Facilitating remote access to specialist medical expertise through the scaled up adoption of a smartphone application: A South African case.

BACKGROUND: In the context of a shortage of medical specialists, a medical referral app, designed for use on smartphones, was launched in 2014 for use by doctors in the public health service in South Africa. OBJECTIVES: As this is a novel intervention, with potential to have an impact on the use of scarce resources, and because not much was known about the use of the app, a descriptive study was undertaken to assess its adoption in Western Cape Government Health (WCGH) facilities. METHODS: Usage data of the app in WCGH facilities, in terms of referral and user numbers, were obtained from the date of its introduction in 2014. In addition, all the referrals to WCGH facilities for July 2019, stripped of any identifying data of patients or doctors, were analysed for origin, destination, outcome and response times. Descriptive statistics were used to analyse the data. RESULTS: Use of the app grew rapidly from 40 referrals per quarter to 16 437 per quarter after 5 years in use, with a cumulative total of 95 381 referrals. In July 2019, active users of the system included 913 sending doctors and 298 receiving doctors, representing 20 medical specialties. The senders and receivers were representative of every level in the healthcare system, from clinic to tertiary hospital. In July 2019, a total of 5 941 referrals were sent by means of the app to public facilities in Western Cape Province. Of the referrals, 80% were classified as acute and 20% as non-urgent. The referral outcomes included 51% accepted for transfer, 19% accepted for a specialist appointment, and 13% concluded with advice alone without the need for a specialist appointment or patient transfer - this category accounted for 28% of non-urgent referrals and 9% of acute referrals. In 50% of referrals, advice was given to the referring doctor, either as an additional or the only outcome. The median response times were 9 minutes for acute referrals and 19 minutes for non-urgent referrals. CONCLUSIONS: This study documents the scale-up of a mobile phone consultation and referral app from pilot phase to significant growth in use across a resource-constrained healthcare system. In a large proportion of cases, advice was given to the referring doctor by means of the app, frequently obviating the need for a specialist appointment or patient transfer. This finding demonstrates that a mobile app has the potential to reduce the need for face-to-face specialist visits, thereby improving the use of scarce medical resources.

The Emergency Medicine Physician Workforce: Projections for 2030.

STUDY OBJECTIVE: The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians. METHODS: To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios. RESULTS: The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030. CONCLUSION: The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

Physician distribution across China's cities: regional variations.

BACKGROUND: Distribution of physicians is a key component of access to health care. Although there is extensive research on urban-rural disparities in physician distribution, limited attention has been directed to the heterogeneity across urban areas. This research depicts variations in physician density across over 600 cities in the context of China's rapid urbanization. METHODS: Data came from National Census Surveys and China statistical yearbooks, 2000-2003, and 2010-2013. Cities were characterized in terms of not only administrative level but also geographic regions and urban agglomerations. We analyzed variations in physician supply by applying generalized estimating equations with an ordinal logistic linking function. RESULTS: Although overall physician density increased between 2003 and 2013, with population and socioeconomic attributes adjusted, physician density declined in urban China. On average, urban districts had a higher physician density than county-level cities, but there were regional variations. Cities in urban agglomerations and those outsides did not differ in physician density. CONCLUSION: Despite the reduced inequality between 2003 and 2013, the growth in physician density did not appear to be commensurate with the changes in population health demand. Assessment in physician distribution needs to take into account heterogeneity in population and socioeconomic characteristics.

Building a sustainable rural physician workforce.

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants. MAIN OUTCOME MEASURES: Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. RESULTS: Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8). CONCLUSION: Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas. DESIGN, SETTING AND PARTICIPANTS: In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19. MAIN OUTCOME MEASURES: Individual and collective descriptors of professional identity. RESULTS: We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation. CONCLUSION: Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters. MAIN OUTCOME MEASURES: Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location. RESULTS: Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors. CONCLUSION: Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action. DESIGN: We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles. RESULTS: Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles. CONCLUSION: These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.

The Association of American Medical Colleges' Local Area Physician Workforce Modeling Project.

