Undisclosed Conflict of Interest Is Prevalent in Spine Literature.

STUDY DESIGN: Cohort study. OBJECTIVE: The aim of this study was to determine the rate of accurate conflict of interest (COI) disclosure within three prominent subspecialty Spine journals during a 4-year period. SUMMARY OF BACKGROUND DATA: Industry-physician relationships are crucial for technological advancement in spine surgery but serve as a source of bias in biomedical research. The Open Payments Database (OPD) was established after 2010 to increase financial transparency. METHODS: All research articles published from 2014 to 2017 in Spine, The Spine Journal (TSJ), and the Journal of Neurosurgery: Spine (JNS) were reviewed in this study. In these articles, all author's COI statements were recorded. The OPD was queried for all author entries within the disclose period of the journal. Discrepancies between the author's self-reported COIs and the documented COIs from OPD were recorded. RESULTS: A total of 6816 articles meeting inclusion criteria between 2014 and 2017 in Spine, TSJ, and JNS with 39,869 contributing authors. Overall, 15.8% of all authors were found to have an OPD financial relationship. Of 2633 authors in Spine with financial disclosures, 77.1% had accurate financial disclosures; 42.5% and 41.0% of authors with financial relationships in the OPD had accurate financial disclosures in TSJ and JNS, respectively. The total value of undisclosed conflicts of interest between 2014 and 2017 was $421 million with $1.48 billion in accurate disclosures. Of undisclosed payments, 68.7% were <$1000 and only 7.2% were >$10,000. Undisclosed payments included $180 million in research funding and $188 million in royalties. CONCLUSION: This study demonstrates that undisclosed COI is highly prevalent for authors in major Spine journals. This study indicates that there remains a need to standardize definitions and financial thresholds for significant COI as well as to shift the reporting burden for COI to journals who actively review potential COIs instead of relying on self-reporting. LEVEL OF EVIDENCE: 3.

[Characteristics of compulsory service programs for medical professionals in the Andean states]. / Características del servicio social para profesionales médicos en los estados andinos.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programsincluding remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

Características del servicio social para profesionales médicos en los estados andinos / Characteristics of compulsory service programs for medical professionals in the Andean states

INTRODUCCIÓN: Se ha estudiado poco sobre el impacto de los programas de servicio social en salud en el desarrollo profesional de médicos de los Estados Andinos (Argentina, Bolivia, Chile, Colombia, Ecuador, Perú y Venezuela), programas cuya finalidad es incrementar los recursos humanos en salud en zonas rurales y remotas. OBJETIVO: Describir la normativa de los programas de servicio social para profesionales médicos de los Estados Andinos. MÉTODOS: Se realizó una revisión bibliográfica de documentos normativos concernientes al servicio social para profesionales médicos en sitios web de gobiernos de los Estados Andinos, con la finalidad de obtener información la condición de servicio, financiamiento del programa/remuneraciones y modos de adjudicación. Adicionalmente, se empleó el motor de búsqueda PubMed para complementar la información sobre servicios sociales obligatorios en estos países. RESULTADOS: El servicio social para profesionales médicos está establecido bajo un marco normativo en todos los Estados Andinos, a excepción de Argentina, donde no existe este programa. Los participantes perciben una remuneración, salvo en Bolivia, donde el servicio es realizado por estudiantes. Los sistemas de adjudicación para estos programas son heterogéneos, siendo que en algunos Estados Andinos existe asignación de plazas según criterios meritocráticos. La participación en programas sociales en salud condiciona el ejercicio profesional (Ecuador, Colombia y Venezuela) y el poder realizar una especialización (Chile y Perú). CONCLUSIONES: Se requiere estudiar del impacto de estos programas en el desarrollo profesional del participante, con el objetivo de implementar estrategias de mejora adecuadas a sus contextos particulares.

