Do surgeon interviewers have human factor-related issues during the long day UK National Trauma and Orthopaedic specialty recruitment process?

PURPOSE: The role that human factors (HF) play in contributing to medical error is increasingly being recognised by healthcare professionals. Surprisingly, much less is known about the possible effects of HF including boredom, fatigue and organisational influences, on performance outside of the clinical environment such as examining or assessing candidates in other high stakes situations. METHODS: The authors used a validated 38 response questionnaire based around the HF analysis and classification system (HFACS) to assess factors including stress and pressure, care and support and working within the rules for surgeon interviewers at the UK national trainee selection process in Trauma and Orthopaedic surgery. RESULTS: 121 completed questionnaires were analysed (86% response rate). No statistically significant differences were found between interviewer experience, grade or role at the interview and the mean scores obtained for all four factor items. Overall interviewers had a positive experience during national selection with mean factor scores ranging from 3.80 to 3.98 (out of a maximum satisfaction score of 5). CONCLUSIONS: Careful planning by organisations and recognising the importance of the human element are essential to ensure assessors are looked after properly during high stakes assessment processes. Our data suggests that a positive experience for examiners is likely to benefit candidate performance and contribute to a fair and reliable recruitment process. The relationship between examiner experience and candidate performance merits further investigation.

Irish Medical Students Understanding of the Intern Year.

Upon completion of medical school in Ireland, graduates must make the transition to becoming interns. The transition into the intern year may be described as challenging as graduates assume clinical responsibilities. Historically, a survey of interns in 1996 found that 91% felt unprepared for their role. However, recent surveys in 2012 have demonstrated that this is changing with preparedness rates reaching 52%. This can be partially explained by multiple initiatives at the local and national level. Our study aimed evaluate medical student understanding of the intern year and associated factors. An online, cross-sectional survey was sent out to all Irish medical students in 2013 and included questions regarding their understanding of the intern year. Two thousand, two hundred and forty-eight students responded, with 1,224 (55.4%) of students agreeing or strongly agreeing that they had a good understanding of what the intern year entails. This rose to 485 (73.7%) among senior medical students. Of junior medical students, 260 (42.8%) indicated they understood what the intern year, compared to 479 (48.7%) of intermediate medical students. Initiatives to continue improving preparedness for the intern year are essential in ensuring a smooth and less stressful transition into the medical workforce.

Spinal Stabilization Using Orthopedic Extremity Instrumentation Sets During Operation Enduring Freedom-Afghanistan.

BACKGROUND: The Role III, Multinational Medical Unit at Kandahar Air Field, Afghanistan, was established to provide combat casualty care in theater for International Security Assistance Forces, Afghanistan National Security Forces, and local nationals during Operation Enduring Freedom-Afghanistan. The authors describe their experience of treating unstable lumbar spine fractures with orthopedic extremity instrumentation sets from January 2007 to January 2008 and November 2010 to May 2011. METHODS: During the study periods, 15 patients comprising Afghanistan National Security Forces and local nationals presented to the medical facility for treatment of unstable lumbar spine fractures. The patients underwent surgery for either anterior corpectomy and instrumented fusion (n = 5) or posterior instrumented fusion (n = 10). Because of periodic scarcity of spinal instrumentation sets, orthopedic extremity instrumentation sets were used (Synthes Large Fragment LCP Instrument and Implant Set) for spinal stabilization. RESULTS: Immediate postoperative standing and sitting plain radiographs demonstrated no evidence of fracture progression or immediate hardware failure. One patient was seen in follow-up at 4 weeks and demonstrated construct stability on follow-up radiographs. CONCLUSIONS: In the combat environment with sparse resources, unstable spine fractures may potentially be treated using instrumentation not specifically designed for spinal implantation. This is an off-label use, and the authors do not recommend the use of these techniques as standard treatment in most medical environments.

Graduate medical education in Ireland: a profile of the first cohort of students.

BACKGROUND: The first graduate-entry programmes to Irish medicine were established at the Royal College of Surgeons in Ireland (RCSI) and the University of Limerick (UL) in 2007. There were over 400 applications across both institutions and 306 people sat a special aptitude test (GAMSAT) in Ireland in 2007. Ultimately, 61 Irish/EU students were admitted to one or other programme. AIMS AND METHODS: We describe the demographic profile, academic background and aggregated GAMSAT performance of 306 people who sat GAMSAT in Ireland in 2007 and of the 61 people admitted to the RCSI/UL programmes. RESULTS: While more females than males sat GAMSAT, slightly more males were admitted. Over 90% of those admitted were aged in their 20s, almost 20% had a higher degree and they came from a wide range of academic backgrounds. CONCLUSIONS: Among others, this information should be of interest to prospective students and to government policy makers.

Reconciling medical expenditure estimates from the MEPS and the NHA, 1996.

