Primer informe del Observatorio de la Academia de Medicina Familiar y Comunitaria de España (AMFE) en la universidad española, 2023 / Initial descriptive evaluation of Family and Community Medicine as a field within undergraduate medicine degrees in Spanish universities, 2023

Objetivos: conocer el grado de implementación de la Medicina Familiar y Comunitaria (MFyC) en el grado de Medicina de todas las universidades españolas.Métodos: estudio descriptivo transversal, llevado a cabo entre enero y marzo de 2023. Cuestionario ad hoc, cumplimentado por docentes de las 44 facultades de Medicina (año académico 2022-2023), sobre seis temáticas centradas en la asignatura de MFyC, las prácticas tuteladas, las rotaciones, metodologías docentes y evaluativas, y el profesorado. Resultados: participan 41 facultades (93,2%), 83% públicas y 17% privadas. La asignatura de MFyC está implantada en 34 facultades (82,9%), siendo obligatoria en 32 (94,1%), un 78% del total.La asignatura se denomina Medicina Familiar y Comunitaria solo en 14 facultades (34%) y cuenta con gran variabilidad en créditos ECTS: 3 créditos en 13 facultades (36%) y 6 créditos en 11 facultades (30%). Se imparte en quinto curso en 21 facultades (51%) y en sexto curso en 13 (32%). Hay prácticas tuteladas de MFyC en 28 facultades (68%) y créditos propios en 19 (46%). Mediana duración de 5 semanas. Gran variabilidad en las denominaciones. Coordinación por MFyC en 14 facultades (50%). Hay rotaciones en el centro de salud en 34 facultades (83%), siendo obligatorias en 29 (85%). No hay departamentos de Medicina Familiar, y solo hay unidades docentes universitarias en 4 facultades. Actualmente, hay 3 catedráticos y 13 profesores titulares. Conclusiones: se observa una progresión de la MFyC en la universidad en asignaturas, contenidos y profesorado, pero aún estamos lejos del nivel en el que se encuentran las universidades de otros países. Debilidades: gran heterogeneidad en denominación, contenidos, metodologías, carga docente y estructura. Fortalezas: implementación de metodologías docentes y evaluativas innovadoras.(AU)

Aims: to ascertain the degree of implementation of Family and Community Medicine (MFyC) on the undergraduate medicine degree course of Spanish universities.Methods: cross-sectional descriptive study, January-March 2023. Ad-hoc questionnaire, completed by lecturers of 44 medical schools (academic year 2022-2023). The questionnaire included six MFyC topics; that is, supervised family practice internships, shifts, teaching and evaluation methodologies and lecturers in medical schools.Results: a total of 41 faculties (93.2%) took part; 83% public and 17% private. MFyC course was implemented in 34 faculties (82.9%). The course was mandatory in 32 faculties (94.1%), 78% of the total.The course was named family and community medicine only in 14 medical schools (34%) with a major variability in ECTS credits (3 credits in 13 schools [36%] and 6 credits in 11 schools [30%]). It was taught in the 5th and 6th years in 21 (51%) and 13 (32%) faculties, respectively. There was supervised work experience in 28 faculties (68%), own credits in 19 (46%). Median duration was five weeks. There was a major variability in denomination. There was coordination by family practitioners in 14 faculties (50%).There were health centre internships in 34 faculties (83%), mandatory in 29 (85%).There are no family medicine departments and only university teaching units in four faculties. Currently, there are only three professors and 13 tenured lecturers.Conclusions: development of F&CM as a field was observed in terms of courses, content and teaching staff. However, this still falls well below international standards. Weaknesses are a major heterogeneity in denomination, content, methodologies, teaching load and structure and implementation of innovative teaching and evaluation methodologies was perceived as a strength.(AU)

Research Involving Participants With Impaired Consent Capacity: An Examination of Methods to Determine Capacity to Consent.