INTRODUCTION: There are few studies on the impact of social service programs on health in the professional development of doctors in the Andean States (Argentina, Bolivia, Chile, Colombia, Ecuador, Peru, and Venezuela). The purpose of these programs is to increase the availability of human resources in health in rural and remote areas. OBJECTIVE: To describe the regulations of social service programs for medical professionals in the Andean countries. METHODS: We carried out a bibliographic review of normative documents concerning the social service for medical professionals using websites of governments of the Andean States as data sources. We sought to obtain information regarding service conditions, funding of these programs­including remunerations, and means of program allocation. Additionally, we used PubMed/MEDLINE to find complementary information on mandatory social services in these countries. RESULTS: Social service for medical professionals is established under a regulatory framework in all the Andean countries, except for Argentina, where this program does not exist. Participants receive remuneration (except in Bolivia, where students perform the service). The allocation systems used for these programs are heterogeneous, and in some Andean countries, the allocation is merit-based. Participation in social programs influences later professional opportunities (Ecuador, Colombia, and Venezuela) and the ability to specialize (Chile and Peru). CONCLUSIONS: It is necessary to study the impact of these programs on the professional development of the participants to design and implement quality improvement strategies tailored to each context.

The gender differences in highly paid wage: a case study of Peruvian physicians.

In recent decades, the number of women pursuing careers in health has significantly increased. However, the physician labor market is still characterized by gender differences regarding payment. Using a nationally representative Peruvian sample of health providers (3,219 male and 1,063 female physicians), we estimated the gender gap in the likelihood of earning high wages for physicians and decomposed this gap in a proportion related to differences in individual characteristics (e.g. specialty, labor experience), and a residual proportion related to differences in returns to these characteristics. Our main results reveal that male physicians have on average an 81% higher likelihood of earning high salaries (monthly earning level > 5,000 PEN) relative to their female counterparts. Further, the main proportion of this gap is associated to the unexplained component (among 57% and 77%, according to the model specification), which may be associated to unobservable characteristics and discrimination in the Peruvian labor market.

A Novel, Synergistic Model in Total Joint Arthroplasty: A Report of 2 Specialty Hospitals With Joint Ownership Between Physicians and Healthcare Systems.

BACKGROUND: In 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA. METHODS: After institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs. RESULTS: Of the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001). CONCLUSION: Even after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways.

What explains wage differences between male and female Brazilian physicians? A cross-sectional nationwide study.

OBJECTIVE: In many countries an increase in the number of women in medicine is accompanied by gender inequality in various aspects of professional practice. Women in medical workforce usually earn less than their male counterparts. The aim of this study was to describe the gender wage difference and analyse the associated factors in relation to Brazil's physicians. PARTICIPANTS: 2400 physicians. SETTING: Nationwide, cross-sectional study conducted in 2014. METHODS: Data were collected via a telephone enquiry. Sociodemographic and work characteristics were considered factors, and monthly wages (only the monthly earnings based on a medical profession) were considered as the primary outcome. A hierarchical multiple regression model was used to study the factors related to wage differences between male and female physicians. The adjustment of different models was verified by indicators of residual deviance and the Akaike information criterion. Analysis of variance was used to verify the equality hypothesis subsequently among the different models. RESULTS: The probability of men receiving the highest monthly wage range is higher than women for all factors. Almost 80% of women are concentrated in the three lowest wage categories, while 51% of men are in the three highest categories. Among physicians working between 20 and 40 hours a week, only 2.7% of women reported receiving >US$10 762 per month, compared with 13% of men. After adjustment for work characteristics in the hierarchical multiple regression model, the gender variable estimations (ß) remained, with no significant modifications. The final effect of this full model suggests that the probability of men receiving the highest salary level (≥US$10 762) is 17.1%, and for women it is 4.1%. Results indicate that a significant gender wage difference exists in Brazil. CONCLUSION: The inequality between sexes persisted even after adjusting for working factors such as weekly workload, number of weekly on-call shifts, physician office work, length of practice and specialisation.

Adherence of Mexican physicians to clinical guidelines in the management of breast cancer: Effect of the National Catastrophic Health Expenditure Fund.