Physician workforce planning must address multiple concerns such as having sufficient numbers and adequate geographic distribution of physicians and pressures for physicians to adapt to new models of care and payment. Though there are national workforce planning tools, planning tools for local areas have been scarce. This article describes a dynamic simulation model developed as a pilot project to support physician workforce planning in 2 metropolitan areas, Cleveland and Albuquerque (February 2014-June 2016). This model serves as a prototype for planning tools that could be used by medical educators and local health systems to project the effect of different policies on physician supply and demand. System dynamics and group model building approaches were used to develop the model with the participation of local stakeholders to create the model's causal structure. The model included determinants of the demand for primary and specialty care for the local population and projected the effects of births and deaths, aging, level of chronic illness present, and migration on demand. Physician supply was disaggregated by primary versus specialty care, age, sex, and work setting and projected based on completions of local residency programs, physician migration in and out of the area, and retirements. Feedback relationships between supply and demand (e.g., adequacy of care affecting the distribution of chronic illnesses, demand for care influencing in- and out-migration of physicians) were also included and had important effects on the results produced by the model. Scenarios were simulated that projected increased demand for care (e.g., through expanded insurance coverage) and increased supply (e.g., through practice incentives to encourage in-migration) and a combination of these. An expanded advanced practice registered nurse and physician assistant capacity scenario was also simulated. In Albuquerque, the combination scenario yielded the greatest increases in local physician supply.

Addressing Kentucky's Physician Shortage While Securing a Network for a Research-Intensive, Referral Academic Medical Center: Where Public Policy Meets Effective Clinical Strategic Planning.

A critical shortage of physicians is looming in the United States. The situation in Kentucky is especially dire, especially in rural areas. Class size constraints have resulted in the University of Kentucky College of Medicine (UK COM) unable to admit over 100 qualified Kentuckians each year. This article describes how leadership at University of Kentucky committed to addressing the state physician shortage while simultaneously strengthening relationships with critical partners through the establishment of two 4-year UK COM regional medical campuses. Based on criteria (such as a commitment to educating physicians, ample patients, sufficient willing physician preceptors, etc.), partners selected were Med Center Health, the leading health care system in southwestern Kentucky, and St. Elizabeth Healthcare, the predominant health care system in northern Kentucky. These regional campuses allow UK COM to expand its class size to 201 and total enrollment to 804, increasing from historically 70 to currently 120 graduates per year expected to practice in Kentucky. Critical to the success of this expansion is the buy-in of leadership and the Admissions Committee to consider students with a wider range of Medical College Admission Test scores. The regional clinical partners have substantially increased their teaching opportunities, with a greater ability to attract physicians. Both partners have made substantial financial contributions in support of the regional campuses. These relationships have energized UK COM engagement with its area alumni and have resulted in fewer Kentuckians referred out of state for advanced specialty care. Partnerships are also occurring with UK COM to increase graduate medical education offerings at the regional sites, fulfilling the vision of "training Kentuckians in Kentucky to practice in Kentucky."

Modeling Emergency Department crowding: Restoring the balance between demand for and supply of emergency medicine.

Emergency Departments (EDs) worldwide are confronted with rising patient volumes causing significant strains on both Emergency Medicine and entire healthcare systems. Consequently, many EDs are in a situation where the number of patients in the ED is temporarily beyond the capacity for which the ED is designed and resourced to manage-a phenomenon called Emergency Department (ED) crowding. ED crowding can impair the quality of care delivered to patients and lead to longer patient waiting times for ED doctor's consult (time to provider) and admission to the hospital ward. In Singapore, total ED attendance at public hospitals has grown significantly, that is, roughly 5.57% per year between 2005 and 2016 and, therefore, emergency physicians have to cope with patient volumes above the safe workload. The purpose of this study is to create a virtual ED that closely maps the processes of a hospital-based ED in Singapore using system dynamics, that is, a computer simulation method, in order to visualize, simulate, and improve patient flows within the ED. Based on the simulation model (virtual ED), we analyze four policies: (i) co-location of primary care services within the ED, (ii) increase in the capacity of doctors, (iii) a more efficient patient transfer to inpatient hospital wards, and (iv) a combination of policies (i) to (iii). Among the tested policies, the co-location of primary care services has the largest impact on patients' average length of stay (ALOS) in the ED. This implies that decanting non-emergency lower acuity patients from the ED to an adjacent primary care clinic significantly relieves the burden on ED operations. Generally, in Singapore, there is a tendency to strengthen primary care and to educate patients to see their general practitioners first in case of non-life threatening, acute illness.