OBJECTIVE: To examine methods of assessing consent capacity in research protocols involving participants with impaired consent capacity, and examine instruments used to evaluate research consent capacity. METHODS: A retrospective review of 330 active research protocols involving participants lacking capacity to consent over a 10-year period (January 1, 2009, through March 1, 2019) was conducted to collect protocol characteristics (medical specialty, level of risk and type of study, consent and assent procedures, and type of vulnerable or protected population). Methods to assess consent capacity are described, and instruments to assess consent capacity are summarized. RESULTS: The specialties most frequently involving participants with impaired consent capacity in research were Neurology (27.3%), Critical Care (16.7%), and Surgery (10%). Type of studies are observational (43.9%), clinical trials (33%), chart review (11.5%), biobank (6.1%), and biomarker (5.5%). Minimal risk (53.3%) outnumbered greater than minimal risk (46.7%) studies. Most obtained written informed consent (77%) and assent (40.9%). The most common method to assess consent capacity was direct assessment by investigators (32.7%). Only 86 (26%) studies used instruments to assess consent capacity. Of the 13 instruments used, the most common was the Evaluation of Decision-Making Capacity for Consent to Act as a Research Subject, and is the only instrument that assesses all four components of decisional capacity: understanding, appreciation, reasoning, and choice. CONCLUSION: Generally, there was lack of uniformity in determining capacity to consent to research participation. Very few studies used instruments to assess consent capacity. Institutional review boards can provide greater guidance for research consent capacity determination.

Diversity of the physician workforce: Specialty choice decisions during medical school.

BACKGROUND: Despite efforts to increase the overall diversity of the medical student body, some medical specialties have a less diverse applicant pool based on both gender and race than would be expected based on medical graduate demographics. OBJECTIVES: To identify whether women and Underrepresented in Medicine (URiM) medical students have baseline differences in their career interests or if their career plans change more during medical school when compared to men and non-URIM students. METHODS: Secondary data analyses of all medical students who applied through ERAS from 2005-2010 was conducted. Binary logistic regression models with the response being a planned career in one of four medical specialties (internal medicine, pediatrics, OB/GYN, and general surgery/surgical specialties) at medical school entry and graduation. Regression models included demographics, student attitudes, debt, academic metrics, and medical school experiences. RESULTS: Comparatively, women were less likely to be interested in internal medicine and surgery and more interested in pediatrics and OB/GYN at matriculation. URiM students expressed more interest in OB/GYN and surgery when starting medical school. At graduation, women were less likely to plan for internal medicine and surgery and were more interested in pursuing OB/GYN and pediatrics. URiM students were more likely to plan for a career in internal medicine and less likely to choose pediatrics. CONCLUSIONS: From matriculation to graduation, women have relatively stable preferences regarding planned medical specialties. In contrast, URiM students' specialty plans shifted over time among the four specialties, with variation in preferences occurring between matriculation and graduation.

Metabolic Shifts as the Hallmark of Most Common Diseases: The Quest for the Underlying Unity.

A hyper-specialization characterizes modern medicine with the consequence of classifying the various diseases of the body into unrelated categories. Such a broad diversification of medicine goes in the opposite direction of physics, which eagerly looks for unification. We argue that unification should also apply to medicine. In accordance with the second principle of thermodynamics, the cell must release its entropy either in the form of heat (catabolism) or biomass (anabolism). There is a decreased flow of entropy outside the body due to an age-related reduction in mitochondrial entropy yield resulting in increased release of entropy in the form of biomass. This shift toward anabolism has been known in oncology as Warburg-effect. The shift toward anabolism has been reported in most diseases. This quest for a single framework is reinforced by the fact that inflammation (also called the immune response) is involved in nearly every disease. This strongly suggests that despite their apparent disparity, there is an underlying unity in the diseases. This also offers guidelines for the repurposing of old drugs.