AIM: To assess the adherence of physicians to the Medical-Care Guidelines for Malignant Breast Tumors in Mexico, before and after the allocation of federal subsidies from the Catastrophic Health Expenditure Fund (FPGC by its Spanish initials) to accredited hospitals, a strategy implemented with the view of offering free treatment to women with breast cancer (BC). MATERIAL AND METHODS: Based on a cross-sectional design, we gathered information on 479 BC patients who had been attended to at in four FPGC-accredited hospitals. Analysis centered on those treated within either three years before or three years after the accreditation of their attending hospitals. The four hospitals analyzed were located in the North, South, West and Center of the country. Information on all medical procedures performed during treatment was drawn from hospital medical records. Information on the socio-demographic characteristics of the patients was obtained by means of face-to-face interviews conducted in their homes. RESULTS: Adherence of physicians to the Guidelines grew by 12.8 percent (from 43.4 to 56.2 percent) after FPGC accreditation (p<0.001) and varied according to the clinical stage of the disease, with much lower levels of adherence observed in the advanced stages (p<0.05). CONCLUSIONS: The FPGC strategy increased the adherence of physicians to the Medical-Care Guidelines for Malignant Breast Tumors in Mexico.

The gender differences in highly paid wage: a case study of Peruvian physicians / Las diferencias de género en los sueldos de mejor remuneración: el estudio de caso de los médicos peruanos / Diferenças de gênero em salários altos: um estudo de caso de médicos peruanos

Abstract: In recent decades, the number of women pursuing careers in health has significantly increased. However, the physician labor market is still characterized by gender differences regarding payment. Using a nationally representative Peruvian sample of health providers (3,219 male and 1,063 female physicians), we estimated the gender gap in the likelihood of earning high wages for physicians and decomposed this gap in a proportion related to differences in individual characteristics (e.g. specialty, labor experience), and a residual proportion related to differences in returns to these characteristics. Our main results reveal that male physicians have on average an 81% higher likelihood of earning high salaries (monthly earning level > 5,000 PEN) relative to their female counterparts. Further, the main proportion of this gap is associated to the unexplained component (among 57% and 77%, according to the model specification), which may be associated to unobservable characteristics and discrimination in the Peruvian labor market.

Resumen: En décadas recientes, el número de mujeres realizando su carrera en el ámbito de salud se ha incrementado significativamente. No obstante, el mercado laboral de los médicos está todavía caracterizado por diferencias de género respecto a los salarios. Utilizando una muestra peruana nacionalmente representativa de proveedores de salud (3.219 hombres y 1.063 mujeres médicos), estimamos la brecha de género en la probabilidad para los médicos de ganar sueldos altos y la desglosamos según los porcentajes vinculados a las diferencias relacionadas con las características individuales (p.ej. especialidad, experiencia laboral) y un porcentaje residual vinculado a las diferencias relacionadas con estas características. Nuestros resultados principales revelaron que los médicos hombres contaban en promedio con un 81% mayor probabilidad de ganar sueldos más altos (nivel mensual de renta > 5.000 PEN) frente a sus compañeras mujeres. Asimismo, gran parte del porcentaje de esta brecha está asociado a un componente inexplicable (entre un 57% y un 77%, según la especificación del modelo), lo que tal vez esté relacionado con las características no observables y la discriminación en el mercado laboral peruano.

Resumo: Nas últimas décadas, o número de mulheres atuando em carreiras da saúde aumentou significativamente. Contudo, o mercado de trabalho médico continua caracterizado por diferenças de gênero nos salários. Usando uma amostra nacional representativa de profissionais da saúde peruanos (3.219 médicos e 1.063 médicas), nós estimamos a diferença de gênero na probabilidade de receber altos salários para médicos e decompomos essa diferença em uma proporção relacionada a diferenças em características individuais (p.ex.: especialidade, experiência profissional) e uma proporção residual relacionada a diferenças de retornos dessas características. Nossos resultados principais revelam que os médicos têm, em média, uma probabilidade 81% maior de receber salários altos (nível de rendimentos mensais > 5.000 PEN) em relação às médicas. Adicionalmente, a principal proporção dessa diferença está associada ao componente não-explicado (entre 57% e 77%, de acordo com a especificação do modelo), o que pode estar associado a características não-observadas e discriminação no mercado de trabalho peruano.

[Economic income in peruvian physicians according to the specialty: A cross-sectional analysis of the ENSUSALUD 2015]. / Ingresos económicos en médicos peruanos según especialidad: Un análisis transversal de la ENSUSALUD 2015.