This article compares 1996 estimates of national medical care expenditures from the Medical Expenditure Panel Survey (MEPS) and the National Health Accounts (NHA). The MEPS estimate for total expenditures in 1996 was $548 billion; whereas, the NHA estimate for personal health care (PHC) in 1996 was $912 billion. Much of this apparent difference, however, arises from differences in scope between MEPS and NHA--rather than from differences in estimates for comparably-defined expenditures. We adjusted the NHA for differences in included populations and types of services covered, finding a much smaller difference between MEPS and a comparably-defined NHA.

Human plasma concentrations of R, S, and racemic flurbiprofen given as a toothpaste.

Flurbiprofen, an arylpropionic acid (APA) class nonsteroidal antiinflammatory drug (NSAID), is commercially available only as the racemic mixture, although its pharmacologic effect has been credited primarily to the S isomer. In humans, the bioavailability of racemic flurbiprofen absorbed from the oral cavity has been studied measuring the total concentration of S- and R-flurbiprofen, and the pharmacokinetics of S- and R-flurbiprofen have been studied after oral administration of racemic flurbiprofen. In this study, the plasma concentrations of S-flurbiprofen and to some extent R-flurbiprofen were studied after brushing with a toothpaste containing different mixtures of S- and R-flurbiprofen. The toothpaste formulations contained 1% racemic (50:50), eutectic (14:86), 1%, 0.5%, and 0.25% (5:95) R- to S-flurbiprofen. Both S- and R-flurbiprofen were rapidly absorbed, with a time to reach maximum concentration (tmax) of 1.2 to 1.4 hours. Based on the AUC, the amount of S-flurbiprofen absorbed increased proportionally when given as the 0.25% (5:95) preparation to the 0.5% (5:95) mixture but did not increase significantly above the 0.5% (5:95) mixture when given as 1% (5:95) R- to S-flurbiprofen. This suggests that dose-proportional absorption of S-flurbiprofen is not maintained at higher concentrations. The elimination of S-flurbiprofen appears to be variable and prolonged after this mode of administration, as observed from plasma concentrations. Further controlled and more prolonged studies of S- and R-flurbiprofen are needed to confirm these observations.

The Medical Expenditure Panel Survey: a national health information resource.

This article describes the Medical Expenditure Panel Survey (MEPS), the third in a series of nationally representative surveys of medical care use and expenditures sponsored by the Agency for Health Care Policy and Research. The MEPS is designed to provide extensive data on the types of health care services American use, how frequently they use them, how much is paid for the services, and who pays for them. It also will provide information on the types and costs of private health insurance available to the U.S. population. The survey is unparalleled in its degree of detail, as well as its ability to link medical care use, payments, and health insurance coverage to specific survey respondents and their families. It allows analysts to examine how individual and family characteristics, including the characteristics of their health insurance, affect medical care use and spending. This article discusses each of the MEPS components, focusing on design enhancements that have been made since the survey was last conducted nearly a decade ago.

Why more cost-sharing won't slow Medicare spending.

In considering ways to slow the growth in Medicare expenditures, policymakers have concluded that increasing point-of-service cost-sharing for patients will reduce demand for health services. Under the current system, Medicare beneficiaries faced with increased cost-sharing can reduce their demand for services or purchase additional private insurance. New data from the 1991 Medicare Current Beneficiary Survey show that high-income persons protect themselves from out-of-pocket costs by purchasing private supplemental insurance. Surprisingly, the data also reveal that many low-income persons also purchase private insurance, demonstrating that the elderly--whatever their income level--consider supplementary insurance more of a necessity than a luxury. Thus, it appears that increased beneficiary cost-sharing would have a limited effect on Medicare spending growth.

Health insurance and the elderly.

The effectiveness of proposed changes to the Medicare program depends on consumers' responses to different market incentives, which vary according to the coverage the elderly possess to supplement their Medicare coverage. This Data Watch explores the extent of supplemental insurance among the elderly, based on a new data set from the Medicare Current Beneficiary Survey. Only 11 percent of Medicare beneficiaries have only Medicare as their source of coverage; the rest of the elderly population is covered by either private coverage (employer-sponsored retiree coverage or individually purchased coverage) or Medicaid. An increase in Medicare cost sharing would likely affect one-third of elderly beneficiaries, which calls into question the effectiveness of this approach to Medicare program reform.

Health insurance and the elderly: data from MCBS (Medicare Current Beneficiary Survey).

This article shows the supplemental insurance distribution and Medicare spending per capita by insurance status for elderly persons in 1991. The data are from the Medicare Current Beneficiary Survey (MCBS) and Medicare bill records. Persons with Medicare only are a fairly small share of the elderly (11.4 percent). About three-fourths of the Medicare elderly have some form of private insurance. The share with Medicaid is 11.9 percent, which has increased recently as qualified Medicare beneficiaries (QMBs) started to receive partial Medicaid benefits. In general, Medicare per capita spending levels increase as supplemental insurance comes closer to first dollar coverage. When the data were recalculated to control for differences in reported health status between the insurance groups, essentially the same spending differences were observed.