Developing challenges in the urbanisation of village doctors in economically developed regions: A survey of 844 village doctors in Changzhou, China.

OBJECTIVE: To reveal the challenges of village doctors' survival and training in economically developed areas in eastern China. DESIGN: A field survey was used to assess the challenges of village doctors. SETTING: The study was conducted in Changzhou, Jiangsu province, which is an economically developed region in eastern China. PARTICIPANTS: The participants included 844 village doctors, 15 township hospital staff members and 6 health bureau leaders. RESULTS: The main challenges in Changzhou include an insufficient amount of village doctors, difficulties in obtaining professional qualification for village doctors, low salaries and benefits, and difficulties in recruitment. CONCLUSION: With increasing urbanisation in China, the gap between actual and expected income and social security has been increasing. Changes to training have influenced the stability of village doctor teams. Declining attachment of young people to their hometown village has contributed to recruitment difficulties.

The Coronavirus Disease 2019 Pandemic's Effect on Critical Care Resources and Health-Care Providers: A Global Survey.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. RESEARCH QUESTION: How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? STUDY DESIGN AND METHODS: Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. RESULTS: We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). INTERPRETATION: Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.

Utilizing Google Trends to Assess Worldwide Interest in Irritable Bowel Syndrome and Commonly Associated Treatments.

BACKGROUND: Examining the prevalence of irritable bowel syndrome (IBS) across regions has been challenging given significant methodological heterogeneity. AIMS: We aimed to perform a uniform assessment of the global burden of IBS using data from Google Trends, a novel, online tool. METHODS: Google Trends measures popularity of a search term in a given week compared to popularity of all search terms in that week, calculated as relative search volume (RSV). We compiled data on the popularity of IBS and its treatments across 173 countries between 2014 and 2018. We compared Google Trends popularity for IBS with prior epidemiological prevalence data, while controlling for gross domestic product (GDP) per capita and physician density. RESULTS: Of the 173 countries with Google Trends data, 137 countries also had data for GDP per capita and physician density. Worldwide popularity of IBS as a search topic increased from 79 to 89 (13% increase by RSV) over the 5-year period between 2014 and 2018. Country-specific change in IBS RSV ranged from - 35% (Nigeria) to + 64% (Pakistan). There was poor correlation between the Google Trends data and prior epidemiological data (0.08, Pearson correlation, p = 0.64). Popularity of the low-FODMAP diet increased the most among 8 common therapies (RSV 41 to 89, 117% increase). CONCLUSIONS: Google Trends is a novel tool that can complement traditional epidemiological methods in gastrointestinal disease. Future research is needed to assess its utility and accuracy as a measure of disease burden across different gastrointestinal diseases.

Impact of a 50-Year Premedical Postbaccalaureate Program in Graduating Physicians for Practice in Primary Care and Underserved Areas.

PURPOSE: To evaluate the effectiveness of Wayne State University School of Medicine's (WSUSOM's) 50-year premedical postbaccalaureate program (PBP)-the first and oldest in the United States-in achieving its goals, as measured by medical school matriculation and graduation, primary care specialization, and current practice location. METHOD: A retrospective study of a complete comparative dataset of 9,856 WSUSOM MD graduates (1979-2017) was performed in July-August 2018. This included 539 graduates who were admitted to the PBP between 1969 and 2012. Data collected included PBP students' sociodemographics, postgraduate specialization, residence location at time of admission to the PBP, and current medicine practice location. Health professional shortage areas (HPSAs) and medically underserved areas/populations (MUA/Ps) were determined for residence at admission to the PBP and current medicine practice location. RESULTS: Of the 539 PBP students, 463/539 (85.9%) successfully completed the PBP and matriculated to WSUSOM. Of those, 401/463 (86.6%) obtained an MD, and of those, 233/401 (58.1%) were female and 277/401 (69.1%) were African American. Average investment per PBP student was approximately $52,000 and for an MD graduate was approximately $77,000. The majority of PBP MD graduates with current practice information resided in HPSAs or MUA/Ps at admission to PBP (204/283, 72.1%) and were currently practicing in HPSAs or MUA/Ps (232/283, 82.0%), and 139/283 (49.1%) became primary care physicians (PCPs). Comparison of WSUSOM PBP and non-PBP MD graduates showed PBP physicians become PCPs and practice in HPSAs or MUA/Ps at higher rates than non-PBP physicians (P < .001). CONCLUSIONS: The PBP was successful in graduating a large proportion of physicians from socioeconomically disadvantaged and diverse backgrounds, who practice as PCPs and who practice in HPSAs and MUA/Ps, thereby accomplishing the PBP's goals of helping to address the broad health care needs of all people in the United States.