OBJECTIVES: To evaluate the relationship between having a medical specialty and the monthly income of Peruvian doctors, and to compare the economic incomes among areas with higher and lower density of medical doctors in Peru. MATERIALS AND METHODS: : We analyzed data of the National Satisfaction Survey of Health Users (in Spanish: ENSUSALUD) carried out in Peru in the year 2015. This survey, with a national level of inference, was performed on physicians working at health facilities in Peru. Monthly income was measured considering all paid activities of the physician. Crude and adjusted prevalence ratios (PR and aPR) and their 95% confidence intervals (95% CI) were calculated through Poisson regression models with robust variance, taking into account the complex sampling of the survey. RESULTS: Out of 2 219 Physicians surveyed, 2 154 (97.0%) observations were analyzed. The probability of earning > S/5 000 (1 572.3 USD) per month was 29.1% for general practitioners; 65.6% for specialists; 63.0% for clinical specialists; 70.5% for surgeons, and 55.7% for other specialties. Compared to general practitioners, physicians with clinical, surgical, and other specialties were more likely to earn > S/5 000 per month (aPR = 1.44, 1.49, and 1.26, respectively). The probability of earning > S/5 000 was higher in those working in departments with low medical density. CONCLUSIONS: Monthly incomes were higher for specialist physicians than for non-specialists. Economic incomes were higher in departments with lower density of physicians, which may encourage physicians to work in these departments.

OBJETIVOS: Evaluar la asociación entre tener una especialidad médica y el ingreso económico mensual en médicos peruanos, y comparar los ingresos económicos entre áreas con mayor y menor densidad de médicos en Perú. MATERIALES Y MÉTODOS: Se analizaron los datos de la Encuesta Nacional de Satisfacción de Usuarios de Salud realizada en Perú el año 2015. Esta encuesta con nivel de inferencia nacional fue realizada a médicos que laboran en establecimientos de salud de Perú. Se evaluó el ingreso económico considerando todas las actividades remuneradas del médico. Se calcularon las razones de prevalencia crudas y ajustadas (RP y RPa) y sus intervalos de confianza al 95% (IC95%) mediante regresiones de Poisson con varianza robusta, tomando en cuenta el muestreo complejo de la encuesta. RESULTADOS: De 2219 médicos encuestados, se analizaron 2154 (97,0%) observaciones. La frecuencia de ganar >S/ 5000 (1572,3 USD) mensuales fue de 29,1% en médicos generales; 65,6% en especialistas; 63,0% en especialidades clínicas; 70,5% en especialidades quirúrgicas, y 55,7% en otras especialidades. En comparación a los médicos generales, los médicos con especialidades clínicas, quirúrgicas, y otras especialidades, tuvieron más probabilidades de ganar >S/ 5000 mensuales (RPa = 1,44, 1,49, y 1,26, respectivamente). La probabilidad de ganar >S/ 5000 fue mayor en quienes laboraban en departamentos con baja densidad de médicos. CONCLUSIONES: Los ingresos económicos fueron mayores en médicos especialistas que en no especialistas. Los ingresos económicos fueron mayores en departamentos con menor densidad de médicos, lo cual puede animar a que los médicos laboren en dichos departamentos.

The sum of us: considerations on physician-industry relationships. / La suma de nosotros: una reflexión sobre las relaciones médico-industria.

This essay describes critically the physician-industry relationships and how the latter influences economically in the realization of continuing medical education (CME), industry expenses in sponsoring the academic events of medical societies, travel costs and enrollment, payment for consultants and speakers. It also refers to the movements that have been created in the academic world to counteract this influence, such as No Free Lunch (Spanish version “NoGracias”) and PharmFree. And the struggles between major scientific medical journals, with editorials and among editorialists on the concept of conflicts of interest. All this seen through the existence of an academic institution in Mexico and the exemplary life of one of its members.

En este ensayo se describen de forma crítica las relaciones médico-industria, su influencia económica en la realización de la educación médica continua, los gastos de la industria en el patrocinio de los eventos académicos de las sociedades médicas, los costos de sus inscripciones y los viajes asociados a ellos, el pago por consultorías y “conferencistas a sueldo” (speakers). También hace referencia a los movimientos que se han creado en el mundo académico para contrarrestar esta influencia, como el No Free Lunch (su versión española No Gracias) y PharmFree. Asimismo, se alude a las pugnas entre las grandes revistas médicas científicas, con editoriales y entre editorialistas sobre el concepto del conflicto de intereses. Todo ello es visto a través de la existencia de una institución académica en México y la vida ejemplar de uno de sus miembros.