Elección de especialidad médica en estudiantes de medicina de la Universidad de Oriente, Ciudad Bolívar, Venezuela / Specialty choice in medical students of the Universidad de Oriente, Ciudad Bolívar, Venezuela

Introducción: La elección de la especialidad médica es una decisión que marca la vida del estudiante de medicina. Según estudios, existen diferencias entre hombres y mujeres en el momento de decidir sus futuras especialidades. En el presente estudio se analizó la elección de especialidad en estudiantes de medicina de la Universidad de Oriente y su relación con el sexo y la percepción de la calidad de vida ofrecida por cada una. Sujetos y métodos: Se aplicó un cuestionario a 120 estudiantes de pregrado del undécimo semestre de la carrera de medicina en relación con su género, preferencia de futura especialidad médica, y especialidades que considerasen que ofrecieran la mejor y la peor calidad de vida. Resultados: Pediatría (15%), cirugía general (13%) y cirugía plástica (11%) resultaron las más elegidas. Las mujeres prefirieron pediatría (19%) y ginecoobstetricia (13%), mientras que los hombres se inclinaron por cirugía plástica (19%) y cirugía ortopédica (16%). Como representantes de una mejor calidad de vida se eligieron dermatología (19%) y anestesiología (10%); en cuanto a la peor calidad de vida, se seleccionaron cirugía general (17%) y ginecoobstetricia (15%). Conclusiones: Las mujeres prefirieron las especialidades clínicas, mientras que los hombres tuvieron una marcada predilección por las quirúrgicas. La calidad de vida no pareció tener influencia relevante en la elección de especialidad, por lo que debe profundizarse en el estudio de otros factores.(AU)

Introduction: The specialty choice is an important decision for medical students, according to studies there are differences between men and women when they decide their future specialties, in the present study was analyzed the specialty choice in medical students in the Universidad de Oriente and its relationship with gender and the perception of quality of life offered by each one. Subjects and methods: Trough a questionnaire, 120 students were surveyed about their gender, preference of medical specialty, and the specialties they think have the best and worst quality of life. Results: Pediatrics (15%), general surgery (13%) and plastic surgery (11%) were the most chosen. Women's preferred pediatrics (19%) and obstetrics-gynecology (13%) meanwhile men's preferred plastic surgery (19%), and orthopedics (16%). As representatives of a better quality of life were chosen dermatology (19%) and anesthesiology(10%), in the case of worst quality of life were general surgery (17%) and obstetrics-gynecology(15%). Conclusions: Women's preferred clinical specialties meanwhile men's had a marked preference on surgical ones. Quality of life doesn't appeared to have a relevant impact in the specialty choice, so it should be deepen in the study of other factors.(AU)

Inter-specialty variation of the Press Ganey Outpatient Medical Practice Survey.

ABSTRACT: Measuring patient satisfaction scores and interpreting factors that impact their variation is of importance as scores influence various aspects of health care administration. Our objective was to evaluate if Press Ganey scores differ between medical specialties.New patient visits between January 2014 and December 2016 at a single tertiary academic center were included in this study. Press Ganey scores were compared between specialties using a multivariable logistic mixed effects model. Secondary outcomes included a comparison between surgical versus non-surgical specialties, and pediatric versus adult specialties. Due to the survey's high ceiling effect, satisfaction was defined as a perfect total score.Forty four thousand four hundred ninety six patients met inclusion criteria. Compared to internal medicine, plastic surgery, general surgery, dermatology, and family medicine were more likely to achieve a perfect overall score, as, with odds ratios of 1.46 (P = .02), 1.29 (P = .002), 1.22 (P = .004), and 1.16 (P = .02) respectively. Orthopaedics, pediatric medicine, pediatric neurology, neurology, and pain management were less likely to achieve satisfaction with odds ratios of 0.85 (P = .047), 0.71 (P < .001), 0.63 (P = .005), 0.57 (P < .001), and 0.51 (P = .006), respectively. Compared to pediatric specialties, adult specialties were more likely to achieve satisfaction (OR 1.73; P < .001). There were no significant differences between surgical versus non-surgical specialties.Press Ganey scores systematically differ between specialties within the studied institution. These differences should be considered by healthcare systems that use patient satisfaction data to modify provider reimbursement.