Role of the Health System in Combating Covid-19: Cross-Section Analysis and Artificial Neural Network Simulation for 124 Country Cases.

In the fight against Covid-19, developed countries and developing countries diverge in success. This drew attention to the discussion of how different health systems and different levels of health spending are effective in combating Covid-19. In this study, the role of the health system in the fight against Covid-19 is discussed. In this context, the number of hospital beds, the number of doctors, life expectancy at 60, universal health service and the share of health expenditures in GDP were used as health indicators. In the study, firstly 2020 data was estimated by using the Artificial Neural Networks simulation method and this year was used in the analysis. The model, with the data of 124 countries, was estimated using the cross-sectional OLS regression method. The estimation results show that the number of hospital beds, number of doctors and life expectancy at the age of 60 have statistically significant and positive effects on the ratio of Covid-19 recovered/cases. Universal health service and share of health expenditures in GDP are not significant statistically on the cases and recovered. Hospital bed capacity is the most effective variable on the recovered/case ratio.

Education in the Mais Médicos program: the gap between proposals and implementation / A dimensão da formação no Programa Mais Médicos: hiato entre propostas e implementação

Abstract: Introduction: The scarcity and inequalities in the geographical distribution of physicians challenge the consolidation of the right to health and create migratory flows that increase health inequities. Due to their complex and multidimensional characteristics, they demand multisectoral political approaches, considering several factors related to the availability and area of ​​practice of medical doctors, as well as the social vulnerability of local populations. Objective: This study aimed at analysing results of the "Mais Médicos" (More Doctors) Program Educational Axis in Brazil. Methodology: A documental research was conducted, highlighting the location and the public or private nature of new undergraduate medical school vacancies between the years 2013 until 2017, which were then compared to the goals and strategies outlined in the official Program documents. Results: The Educational Axis reached important milestones despite the resistance of some institutional actors. The Program extended its undergraduate vacancies by 7696 places, 22.48% of that in public institutions and 77.52% in private ones. Vacancy distribution prioritized cities in rural areas of Brazil, at the same instance bringing forward significant regulatory changes for undergraduate medical courses. However, political disputes with representatives of medical societies and stakeholders interested in favouring the private educational and healthcare sectors surface in the official discourses and documents. These factors weakened the program normative body, creating a hiatus between its core objectives and respective implementation. Evidence related to the concentration of vacancies in the Southeast regions allow the maintenance of a known unequal workforce distribution, despite a proportionally bigger increase in the Midwest, North and Northeast regions. Conclusion: The predominance of vacancies in private institutions and the weakening of the new undergraduate courses monitoring instruments can compromise changes in the graduate students' profiles, which are necessary for the fixation of physicians in strategic geographic areas to promote Primary Healthcare.