Ingresos económicos en médicos peruanos según especialidad: Un análisis transversal de la ENSUSALUD 2015 / Economic income in peruvian physicians according to the specialty: A cross-sectional analysis of the ENSUSALUD 2015

RESUMEN Objetivos Evaluar la asociación entre tener una especialidad médica y el ingreso económico mensual en médicos peruanos, y comparar los ingresos económicos entre áreas con mayor y menor densidad de médicos en Perú. Materiales y métodos Se analizaron los datos de la Encuesta Nacional de Satisfacción de Usuarios de Salud realizada en Perú el año 2015. Esta encuesta con nivel de inferencia nacional fue realizada a médicos que laboran en establecimientos de salud de Perú. Se evaluó el ingreso económico considerando todas las actividades remuneradas del médico. Se calcularon las razones de prevalencia crudas y ajustadas (RP y RPa) y sus intervalos de confianza al 95% (IC95%) mediante regresiones de Poisson con varianza robusta, tomando en cuenta el muestreo complejo de la encuesta. Resultados De 2219 médicos encuestados, se analizaron 2154 (97,0%) observaciones. La frecuencia de ganar >S/ 5000 (1572,3 USD) mensuales fue de 29,1% en médicos generales; 65,6% en especialistas; 63,0% en especialidades clínicas; 70,5% en especialidades quirúrgicas, y 55,7% en otras especialidades. En comparación a los médicos generales, los médicos con especialidades clínicas, quirúrgicas, y otras especialidades, tuvieron más probabilidades de ganar >S/ 5000 mensuales (RPa = 1,44, 1,49, y 1,26, respectivamente). La probabilidad de ganar >S/ 5000 fue mayor en quienes laboraban en departamentos con baja densidad de médicos. Conclusiones Los ingresos económicos fueron mayores en médicos especialistas que en no especialistas. Los ingresos económicos fueron mayores en departamentos con menor densidad de médicos, lo cual puede animar a que los médicos laboren en dichos departamentos.

ABSTRACT Objectives To evaluate the relationship between having a medical specialty and the monthly income of Peruvian doctors, and to compare the economic incomes among areas with higher and lower density of medical doctors in Peru. Materials and methods : We analyzed data of the National Satisfaction Survey of Health Users (in Spanish: ENSUSALUD) carried out in Peru in the year 2015. This survey, with a national level of inference, was performed on physicians working at health facilities in Peru. Monthly income was measured considering all paid activities of the physician. Crude and adjusted prevalence ratios (PR and aPR) and their 95% confidence intervals (95% CI) were calculated through Poisson regression models with robust variance, taking into account the complex sampling of the survey. Results Out of 2 219 Physicians surveyed, 2 154 (97.0%) observations were analyzed. The probability of earning > S/5 000 (1 572.3 USD) per month was 29.1% for general practitioners; 65.6% for specialists; 63.0% for clinical specialists; 70.5% for surgeons, and 55.7% for other specialties. Compared to general practitioners, physicians with clinical, surgical, and other specialties were more likely to earn > S/5 000 per month (aPR = 1.44, 1.49, and 1.26, respectively). The probability of earning > S/5 000 was higher in those working in departments with low medical density. Conclusions Monthly incomes were higher for specialist physicians than for non-specialists. Economic incomes were higher in departments with lower density of physicians, which may encourage physicians to work in these departments.

[Clinics adjacent to private pharmacies in Mexico: infrastructure and characteristics of the physicians and their remuneration]. / Consultorios adyacentes a farmacias privadas en México: infraestructura y características del personal médico y su remuneración.

OBJECTIVE: To analyze and compare the physicians' characteristics, their remuneration, the compliance with regulation and the services offered between clinics adjacent to pharmacies (CAF) and independent medical clinics (CMI). MATERIALS AND METHODS: Questionnaire applied to 239 physicians in 18 states including the Federal District, in Mexico in 2012. RESULTS: Physicians in CAF had less professional experience (5 versus 12 years), less postgraduate studies (61.2 versus 81.8%) and lower average monthly salaries (USD 418 versus USD 672) than their peers in CMI. In CAF there was less compliance in relation to medical record keeping and prescribing. CONCLUSIONS: The employment situation of physicians in CAF is more precarious than in CMI. It is necessary to strengthen the enforcement of existing regulations and develop policies according to the monitoring of its performance, particularly, but not exclusively, in CAF.

