Associations Between State Practice Regulations and Access to Midwifery Care.

INTRODUCTION: This study aimed to identify associations between state policies and access to midwifery care. Identifying policies that facilitate increased access to midwives will help policymakers determine the best methods for increasing access to midwives in their states. METHODS: This cross-sectional study was conducted at the county level as a secondary analysis of National Vital Statistics data from the Natality online database. The unit of analysis was counties with populations of at least 100,000, and the outcome was the proportion of births attended by midwives in 2019. The potential predictors of increased access to midwifery care were independent midwife licensure, independent midwife prescribing, midwife access to hospital medical staff membership, and midwife Medicaid parity. Medicaid provider resources and state statutes verified Medicaid reimbursement rates and eligibility for hospital medical staff privileges. Each state was categorized as an independent or restricted licensure state according to data from the American College of Nurse-Midwives. Data for the control variable, the presence of a midwifery education program, were gathered from the Accreditation Commission for Midwifery Education. The analysis was conducted as a Poisson regression. RESULTS: There was no association between independent licensing and increased access among all states. Stratifying the analysis by independent licensing law revealed that all but one policy was related to higher rates of midwife attendance at birth. Maximum Medicaid reimbursement correlated with greater access regardless of licensing status. The rate of midwife-attended births in independent licensing states grew as the number of potential predictors in a county increased. DISCUSSION: Regulatory policies beyond independent licensing are associated with women's access to midwifery services. In independent licensing states, adopting additional policies favorable to midwives may strengthen access to midwifery. Policymakers and regulators can use these findings to identify strategies for accelerating the expansion of midwifery access in their states.

Long-Term Health Benefits of Occupational Licensing: Evidence from Midwifery Laws.

During the late 19th and early 20th century, several states mandated midwifery licensing requirements to improve midwives' knowledge, education, and quality. Previous studies point to the health benefits of midwifery quality improvements for maternal and infant health outcomes. This paper exploits the staggered adoption of midwifery laws across states using event-study and difference-in-difference frameworks. We use the universe of death records in the US over the years 1979-2020 and find that exposure to a midwifery licensing law at birth is associated with a 2.5 percent reduction in cumulative mortality rates and an increase of 0.6 months in longevity during adulthood and old age. The effects are concentrated on deaths due to infectious diseases, neoplasm diseases, and suicide mortality. We also show that the impacts are confined among blacks and are slightly larger among males. Additional analyses using alternative data sources suggest small but significant increases in educational attainments, income, measures of socioeconomic status, employment, and measures of height as potential mechanism channels. We provide a discussion on the economic magnitude and policy implication of the results.

Adequacy of the examination-based licensing system and a training-based licensing system for midwifery license according to changes in childbirth medical infrastructure in Korea: a surveybased descriptive study

PURPOSE: The number of Korean midwifery licensing examination applicants has steadily decreased due to the low birth rate and lack of training institutions for midwives. This study aimed to evaluate the adequacy of the examination-based licensing system and the possibility of a training-based licensing system. METHODS: A survey questionnaire was developed and dispatched to 230 professionals from December 28, 2022 to January 13, 2023, through an online form using Google Surveys. Descriptive statistics were used to analyze the results. RESULTS: Responses from 217 persons (94.3%) were analyzed after excluding incomplete responses. Out of the 217 participants, 198 (91.2%) agreed with maintaining the current examination-based licensing system; 94 (43.3%) agreed with implementing a training-based licensing system to cover the examination costs due to the decreasing number of applicants; 132 (60.8%) agreed with establishing a midwifery education evaluation center for a training-based licensing system; 163 (75.1%) said that the quality of midwifery might be lowered if midwives were produced only by a training-based licensing system, and 197 (90.8%) said that the training of midwives as birth support personnel should be promoted in Korea. CONCLUSION: Favorable results were reported for the examination-based licensing system; however, if a training-based licensing system is implemented, it will be necessary to establish a midwifery education evaluation center to manage the quality of midwives. As the annual number of candidates for the Korean midwifery licensing examination has been approximately 10 in recent years, it is necessary to consider more actively granting midwifery licenses through a training-based licensing system.