Proyecto educativo de investigación clínica en el programa de formación sanitaria especializada del Hospital Universitario de Canarias: evaluación del impacto a 10 años / Clinical research educational programme in the health training specialty of the Hospital Universitario de Canarias: 10-year impact assessment

Aunque todas las especialidades incorporan en sus programas formativos los objetivos relacionados con la adquisición de competencias y habilidades en investigación, la valoración de los residentes en cuanto a la formación recibida y el tiempo de dedicación es deficiente. El presente estudio trata de evaluar el impacto de una nueva estrategia formativa en investigación, que incorpora un nivel básico y un nivel avanzado con el desarrollo y puesta en marcha durante la residencia de un proyecto de investigación. La presentación de dicho proyecto permite aplicar los conocimientos teóricos adquiridos, tratando de responder de forma sistematizada y metódica a una pregunta de investigación que surja de la observación de la práctica clínica diaria. Tras 4 ediciones, el 100% de los residentes presentó algún trabajo a congresos, el 27% presentaron más de 30 y el 33% presentaron entre 20 y 30. El 64% terminaron la formación con publicaciones científicas y la valoración de la formación percibida por el residente ha mejorado en las encuestas de satisfacción, siendo de excelente o muy buena en más de un 55%. Un programa de formación con un nivel básico y avanzado de investigación que concluya con la puesta en marcha de un proyecto de investigación podría mejorar los indicadores de la actividad investigadora de residentes y de especialistas de un hospital universitario, aspectos que contribuyen a la adquisición de competencias y el cumplimiento de objetivos del programa de la especialidad

All the specialties incorporate objectives related to the acquisition of competences and skills in research in their training programs. However, from the point of view of residents, the training received and the length of time seems deficient. The present study attempts to evaluate the impact of a new training strategy in research, which incorporates a basic level and an advanced level with the development and implementation of a research project during the residency. The presentation of this project allows the acquired theoretical knowledge to be applied, trying to answer a research question that arises from the observation in the daily clinical practice. After 4 editions, 100% of the residents presented some work at congresses, with 27% presenting more than 30, and 33% presenting between 20 and 30. Almost two-thirds (64%) finished the training period with scientific publications. The evaluation of the training programme has also improved in the satisfaction surveys, being excellent or very good in more than 55%. A speciality training program with a basic and advanced level of research with a research project performed during the residency could improve the indicators in relation to research activity of residents and specialists in a university hospital. These aspects could contribute to the acquisition of competencies and compliance with the objectives of the specialty program

H-Accuracy, an Alternative Metric to Assess Classification Models in Medicine.

As widely known, regular accuracy is a misleading and shallow indicator of the performance of a predictive model, especially in real-life domains like medicine, where decisions affect health or life. In this paper we present and discuss a new accuracy measure, the H-accuracy, as a more conservative alternative to regular accuracy, which we claim is more informative in the medical domain (and others of similar needs) for the elements it encompasses. In particular, the proposed measure takes into account important information such as the complexity of the cases and the case prevalance in the population. We also provide proof that the H-accuracy is a generalization of the balanced accuracy and illustrate the descriptive power of this score.

Medicina intensiva: la columna vertebral del proceso de donación en España / Intensive Care Medicine: The cornerstone of the donation process in Spain

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Assessment methods in medical specialist assessments in the DACH region - overview, critical examination and recommendations for further development.