Consultorios adyacentes a farmacias privadas en México: infraestructura y características del personal médico y su remuneración / Clinics adjacent to private pharmacies in Mexico: infrastructure and characteristics of the physicians and their remuneration

Objetivo. Analizar las características del personal médico y su remuneración, así como la infraestructura, apego a la regulación y servicios ofrecidos en consultorios adyacentes a farmacias (CAF), y compararlos con consultorios médicos independientes (CMI). Material y métodos. Cuestionario aplicado a 239 médicos generales en 18 entidades federativas, incluido el Distrito Federal, en México en 2012. Resultados. Los médicos en CAF tenían menor experiencia profesional (5 vs 12 años), menos estudios de posgrado (61.2% vs 81.8%) y menor salario base promedio mensual (MXN 5500 vs MXN 8500) que en CMI. En CAF hubo menor cumplimiento de la regulación en relación con la historia clínica y la receta médica. Conclusiones. Los aspectos laborales explorados de médicos en CAF son más precarios que en CMI. Es necesario fortalecer la aplicación de la regulación vigente para consultorios y generar políticas a partir del monitoreo de su funcionamiento, particularmente, pero no de forma exclusiva, en CAF.

Objective. To analyze and compare the physicians' characteristics, their remuneration, the compliance with regulation and the services offered between clinics adjacent to pharmacies (CAF) and independent medical clinics (CMI). Materials and methods. Questionnaire applied to 239 physicians in 18 states including the Federal District, in Mexico in 2012. Results. Physicians in CAF had less professional experience (5 versus 12 years), less postgraduate studies (61.2 versus 81.8%) and lower average monthly salaries (USD 418 versus USD 672) than their peers in CMI. In CAF there was less compliance in relation to medical record keeping and prescribing. Conclusions. The employment situation of physicians in CAF is more precarious than in CMI. It is necessary to strengthen the enforcement of existing regulations and develop policies according to the monitoring of its performance, particularly, but not exclusively, in CAF.

[Historical and social perspective from the 64-65 Mexican medical movement]. / Perspectiva histórica y social del Movimiento Médico de 1964-1965 en México.

The Mexican Medical Movement from 1964-1965 constitutes an important event from the rising urban middle-class, besides it was the first time medical doctors claimed for fair working conditions. The background of this movement is the so-called Crisis of 1958, which included the Movements from the educators union, oil workers union, telegraph workers union and the railroad workers union. The conflict began because interns and residents from the "Hospital 20 de Noviembre" would not get a payment at the end of the year, so on November 26th, 1964, the movement started. The Asociación Mexicana de Médicos Residentes e Internos (AMMRI) was created and their demands were the following: 1) Full working site restitution without retaliations, 2) Legal examination of the scholarship-contract terms, in order to get annual, renewable and progressive contracts, and a fixed salary with the usual working-hours and characteristics of each institution, 3) To have preference to get an adscription at the hospital where the resident studied, 4) Active participation from the resident in the elaboration of the academic plans, and 5) Resolution of each hospital's problems. This movement had social impact for Mexico's contemporary life, nevertheless some of the demands are still unchanged among medical residents.

El movimiento médico mexicano de 1964-1965 constituyó parte del primer despertar de la clase media urbana, además de haber sido la primera vez que los médicos reclamaron condiciones de trabajo justas. Como antecedente se tiene la llamada crisis de 1958, la cual incluyó los movimientos: revolucionario del Magisterio, del Sindicato de Trabajadores Petroleros, de la Alianza de Telegrafistas, y del Sindicato de Trabajadores Ferrocarrileros de la República Mexicana. El comienzo del conflicto médico se debió a que los residentes e internos del Hospital 20 de Noviembre del hoy Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) no recibieron su aguinaldo, por lo que el 26 de noviembre de 1964 inició el paro, a partir del cual se formó la Asociación Mexicana de Médicos Residentes e Internos (AMMRI), cuyas demandas fueron: 1) Restitución total en sus puestos, sin represalias, 2) Revisión legal y cambio de los términos del contrato-beca, en el sentido de lograr contratos de trabajo anuales, renovables y progresivos, con el horario y características acostumbrados en cada institución además de determinación de sueldos base, 3) Preferencia para ocupar plaza de médico adscrito a los residentes egresados de las propias instituciones, 4) Participación activa del residente en la elaboración de los planes de enseñanza, y 5) Resolución de los problemas de cada hospital. Este movimiento, aunque tuvo repercusiones sociales para la vida contemporánea en México, a 50 años de su inicio, algunas de las demandas siguen sin ser resueltas para los médicos residentes.