Impact of considering United States Medical Licensing Examination Step 1 pass/fail on diversity in dermatology residency recruitment.

The University of Chicago dermatology residency program considered the United States Medical Licensing Examination (USMLE) Step 1 pass/fail during the 2020-2021 application cycle with the goal of recruiting diverse dermatology residency candidates. We conducted a retrospective multiyear cross-sectional study among applicants to the dermatology residency program during the 2018-2019 and 2020-2021 application cycles, the latter excluding use of USMLE Step 1 cutoff scores as a screening tool. Of the applicants, 69.8% (n = 419) and 94.5% (n = 605) had their residency applications reviewed by our program during the 2018-2019 and 2020-2021 application cycles, respectively. There was a statistically significant upward trend in the number of underrepresented in medicine (URiM) applicants offered an interview from 10.4% (n = 5) to 37.7% (n = 20) across the application cycles. Multiple linear regression demonstrated there was a statistically significant decrease in the mean USMLE Step 1 score among applicants reviewed across application cycle and URiM status independently, and as a factor of their interaction (P = .016 and P = .001). By de-emphasizing the USMLE Step 1 score and using the test as originally intended, a marker for licensure, our program significantly increased the number of URiM applicants who were offered an interview and implemented a holistic review process focused on individual attributes and cultural competence.

Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Outcomes of a holistic admissions process in an Accelerated Baccalaureate Nursing Program.

An accelerated bachelor of science in nursing program adopted holistic admissions practices to increase diversity in the student body. This quality improvement project aimed to compare three cohorts of students accepted before holistic admissions practices to three cohorts accepted after holistic admissions. The authors examined demographic data, on-time graduation rate, licensure exam passing rate, remediation status, and student perceptions expressed on exit surveys. After holistic admissions were implemented, student diversity increased and on-time graduation and licensure exam pass rates were maintained. The need for student remediation decreased after holistic admissions were implemented, and student perceptions of their classmates and the relevance of their schooling to their future professional career increased.

Training hour requirements to provide acupuncture in the United States.

INTRODUCTION: The National Academy of Medicine recommends, and Joint Commission requires, offering non-pharmacologic approaches to pain management, including acupuncture, to reduce opioid overuse in the United States. This study describes 2019 state training requirements to evaluate how they represent opportunities and barriers to increasing access to acupuncture. METHODS: We searched publicly available databases to identify Acupuncture Practice Acts and additional statutes and regulations pertaining to acupuncture training requirements on state licensure board websites. We then extracted state-specific acupuncture training requirements for individuals with and without a healthcare-related professional license. RESULTS: Thirty-three states allow physicians to provide acupuncture without requiring any additional training requirements, 11 states and the District of Columbia (DC) require 200-300 training hours, and three require physicians to obtain a separate acupuncture license. Three states have no regulatory agency ruling. Forty states require non-healthcare professionals to complete an accredited program of more than 1900 h and pass an examination. Twenty-three states have an Acupuncture Detoxification Specialist designation allowing individuals without a clinical professional license to provide auricular acupuncture for substance use disorder treatment after a 70-h training course. DISCUSSION: State-level training requirements are intended to increase safe and effective care, but variations represent a potential barrier to increasing the number of acupuncture providers in the United States. Allowing non-physician medical professionals to complete reduced training requirements for specific indications could be a model to increase access to acupuncture. The influence of training requirements on acupuncture access and opioid overuse needs examination.

A Public Health Ethics Analysis of the Criminalization of Direct Entry Midwifery.

Multiple types of midwives practice in the United States, but regulation of midwifery practice varies by state. In some states, direct entry midwifery practice is unregulated or criminalized. Because regulations are the most burdensome of the public health interventions, they require the most stringent ethical critique. This article uses the most recent Public Health Code of Ethics to analyze the ethics of regulations that criminalize direct entry midwifery practice. The Code establishes 8 criteria for ethical actions: (1) permissibility, (2) respect, (3) reciprocity, (4) effectiveness, (5) responsible use of scarce resources, (6) proportionality, (7) accountability and transparency, and (8) public participation. Laws that criminalize direct entry midwifery practice violate all of these criteria and therefore cannot be considered an ethical approach to the state's duty to safeguard public health. The remedy for this problem is for all states to license and regulate all types of midwives that meet international standards of education and training.