Introduction: Specialist medical assessments fulfil the task of ensuring that physicians have the clinical competence to independently represent their field and provide the best possible care to patients, taking into account the current state of knowledge. To date, there are no comprehensive reports on the status of specialist assessments in the German-speaking countries (DACH). For that reason, the assessment methods used in the DACH region are compiled and critically evaluated in this article, and recommendations for further development are described. Methods: The websites of the following institutions were searched for information regarding testing methods used and the organisation of specialist examinations: Homepage of the Swiss Institute for Medical Continuing Education (SIWF), Homepage of the Academy of Physicians (Austria) and Homepage of the German Federal Medical Association (BAEK). Further links were considered and the results were presented in tabular form. The assessment methods used in the specialist assessments are critically examined with regard to established quality criteria and recommendations for the further development of the specialist assessments are derived from these. Results: The following assessment methods are already used in Switzerland and Austria: written examinations with multiple choice and short answer questions, structured oral examinations, the Script Concordance Test (SCT) and the Objective Structured Clinical Examination (OSCE). In some cases, these assessment methods are combined (triangulation). In Germany, on the other hand, the oral examination has so far been conducted in an unstructured manner in the form of a 'collegial content discussion'. In order to test knowledge, practical and communicative competences equally, it is recommended to implement a triangulation of methods and follow the further recommendations described in this article. Conclusion: While there are already accepted approaches for quality-assured and competence-based specialist assessments in Switzerland and Austria at present, there is still a long way to go in Germany. Following the recommendations presented in this article, a contribution could be made to improving the specialist assessments in the DACH region according to the specialist assessments objectives.

Association between medical student debt and choice of specialty: a 6-year retrospective study.

BACKGROUND: The effect of rapidly increasing student debt on medical students' ultimate career plans is of particular interest to residency programs desiring to enhance recruitment, including primary care specialties. Previous survey studies of medical students indicate that amount of student debt influences choice of medical specialty. Research on this topic to date remains unclear, and few studies have included the average income of different specialties in analyses. The purpose of this study is to observe whether empirical data demonstrates an association between debt of graduating medical students and specialties into which students match. METHODS: This was a retrospective cross-sectional study of a public institution including data from graduation years 2010-2015. For each included student, total educational debt at graduation and matched specialty were obtained. Average income of each specialty was also obtained. Statistical hypothesis testing was performed to analyze any differences in average debt among specialties; subanalysis was performed assessing debt for primary care (PC) versus non-primary care (NPC) specialties. Correlation between student debt and average specialty income was also evaluated. RESULTS: One thousand three hundred ten students met the inclusion criteria and 178 were excluded for a final study population of 1132 (86%). The average debt was $182,590. Average debt was not significantly different among the different specialties (P = 0.576). There was no significant difference in average debt between PC and NPC specialties (PC $182,345 ± $64,457, NPC $182,868 ± $70,420, P = 0.342). There was no correlation between average specialty income and graduation debt (Spearman's rho = 0.021, P = 0.482). CONCLUSIONS: At our institution, student indebtedness did not appear to affect matched medical specialty, and no correlation between debt and average specialty income was observed. Different subspecialties and residency programs interested in recruiting more students or increasing diversity may consider addressing alternative factors which may have a stronger influence on student choices.

Shared decision-making across the specialties: Much potential but many challenges.

Shared decision-making (SDM) is a collaborative process through which patients and clinicians work together to arrive at a mutually agreed-upon treatment plan. The use of SDM has gathered momentum, with it being legally mandated in some areas; however, despite being a ubiquitously applicable intervention, its maturity in use varies across the specialties and requires an appreciation of the nuanced and different challenges they each present. It is therefore our aim in this paper to review the current and potential use of SDM across a wide variety of specialties in order to understand its value and the challenges in its implementation. The specialties we consider are Primary Care, Mental Health, Paediatrics, Palliative Care, Medicine, and Surgery. SDM has been demonstrated to improve decision quality in many scenarios across all of these specialties. There are, however, many challenges to its successful implementation, including the need for high-quality decision aids, cultural shift, and adequate training. SDM represents a paradigm shift towards more patient-centred care but must be implemented with continued people centricity in order to realize its full potential.

Why do trainees leave hospital-based specialty training? A nationwide survey study investigating factors involved in attrition and subsequent career choices in the Netherlands.

