulike utdanningstiltak for å sikre leger til distrikt er etablert i mange land. Målet med denne studien var å samle kunnskap om hvilke tiltak i grunnutdanningen av leger som er etablert for å bidra til distriktsrekruttering, og hvilke resultater disse tiltakene har gitt. KUNNSKAPSGRUNNLAG - Vi gjorde et systematisk søk i databasene Cinahl, Eric, Medline og PsycInfo med søkeordene «rural», «remote», «workforce», «physicians», «recruitment» og «retention». Vi inkluderte artikler som oppfylte følgende kriterier: utdanningstiltak(ene) var tydelig beskrevet, studiepopulasjonen var uteksaminert fra grunnutdanning i medisin samt at utfallsmål omfattet arbeidssted (distrikt/ikke-distrikt) etter endt grunnutdanning. RESULTATER - Analysen inkluderte 58 artikler og omfattet utdanningstiltak i ti land. Tiltakene var av fem hovedtyper, ofte i kombinasjoner: prioritert opptak fra distrikt, studieplan med distriktrelevant læringsutbytte, regionalisert utdanning, praksisnær læring i distrikt samt bindingstid i distrikt etter endt utdanning. I flertallet av studiene (42/58) sammenliknet man arbeidssted (distrikt/ikke-distrikt) blant leger som hadde gjennomført utdanning med og uten tiltak. Bare to av disse rapporterte om ikke-signifikante forskjeller i arbeidssted. I 26 studier var oddsratio for arbeidssted i distrikt signifikant på 5 %-nivå, med oddsratioer mellom 1,5 og 17,2. I 14 studier var det signifikante forskjeller i andelen med arbeidssted i distrikt/ikke-distrikt, med differanser på 11–55 prosentpoeng

Nursing Home Physicians' Assessments of Barriers and Strategies for End-of-Life Care in Norway and The Netherlands

OBJECTIVES: Working conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians' perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands. DESIGN: A cross-sectional study using an electronic questionnaire was conducted in 2015. SETTING AND PARTICIPANTS: All NH physicians in Norway (approximately 1200-1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%). MEASUREMENTS: We explored NH physicians' perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ(2) test and t-test. RESULTS: Most respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients' family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff. CONCLUSIONS: Inadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems

Quantitative Measurements Versus Receiver Operating Characteristics and Visual Grading Regression in CT Images Reconstructed with Iterative Reconstruction. A Phantom Study

Rationale and Objectives: This study aimed to evaluate the correlation of quantitative measurements with visual grading regression (VGR) and receiver operating characteristics (ROC) analysis in computed tomography (CT) images reconstructed with iterative reconstruction. Materials and Methods: CT scans on a liver phantom were performed on CT scanners from GE, Philips, and Toshiba at three dose levels. Images were reconstructed with filtered back projection (FBP) and hybrid iterative techniques (ASiR, iDose, and AIDR 3D of different strengths). Images were visually assessed by five readers using a four- and five-grade ordinal scale for liver low contrast lesions and for 10 image quality criteria. The results were analyzed with ROC and VGR. Standard deviation, signal-to-noise ratios, and contrast-to-noise ratios were measured in the images. Results: All data were compared to FBP. The results of the quantitative measurements were improved for all algorithms. ROC analysis showed improved lesion detection with ASiR and AIDR and decreased lesion detection with iDose. VGR found improved noise properties for all algorithms, increased sharpness with iDose and AIDR, and decreased artifacts from the spine with AIDR, whereas iDose increased the artifacts from the spine. The contrast in the spine decreased with ASiR and iDose. Conclusions: Improved quantitative measurements in images reconstructed with iterative reconstruction compared to FBP are not equivalent to improved diagnostic image accuracy