[Consulting Pharmacists Who Have Advisory Staff License Regarding the Use of Medicines and Health Foods].

The widespread use of health foods, including supplements, is now common among patients. This is because many health foods are being claimed to be beneficial. If patients use medicines and health foods concurrently, the interaction between the two might lead to adverse events. Additionally, it is reported that pharmacists do not generally care about health food use in their patients, because they also lack sufficient knowledge about health foods. On the contrary, there are some licenses to be a health food advisor in Japan, and the generic name of these licenses is "advisory staff". Pharmacists who have this license are specialists in both medicines and health foods, and thus, they might pay more attention to the concurrent use of medicines and health foods compared to those who do not have the advisory staff license. To address this issue, we conducted a study with an online questionnaire about health food consultation, and 87 pharmacists with advisory staff license participated. Only 36.8% of participants were found to always ask their patients about health food use. However, 92.0% of them had experience of consultation about the simultaneous use of medicines and health foods, and 17.2% of them recognized adverse events by knowing about the concurrent use. Patients who experienced adverse events have used either eicosapentaenoic acid/docosahexaenoic acid supplement with epadel or Ginkgo biloba extract with warfarin. Therefore, an active interview with pharmacists is important to avoid such adverse events in patients.

Medical care in unlicensed combat sports: A need for standardised regulatory frameworks.

OBJECTIVES: To explore the provision of medical care at 'unlicensed', full-contact amateur and lower-level professional combat sports competitions in England. DESIGN: Qualitative, mixed methods. METHODS: Observations totalling 200h of fieldwork shadowing medical professionals at 27 individual combat sports events, alongside formal, semi-structured interviews with 25 medical professionals, 7 referees and 9 promoters/event staff. RESULTS: Practices and standards vary widely. Event organisers and promoters often have very little understanding of how different types of medical practitioners operate. They rarely, if ever, check that the staff they are hiring are qualified, sometimes resulting in unqualified staff being used to provide medical cover at events. Venues are often poorly equipped to accommodate basic medical procedures. Patient confidentiality is very often compromised. Medical professionals often have limited autonomy within the combat sports milieu and may find themselves marginalised, with their judgements overruled by non-medical staff during competitive events. Some practitioners are cognisant of the dangers such working environments pose to their professional reputations and livelihoods, but remain working within combat sports regardless. CONCLUSIONS: Despite pockets of good practice, the lack of standardised rules for medical care provision creates substantial risks to athletes, to practitioners and the standing of the profession. The development and implementation of standardised, enforceable regulatory frameworks for full-contact combat sports in England is urgently needed.

Mga tanom na nakakabulong: Medicinal plant studies among the undergraduate researches of Bicol University – Department of Biology from 1991 to 2019

Background@#Undergraduate researches in universities are potential sources of useful data in medicinal plant research. In higher education institutions, many of these manuscripts remain untapped and inaccessible to researchers and scientists. If widely utilized, these can contribute in the growth of knowledge on medicinal plants. @*Objectives@#This article aimed to catalogue the medicinal plant researches of the Bicol University – Department of Biology from 1991 to 2019, highlight significant developments, trends, and responsiveness of the research, and recommend policies to improve medicinal plant research in the next decade. @*Methodology@#A complete list of undergraduate research titles was obtained and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) process. Categorization of researches included the medicinal plants studied, year of study, and the biological assays conducted. The final list included two things: researches that utilized medicinal plants and those researches which tested the biological and medicinal properties of plants. Results were presented in percentages. @*Results@#To date, 18.72% of the 865 thesis titles archived in the department are medicinal plant researches and majority of which focused on antimicrobial and toxicity studies. There were 52 plant families, 99 genera, and 114 plant species investigated. Leguminosae and Asteraceae were the most studied plant families. The years 2011-2019 were the most fruitful in terms of research completed. @*Conclusion@#Undergraduate researches can provide vital information on medicinal plants studies, especially on an institutional and regional level. It is recommended that medicinal plants research be included as a thematic area among higher education institutions, and that policies be implemented to support publication of researches.

Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination.

Nutrition plays an important role in health promotion and disease prevention and treatment across the lifespan. Physicians and other healthcare professionals are expected to counsel patients about nutrition, but recent surveys report minimal to no improvements in medical nutrition education in US medical schools. A workshop sponsored by the National Heart, Lung, and Blood Institute addressed this gap in knowledge by convening experts in clinical and academic health professional schools. Representatives from the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education, the Liaison Committee on Medical Education, and the American Society for Nutrition provided relevant presentations. Reported is an overview of lessons learned from nutrition education efforts in medical schools and health professional schools including interprofessional domains and competency-based nutrition education. Proposed is a framework for coordinating activities of various entities using a public-private partnership platform. Recommendations for nutrition research and accreditation are provided.

The Osteopathic Applicant.

The number of osteopathic students choosing emergency medicine (EM) as a specialty is continuously increasing. However, EM remains a competitive specialty. Accordingly, in this article we guide osteopathic students interested in EM through the Comprehensive Osteopathic Medical Licensing Examination (COMLEX), the United States Medical Licensing Examination (USMLE), third- and fourth-year rotations, and the match process. Additionally, we provide tips on the process of applying to allopathic programs and we discuss the timeline of both the allopathic and osteopathic match. Finally, we discuss the effect of the Single Accreditation System and the Memorandum of Understanding, an agreement to merge the allopathic and osteopathic graduate medical education systems into a single graduate medical education accreditation system. This is expected to be completed as of July 1, 2020. Therefore, we elucidate the expectations for osteopathic applicants (particularly with regards to the USMLE and COMLEX examinations).

The present state of complementary medicine regulation in Saudi Arabia.

The prevalence of use of traditional and complementary medicine in the Saudi Arabia population has reached 75%. The most used therapies are religious healing, herbal medicine and cupping therapy. The National Center for Complementary and Alternative Medicine is the Saudi national reference for all activities regarding complementary medicine. This article briefly highlights the current state of complementary medicine regulation in Saudi Arabia.

Beyond the United States Medical Licensing Examination Score: Assessing Competence for Entering Residency.

Assessments of physician learners during the transition from undergraduate to graduate medical education generate information that may inform their learning and improvement needs, determine readiness to move along the medical education continuum, and predict success in their residency programs. To achieve a constructive transition for the learner, residency program, and patients, high-quality assessments should provide meaningful information regarding applicant characteristics, academic achievement, and competence that lead to a suitable match between the learner and the residency program's culture and focus.The authors discuss alternative assessment models that may correlate with resident physician clinical performance and patient care outcomes. Currently, passing the United States Medical Licensing Examination Step examinations provides one element of reliable assessment data that could inform judgments about a learner's likelihood for success in residency. Yet, learner capabilities in areas beyond those traditionally valued in future physicians, such as life experiences, community engagement, language skills, and leadership attributes, are not afforded the same level of influence when candidate selections are made.While promising new methods of screening and assessment-such as objective structured clinical examinations, holistic assessments, and competency-based assessments-have attracted increased attention in the medical education community, currently they may be expensive, be less psychometrically sound, lack a national comparison group, or be complicated to administer. Future research and experimentation are needed to establish measures that can best meet the needs of programs, faculty, staff, students, and, more importantly, patients.

The Eight Years' War: Court Sides With TMA in Long-Running Chiropractic Case on Vestibular Testing.

In a split victory, TMA once again prevailed in November 2018 when the Third Court of Appeals upheld a trial court's decision that chiropractors don't have the authority to perform vestibular-ocular-nystagmus testing (VONT). However, a recent change to state law caused the appeals court to find in the Texas Board of Chiropractic Examiners' favor on the use of the word "diagnosis" in the board's administrative rules - meaning chiropractors can diagnose, but only within their scope of practice.

Homocysteine, Thioretinaco Ozonide, and Oxidative Phosphorylation in Cancer and Aging: A Proposed Clinical Trial Protocol.