OBJECTIVE: To gain insight into factors involved in attrition from hospital-based medical specialty training and future career plans of trainees who prematurely left their specialty training programme. DESIGN: Nationwide online survey study. SETTING: Postgraduate education of all hospital-based specialties in the Netherlands. PARTICIPANTS: 174 trainees who prematurely left hospital-based medical specialty training between January 2014 and September 2017. MAIN OUTCOME MEASURES: Factors involved in trainees' decisions to leave specialty training and their subsequent career plans. RESULTS: The response rate was 38%. Of the responders, 25% left their programme in the first training year, 50% in year 2-3 and 25% in year 4-6. The most frequently reported factors involved in attrition were: work-life balance, job content, workload and specialty culture. Of the leaving trainees, 66% switched to another specialty training programme, of whom two-thirds chose a non-hospital-based training programme. Twelve per cent continued their career in a non-clinical role and the remainder had no specific plans yet. CONCLUSIONS: This study provides insight in factors involved in attrition and in future career paths. Based on our findings, possible interventions to reduce attrition are: (1) enable candidates to develop a realistic view on job characteristics and demands, prior to application; (2) provide individual guidance during specialty training, with emphasis on work-life balance and fit with specialty.

Swedish doctors' experiences and personality regarding medical specialty choice: a qualitative study.

OBJECTIVES: To explore an understanding of medical doctors' entire process of specialty choice with a focus on the influence of personal experiences and personality traits on choices made. METHODS: A qualitative study was performed. Semi-structured individual interviews were conducted with medical doctors undergoing their specialty training in Sweden about their experiences and personalities. The transcribed interviews were analyzed with an inductive content analysis approach. RESULTS: A total of 15 medical doctors participated. Three themes were identified using content analysis: To be invited or not, to fit in or not and to contribute or not. Furthermore, the results refute that specialty choice is a long-term, complex process. CONCLUSIONS: First, the importance of being invited to the specialty choice was stressed by the doctors, especially in their early years when they needed to feel valued and trusted. Secondly, the need to fit in was essential to make a sustainable career choice. Finally, the doctors' expressed a will to contribute to the medical field of their chosen specialty. The interviews showed that specialty choice is a long-term, complex process; therefore, one implication for the healthcare sector would be to target the entire chain of medical education to improve recruitment strategies for those specialties with recruitment difficulties. More studies are needed to understand better how positive and negative encounters within the healthcare sector can influence young doctors' specialty choice.

Historical Situatedness of Categories' Meanings in Medicine.

Dichotomies in medicine are real, and the boundaries that define them are constantly shifting. Radical antitheses such as healthy versus ill, reconstructive versus aesthetic, or medical dermatology versus cosmetic dermatology can be more clearly understood by considering the cultural context of medicine. This essay examines the latter two antitheses and asks whether medical dermatology should be a category limited to somatic illness. It also examines how the tendency to create and endorse dichotomies distorts the meaning and delivery of surgical procedures as well as reimbursement practices in contemporary medicine.

Exploring the situational motivation of medical specialists: a qualitative study.

OBJECTIVES: The aim was to obtain insight into the factors in the work environment that motivate or demotivate a medical specialist during his/her working day. METHODS: A qualitative ethnographic design was used, and a constructivist approach was adopted with the Self-Determination theory of motivation as a framework. Six medical specialists from VU University Medical Center in the Netherlands, recruited through convenience, snowball, and purposive sampling, were shadowed for one day each. Data were transcribed and open-coded. Themes were finalized through discussion and consensus. RESULTS: Sixty hours of observation data identified motivating and demotivating factors categorized into four themes that are important for specialists' motivation. Informational technology issues are demotivating factors. Working with colleagues can be both a motivating and demotivating factor, e.g., filling in for each other through feelings of relatedness was motivating. Being in control of one's planning through feelings of autonomy was motivating. Furthermore, patient care and teaching, especially in combination, stimulated specialists' motivation. Regarding the design of the study, we found that situational motivation is indeed observable. CONCLUSIONS: The basic psychological needs autonomy, competence, and relatedness are important for specialists' motivation. Investing in a more motivating, open, transparent, and basic-needs- supportive work environment for medical specialists is necessary. Keywords: Continuing professional development, motivation, medical specialists, self-determination theory, qualitative research.