First, do no harm by adopting evidence-based policy initiatives: the overselling of ICD-10 by congress with high expectations.

While it appears to be beneficial to apply a detailed disease classification system, the costs, cash flow disruptions, and increased investments with physician time incorporated into learning these processes, patient care might unfortunately suffer. This is essentially an unfunded mandate with much of the burden of transitioning to ICD-10 falling on health care providers,especially small independent practices. This will impact interventional pain management practices substantially.Further, as we have shown in previous manuscripts,the so-called advantages of multiple codes with specificity and granularity does not translate into reality where some specificity is actually lost for various codes. As Grimsley and O'Shea (1) have described in clinical practices, doctors do not treat codes, but they treat patients according to the individual clinical condition.A doctor will be losing valuable time and also will not be able to obtain meaningful information due to burdensome regulations of meaningful use, PQRS,value-based reimbursement, electronic prescribing,and now a major impact with change to ICD-10. Thus,very little benefit will be seen by practitioners, which cannot be said for the health care information industry.With overwhelming regulatory atmosphere created by numerous federal regulations and those including under the Affordable Care Act (15), there is no evidence that ICD-10 is needed, there is no evidence that it will be effective, and, finally, there is preponderance of evidence of adverse consequences. Thus, Congress should be cautious in imposing further regulations on already strained independent practices with ongoing regulations and imposing yet another unfunded mandate on the medical profession.

Attitudes and relationship between physicians and the pharmaceutical industry in a public general hospital in Lima, Peru.

BACKGROUND: The interaction between physicians and the pharmaceutical industry influences physicians' attitudes and prescribing behavior. Although largely studied in the US, this topic has not been well studied in resource-poor settings, where a close relationship between physicians and industry still exists. OBJECTIVE: To describe physician interactions with and attitudes towards the pharmaceutical industry in a public general hospital in Lima, Peru. DESIGN: Descriptive, cross-sectional study through an anonymous, self-filled questionnaire distributed among faculty and trainee physicians of five different clinical departments working in a Peruvian public general hospital. A transcultural validation of an existing Spanish questionnaire was performed. Exposure to marketing activities, motivations to contact pharmaceutical representatives and attitudes towards industry were studied. Collected data was analyzed by degree of training, clinical department, gender and teaching status. Attitudes were measured on a four-point LIKERT scale. RESULTS: 155 physicians completed the survey, of which 148 were included in the study sample. 94.5% of attending physicians reported ongoing encounters with pharmaceutical representatives. The most common industry-related activities were receiving medical samples (91.2%), promotional material (87.8%) and attending meetings in restaurants (81.8%). Respondents considered medical samples and continuing medical education the most ethically acceptable benefits. We found significant differences between attendings and residents, and teaching and non-teaching attendings. An association between the amount of encounters with pharmaceutical representatives, and attitudes towards industry and acceptance of medical samples was found. CONCLUSIONS: A close physician-industry relationship exists in the population under study. The contact is established mainly through pharmaceutical representatives. Medical samples are the most received and ethically accepted benefit. The attitudes of physicians on the ethical standards of acceptance of medical samples and other benefits are closely related with their exposure to the pharmaceutical industry. Future studies could explore the motivations of physicians working in resource-poor settings to maintain a close relationship with industry.

Private sector contributions and their effect on physician emigration in the developing world.