The objective of the proposed clinical interventional trial is to demonstrate the efficacy of a novel therapeutic strategy in subjects with cancer and hyperhomocysteinemia. Following discovery of abnormal homocysteine thiolactone metabolism in cultured malignant cells, thioretinamide, the amide synthesized from retinoic acid and homocysteine thiolactone, and thioretinaco, the complex formed from cobalamin and thioretinamide, were demonstrated to have antineoplastic, anticarcinogenic, and anti-atherogenic properties in animal models. Retinol, ascorbate, and homocysteine thiolactone are necessary for biosynthesis of thioretinamide and thioretinaco by cystathionine synthase and for formation of thioretinaco ozonide from thioretinamide, cobalamin, and ozone. Thioretinaco ozonide is required for prevention of abnormal oxidative metabolism, aerobic glycolysis, suppressed immunity, and hyperhomocysteinemia in cancer.The pancreatic enzyme therapy of cancer promotes catabolism of proteins, nucleic acids, and glycosaminoglycans with excess homocysteinylated amino groups resulting from abnormal accumulation of homocysteine thiolactone in malignant cells. Dietary deficiencies of pyridoxal, folate, cobalamin, and nitriloside contribute to hyperhomocysteinemia in cancer, and in protein energy malnutrition. A deficiency of dietary sulfur amino acids downregulates cystathionine synthase, causing hyperhomocysteinemia.The organic sulfur compound diallyl trisulfide increases hydrogen sulfide production from homocysteine in animal models, inhibits Stat3 signaling in cancer stem cells, and produces apoptosis of malignant cells. The furanonaphthoquinone compound napabucasin inhibits Stat3 signaling and causes mitochondrial dysfunction, decreased oxidative phosphorylation, and apoptosis of malignant cells. The protocol of the proposed clinical trial in subjects with myelodysplasia consists of thioretinamide and cobalamin as precursors of thioretinaco ozonide, combined with pancreatic enzyme extracts, diallyl trisulfide, napabucasin, nutritional modification to minimize processed foods, vitamin supplements, essential amino acids, and beneficial dietary fats and proteins.

Cambodia's health professionals and the ASEAN Mutual Recognition Arrangements: registration, education and mobility.

BACKGROUND: From 2006, the Association of South East Asian Nations (ASEAN) has been developing Mutual Recognition Arrangements (MRAs) across key professions, including medicine, dentistry and nursing, that would facilitate the development of an ASEAN Economic Community, with shared regional standards and easier mobility of the workforce. This paper examines the interface between those agreements and the registration, professional education and mobility of health personnel in Cambodia. METHODS: This qualitative health policy analysis combined documentary and policy review with key informant interviews with 16 representatives of agencies relevant to the development and implementation of the MRAs in health. Thematic analysis identified three themes: registration, education and mobility. RESULTS: Cambodia is an active participant in the ASEAN MRA processes for doctors, dentists and nurses reporting progress annually. Education of health professionals has been increasingly formalised in the past 25 years, with nursing moving towards a 4-year bachelor degree. The private university sector has substantially increased, with English increasingly used as a language of instruction. Recent legislation provides for enforcement through fines and/or imprisonment to ensure all practising health professionals hold initial registration as a health professional and a renewable licence to practise as a health practitioner. Continuing Professional Development is a mandatory requirement for licence renewal. This is consistent with the MRA guidelines, though the capacity for enforcement appears limited. The Medical Council of Cambodia (MCC), and more recently, the Dental and Nursing Councils, have introduced continuing professional development initiatives, using them strategically as a positive reinforcer of registration. Midwifery education and registration in Cambodia does not conform with ASEAN guidelines. In education, course durations in medicine and dentistry are longer than regional counterparts, though anxiety around maintaining clinical standards has resulted in the introduction of a National Exit Examination and reluctance to abbreviate courses. The introduction of reforms appears to reference regional standards, though parity is still some way off. Mobility at present is infrequent and more likely to result from informal mechanisms than through the MRA mechanisms. CONCLUSION: The Royal Government of Cambodia is committed to the ASEAN MRA process. Developments in registration appear to use regional standards as benchmarks, as do reforms in the education of health professionals, though domestic factors appear to more directly impact on developments. Informal mechanisms facilitate the limited mobility currently occurring, with little formal application of the MRA provisions evident at this point.