Resumo: Introdução: A carência e as desigualdades na distribuição geográfica de médicos desafiam a consolidação do direito à saúde e criam fluxos migratórios que acirram iniquidades em saúde. Devido ao seu caráter complexo e multidimensional, demandam abordagens políticas multissetoriais, considerando vários fatores relativos à disponibilidade e à área de atuação de médicos, bem como à vulnerabilidade social das populações consideradas. Objetivo: Este estudo teve como objetivo analisar os resultados do eixo Formação do Programa Mais Médicos no Brasil. Métodos: Realizou-se uma pesquisa documental, especificamente relativa à localização e à natureza pública ou privada das novas vagas de graduação em Medicina, no período de 2013 a 2017, em que se confrontaram os resultados obtidos com as metas e estratégias pactuadas nos documentos oficiais do programa. Resultados: O eixo Formação alcançou resultados importantes, apesar da resistência de alguns atores institucionais. O programa expandiu em 7.696 vagas de graduação, sendo 22,48% em instituições públicas e 77,52% em instituições privadas. A distribuição das novas vagas priorizou cidades do interior do Brasil e aprovou mudanças regulatórias importantes para os cursos de Medicina. No entanto, as disputas políticas com atores sociais representativos da classe médica e aqueles interessados no favorecimento do setor privado na educação e assistência à saúde ficaram expressas nos discursos e documentos oficiais. Tais aspectos fragilizaram o corpo normativo do programa e criaram um hiato entre os seus objetivos e a implementação. Evidências referentes à concentração de vagas no Sudeste do país favorecem a manutenção das desigualdades, a despeito de um crescimento proporcionalmente maior nas Regiões Centro-Oeste, Nordeste e Norte. Conclusão: A prevalência de vagas em instituições privadas e a fragilização de instrumentos de monitoramento dos novos cursos podem comprometer a mudança no perfil dos egressos, necessária para a fixação de médicos em áreas estratégicas e na atenção primária à saúde.

Early medical school graduation during the COVID-19 pandemic: preliminary assessment / Graduação antecipada do curso de medicina durante a pandemia de COVID-19: avaliação preliminar

Abstract: Introduction: The current outbreak of the new coronavirus or SARS-CoV-2, which causes COVID-19, was first reported to the World Health Organization on December 31, 2019, being declared a pandemic on March 11, 2020. As for the clinical spectrum of SARS-CoV-2 infection, it is a broad one, ranging from asymptomatic, mild upper respiratory tract disease to severe viral pneumonia with respiratory failure and death. With a chance of severe clinical presentation close to 25%, SARS-CoV-2 infection can lead to health service overload and increase the demand for material and human resources. Aiming to increase the availability of health professionals directly involved in care during the pandemic, the Ministry of Education authorized the early graduation for students pursuing careers in health, including medicine. Objective: The aim of this article is to obtain preliminary results of the impact of early graduation for medical students during the COVID-19 pandemic. Method: Observational and cross-sectional study, carried out by applying a questionnaire with 13 questions, five of which used a Likert scale of assessment, six in multiple choice format and two descriptive, via Google Forms, applied to medical students from the universities of Curitiba-PR that graduated earlier in mid-year 2020, due to the COVID-19 pandemic. Results: 113 recently graduated students answered the questionnaire.101 participants reported that they are working as physicians and, among them, 63.36% stated that they are working directly in the treatment of COVID-19 cases. Regarding the importance of an early graduation, most participants fully agree or agree, while only three participants totally disagree. More than half of the interviewees do not feel harmed by the early graduation. However, 43.3% believe they have failed to acquire important information for their training. Finally, regarding their performance in the pandemic, 79.6% consider important their role in the fight against COVID-19 pandemic. Conclusion: The study shows that, at first, the efforts to give the Class of 2020 an early graduation were successful, since these new physicians are contributing to alleviate workforce shortages and provide better care for patients during the pandemic.