The contribution made by the private sector to health care in a low- or middle-income country may affect levels of physician emigration from that country. The increasing importance of the private sector in health care in the developing world has resulted in newfound academic interest in that sector's influences on many aspects of national health systems. The growth in physician emigration from the developing world has led to several attempts to identify both the factors that cause physicians to emigrate and the effects of physician emigration on primary care and population health in the countries that the physicians leave. When the relevant data on the emerging economies of Ghana, India and Peru were investigated, it appeared that the proportion of physicians participating in private health-care delivery, the percentage of health-care costs financed publicly and the amount of private health-care financing per capita were each inversely related to the level of physician expatriation. It therefore appears that private health-care delivery and financing may decrease physician emigration. There is clearly a need for similar research in other low- and middle-income countries, and for studies to see if, at the country level, temporal trends in the contribution made to health care by the private sector can be related to the corresponding trends in physician emigration. The ways in which private health care may be associated with access problems for the poor and therefore reduced equity also merit further investigation. The results should be of interest to policy-makers who aim to improve health systems worldwide.

La contribution apportée par le secteur privé aux soins de santé dans les pays à revenu faible ou intermédiaire peut modifier les taux d'émigration des médecins de ces pays. L'importance croissante du secteur privé dans les soins de santé dans les pays en voie de développement a suscité un regain d'intérêt académique dans les influences de ce secteur sur de nombreux aspects des systèmes de santé nationaux. La croissance de l'émigration des médecins des pays en voie de développement a conduit à plusieurs tentatives d'identifier à la fois les facteurs qui incitent les médecins à émigrer et les effets de l'émigration des médecins sur les soins primaires et la santé de la population dans les pays qu'ils quittent. Lorsque les données pertinentes sur les économies émergentes du Ghana, de l'Inde et du Pérou ont été étudiées, il est apparu que la proportion de médecins qui participent à la prestation des soins privés, le pourcentage de dépenses de santé financées publiquement et le montant du financement des soins de santé privés par habitant ont été chacun inversement proportionnels au taux d'expatriation des médecins. Ainsi, la prestation et le financement de soins de santé privés peuvent réduire l'émigration des médecins. Il existe clairement un besoin de recherches similaires dans d'autres pays à revenus faible et intermédiaire, ainsi que d'études pour voir si, au niveau du pays, les tendances temporelles de la contribution aux soins de santé par le secteur privé peuvent être liées aux tendances correspondantes de l'émigration des médecins. Les façons dont les soins de santé privés peuvent être associés à des problèmes d'accès pour les pauvres et, par conséquent l'équité réduite, méritent également une enquête plus approfondie. Les résultats devraient intéresser les décideurs politiques qui visent à améliorer les systèmes de santé à travers le monde.

La aportación del sector privado a la atención sanitaria en un país de ingresos medios o bajos puede repercutir en los índices de emigración de médicos de dicho país. La importancia creciente del sector privado en la atención sanitaria en los países en desarrollo ha suscitado un nuevo interés entre los académicos respecto a las influencias de dicho sector sobre muchos aspectos de los sistemas sanitarios nacionales. El aumento de la emigración de médicos procedentes de países en desarrollo ha conducido a varios intentos de identificar, por un lado, los factores implicados en la emigración de médicos y, por otro lado, los efectos de la emigración de médicos sobre la atención primaria y la salud de la población de los países de donde parten los médicos. Tras investigar la información pertinente sobre las economías emergentes de Ghana, India y Perú, se halló una relación inversa entre el índice de médicos expatriados y cada uno de los siguientes factores: la proporción de médicos que prestan atención sanitaria dentro del sector sanitario privado, el porcentaje de los costes sanitarios financiados con fondos públicos y la cuantía de la financiación per cápita del sector sanitario privado. Por consiguiente, parece ser que la prestación de servicios sanitarios por parte del sector privado y la financiación pueden reducir la emigración de médicos. Resulta evidente la necesidad de realizar investigaciones similares en otros países de renta media y baja, así como estudios que esclarezcan si, a escala nacional, se pueden vincular las tendencias temporales de la contribución por parte del sector privado con las correspondientes tendencias de la emigración de médicos. Cómo la sanidad privada puede relacionarse con los problemas de acceso para los pobres y, por lo tanto, con la reducción de la equidad, merece asimismo mayor investigación. Los resultados podrían ser de interés para los responsables políticos que aspiren a mejorar los sistemas sanitarios a escala mundial.