Training needs analysis.

With limited training budgets and an increasing range of training opportunities available, provider units will need to have effective training strategies. The Grantham model, described by Kevin Teasdale and colleagues, offers a clear and practical approach.

Measuring input prices for physicians: the revised Medicare Economic Index.

Medicare payments for physician services under Part B were historically restrained by capping prevailing charges using the Medicare Economic Index (MEI). The MEI, an input price index for physician services that incorporates an adjustment for economywide labor productivity, has not undergone a major revision since 1975. The MEI is an important determinant of the annual volume performance standard that will be used to set aggregate increases in the revised system for paying physicians under Medicare beginning in 1992. The MEI will also be used in establishing the annual changes to the payment conversion factors under the new payment system.

Measuring hospital input price increases: the rebased hospital market basket.

The input prices indexes used in part to set payment rates for Medicare inpatient hospital services in both prospective payment system (PPS) and PPS-excluded hospitals were rebased from 1982 to 1987 beginning with payments for fiscal year 1991. In this article, the issues and evidence used to determine the composition of the revised hospital input price indexes are discussed. One issue is the need for a separate market basket for PPS-excluded hospitals. Also, the payment implications of using hospital-industry versus economywide measures of wage rates as price proxies for the growth in hospital wage rates are addressed.

Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision.

A prospective, controlled, double-blinded investigation was conducted to evaluate whether infants undergoing circumcisions with 1% lidocaine dorsal penile nerve blocks experienced decreased stress as compared with those receiving saline solution injections or no injections. Stress was measured in terms of pulse rate and oxygen saturation on a pulse oximeter. A subjective grading scale was also developed to measure infant irritability. The total number in the study was 51 with 23 infants in the lidocaine group, 21 in the saline solution group, and 7 in the no injection group. The results of the study revealed an average increase of 28.8% in the pulse rate above baseline for the control infants (p less than 0.001) versus no significant change in the lidocaine group. The average oxygen saturation of the control groups decreased by 5.6% from baseline (p less than 0.001), and that of the lidocaine group decreased by 1.0%, which was not a significant change. The subjective data were gained by using a grading scale of 1 to 6 with 1 being the least irritable infant and 6 being the most irritable infant. The physician evaluation gave an average rating of 4.2 to the control group versus 2.4 for the lidocaine group (p less than 0.001). The nursing evaluation during the procedure gave an average rating of 4.2 to the control group versus 2.3 to the anesthetized group (p less than 0.001). The subjective evaluation of infants before and after the procedure was not significantly different. There were no major complications in any of the groups.

National health expenditures, 1988. Office of National Cost Estimates.

Every year, analysts in the Health Care Financing Administration present figures on what our Nation spends for health. As the result of a comprehensive re-examination of the definitions, concepts, methods, and data sources used to prepare those figures, this year's report contains new estimates of national health expenditures for calendar years 1960 through 1988. Significant changes have been made to estimates of spending for professional services and to estimates of what consumers pay out of pocket for health care. In the first article, trends in use of and expenditure for various types of goods and services are discussed, as well as trends in the sources of funds used to finance health care. In a companion article, the benchmark process is described in more detail, as are the data sources and methods used to prepare annual estimates of health expenditures.

Health expenditures by age group, 1977 and 1987.

In recent years, concern has increased over the rapid growth of health care spending, especially spending on behalf of the aged. In 1987, those 65 years or over comprised 12 percent of the population but consumed 36 percent of total personal health care. This article is an examination of the current and future composition of the population and effects on health care spending. National health accounts aggregates for 1977 and 1987 are split into three age groups, and the consumption patterns of each group are discussed. The variations in spending within the aged cohort are also examined.

Self-insured health plans.

Nationwide, 8 percent of all employment-related health plans were self-insured in 1984, which translates into more than 175,000 self-insured plans according to our latest study of independent health plans. The propensity of an organization to self-insure differs primarily by its size, with large establishments more likely to self-insure. In the overwhelming majority of cases, the self-insured benefit was hospital and/or medical. Among employers who self-insure, 23 percent self-administer, and the remaining 77 percent hire a commercial insurance company, Blue Cross/Blue Shield plan, or an independent third-party administrator to administer the health plan.

Projections of health care spending to 1990.

National health expenditures are projected to grow to $640 billion by 1990, 11.3 percent of the gross national product. Growth in health spending is expected to moderate to an 8.7 percent average annual rate from 1984 to 1990, compared with a 12.6 percent rate from 1978 to 1984. These projections assume lower estimates of overall economic price growth, lower use of hospital care, and increased use of less expensive types of care. A preliminary analysis of demographic factors reveals that the aging of the population has almost as great an impact as the growth in total population on projected expenditures for many types of health care services.