Resumo: Introdução: O atual surto do novo coronavírus ou Sars-CoV-2, causador da Covid-19, foi relatado pela primeira vez à Organização Mundial da Saúde, pela China, em 31 de dezembro de 2019, sendo declarada pandemia em 11 de março de 2020. Quanto ao espectro clínico da infecção pelo Sars-CoV-2, ele é amplo, variando de quadro assintomático, doença leve do trato respiratório superior, a pneumonia viral grave com insuficiência respiratória e morte. Com uma chance de apresentação clínica grave próxima a 25%, a infecção pelo Sars-CoV-2 pode levar à sobrecarga dos serviços de saúde e aumentar a demanda tanto por recursos materiais como humanos. Para aumentar a disponibilidade de profissionais da área da saúde envolvidos diretamente no atendimento durante a pandemia, o Ministério da Educação autorizou a antecipação da formatura para estudantes de várias áreas da saúde, incluindo Medicina. Objetivo: O objetivo do presente artigo é realizar uma avaliação preliminar do impacto da antecipação da graduação para os formandos de Medicina durante a pandemia de Covid-19. Método: Trata-se de estudo observacional e transversal realizado por meio da aplicação de questionário com 13 perguntas: em cinco, utilizou-se escala Likert de avaliação; em seis, adotou-se o formato de múltipla escolha; e duas foram descritivas. O questionário foi enviado, via Formulário Google, a alunos de Medicina das universidades de Curitiba, no Paraná, formados no primeiro semestre de 2020, que anteciparam a outorga de grau em razão da pandemia de Covid-19. Resultados: Responderam ao questionário 113 formandos, dos quais 101 relataram que já atuam como médicos. Destes, 63,36% afirmaram que estão trabalhando diretamente no atendimento de casos de Covid-19. Sobre a importância da antecipação da outorga de grau, a maioria dos participantes concorda totalmente ou concorda, e apenas três participantes discordam totalmente. Mais da metade dos entrevistados não se sentem prejudicados com a antecipação da outorga de grau. Contudo, 43,3% acreditam que deixaram de adquirir informações importantes em sua formação. Por fim, quanto ao fato de trabalharem na pandemia, 79,6% consideram importante a atuação de médicos recém-formados no combate à Covid-19. Conclusão: Este estudo mostra que, a princípio, os esforços para a antecipação de formatura foram bem-sucedidos, já que os novos médicos estão contribuindo para aliviar a pressão imposta pela falta de profissionais e promover um melhor cuidado aos pacientes durante a pandemia.

Financial impact of the change in the vulnerability profile of More Doctors Program.

OBJECTIVE: To estimate the flow of professionals and the financial impact of the Programa Mais Médicos para o Brasil (PMMB - More Doctors for Brazil Program) within the More Doctors Program (MDP) for the Brazilian Ministry of Health and the participating municipalities of the state of São Paulo, from January 2019 to March 2022. METHODS: A financial impact study was conducted in the state of São Paulo based on public secondary databases. The number of PMMB vacancies per municipality, of physicians and vulnerability profiles were described to measure the loss of replacement of professionals in the period. RESULTS: In the specified period, the number of PMMB physicians in participating cities will decrease from 2,533 to 320, and the number of participating municipalities from 373 to 86. The municipalities that will need to replace the physicians will have a financial impact of R$ 929,487,904.77 (with sensitivity analysis, ranging from R$ 650,641,533.34 to R$ 1,208,334,276.20). CONCLUSION: The change of vulnerability methodology adopted for the PMMB will represent serious consequences, that is, less population assistance and high financial impact for the municipalities of the state of São Paulo in a scenario of budget limitations.

Hospital and ICU patient volume per physician at peak of COVID pandemic: State-level estimates.

BACKGROUND: In anticipation of patient surge due to COVID-19, many states are working to increase the available healthcare workforce. To help inform state policies and initiatives aimed at physician deployment during COVID-19, we used predictions of peak patient volume for hospitals and intensive care units (ICU) and regional physician workforce estimates to measure patient to physician ratios at the peak of the pandemic for each state. METHODS: We estimated the number of potentially available physicians based on Medicare Part B billings for the care of hospitalized and critically ill patients in 2017, adjusted for attrition due to exposure to SARS-CoV-2 and relevant experience. We used estimates from the Institute of Health Metrics and Evaluation to determine the number of hospitalized and ICU patients expected at the peak of the pandemic in each state. We then determined the expected ratio of patients per physician for each state at the peak of the pandemic. RESULTS: The median number of hospitalized patients per physician was 13 (low estimate) to 18 (high estimate). At the high estimate of hospitalized patients, 35 states would have a patient to physician ratio of more than 15:1 (patient to physician ratios above 15:1 have been associated with poor outcomes). For ICU patients, the median number of patients each physician would treat across states would be 8-11 patients. Nine states would experience patient to physician ratios above 15:1 at the higher end of estimates. Patient-physician ratios decreased if the available physician pool was broadened to include physicians without recent experience treating hospitalized patients, and physicians in surgical specialties with experience treating acutely hospitalized patients. CONCLUSIONS/IMPLICATIONS: We estimate that most states will have sufficient physician capacity to manage hospitalized patients at the peak of the pandemic. However, at the high estimates of hospitalized patients, some Midwestern states will experience high patient to provider ratios that may adversely affect patient outcomes. LEVEL OF EVIDENCE: State.