The Council on Graduate Medical Education (COGME) recently elected F. Marian Bishop, Ph.D., M.S.P.H., as its new vice-chair. Bishop is currently professor and chair emeritus of the University of Utah School of Medicine’s Department of Family and Preventive Medicine, Salt Lake City. The COGME advises the Department of Health and Human Services (HHS) Secretary and Congress on physician workforce trends, training issues and financing policies. The council also makes recommendations about the supply and distribution of physicians and the appropriate efforts of hospitals, medical schools, and accrediting bodies to deliver health care to the nation. Bishop has been president of the STFM and the Association of Teachers of Preventive Medicine, and has served on the National Health Service Corps Advisory Council and the Executive Committee of the National Board of Medical Examiners.

Case Study

TC is a 24-year-old woman who comes to your office for a well-woman visit. Her last physical examination was at age 16 with her pediatrician. She has been sexually active since the age of 15 and has had three “lifetime” partners. TC has been monogamous with her current partner since they were married four months ago. She is currently taking oral contraceptive pills and has used condoms inconsistently in the past. TC has had two miscarriages and also has a family history of breast cancer. She has never been tested for sexually transmitted infections and asks if this is necessary.

The case study and answers to the following questions on screening for chlamydia are based on the recommendations of the current U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2001 and is an update of the 1995 USPSTF Recommendations and Rationale Statement on screening for chlamydial infection. More detailed information on this subject is available in the Systematic Evidence Review, Summary of the Evidence, and USPSTF Recommendations and Rationale on the AHRQ ; through the National Guideline Clearinghouse ;and in print through the AHRQ Publications Clearinghouse (800-358-9295) and the April 2001 Supplement to the American Journal of Preventive Medicine.

Because FIPSE is so well known for its support of innovation and reform in numerous other areas, few outside of the education field have appreciated the centrality of its role in sponsoring innovations in the medical and health sciences. These changes have been varied and far reaching, and they have addressed some of the basic concerns about the provision of health services and medical training in this country. Some were motivated by notions that health service providers can be poor communicators or lack empathy. Others focused on the problem of assessing clinical competencies, exacerbated by concerns of the patients upon whom students practiced their new skills. Still others arose from the perception that the specific health needs of some groups were not receiving enough attention.

The demand to better prepare health-care providers in these and other areas collided with a curriculum that has exploded with so much content that it is often unmanageable–even while many are urging the addition of new content and altered pedagogy to provide more relevant learning and to motivate students to become more active participants in the learning process. And all of these demands come at a time when diminished funding within the health sciences has made innovation difficult.

FIPSE’ s role in supporting change has therefore been vital. But why FIPSE? Because no one else offers significant funding for research and innovation in medical and health education. The National Institutes of Health (NIH) has had and continues to have an essential and respected role in funding fundamental and clinical research in medicine and health, but support of education has not been part of its mandate. From its founding onward, the National Science Foundation (NSF) has supported science education, including pre-medical education, but as a matter of policy excludes the applied clinical sciences from all of its funding programs. So there is no agency other than FIPSE whose primary mission includes support for change in medical and health education.

Medical residents should be limited to working 80 hours per week, according to final standards on resident duty hours announced by the Accreditation Council for Graduate Medical Education (ACGME).

In the wake of disquieting reports of medical errors with sometimes fatal outcomes and increasing concern that sleep deprivation among young doctors could be dangerous for them and for their patients, groups such as the Washington, D.C.-based advocacy group Public Citizen, the American Medical Student Association (AMSA) and the Committee of Interns and Residents (CIR) have been lobbying medical organizations and government officials for stricter limits on medical residents’ work hours. (See “The Doctor Is Still In,” HR Magazine, February 2002.)

ACGME is a private organization that accredits about 7,800 medical residency education programs in 26 specialties. Residency programs that fail to comply with the new standards could endanger their accreditation. The new standards were issued Feb. 17 and will take effect July 1.

The 80-hour duty period will include in-house calls and will be averaged over four weeks. “Under limited circumstances, residency programs may be allowed to increase duty hours by 10 percent if doing so is necessary for optimal resident education and patient care,” ACGME said. Duty hours include time spent on such activities as patient care, administrative duties related to patient care and academic activities.

The standards also include the following provisions:

* Residents must be given one day out of seven free from all clinical and educational responsibilities, averaged over four weeks.

* Residents cannot be scheduled for in-house call more than once every three nights, averaged over four weeks.

* Duty periods cannot last for more than 24 consecutive hours, but residents can remain on duty for up to six additional hours to hand off patients to new teams of caregivers, maintain continuity of care or participate in educational activities.

* Residents must be given adequate time for rest and personal activities. They should have a minimum of 10 hours between daily duty periods and after in-house call.

Residency programs that fail to comply with the standards can be placed on probation or have their accreditation withdrawn.

Healthcare organizations employ many technologies to reduce medical errors and improve patient safety. In hospitals, for example, bar coding lowers the risk of medication errors. In many physician group practices, electronic medical record systems display drug interaction alerts in computerized order entry. Recently, some exciting new technologies have been developed to protect patients from another source of medical error: the “learning curve.”

Learning any new skill means making mistakes, a normal part of the learning process. Learning medical procedures traditionally has meant making mistakes on real patients. Hands-on, experiential learning is indispensable for healthcare professionals during their training, but mistakes can put patients at risk–at times, at serious risk.

Who would want to be the first patient undergoing a colonoscopy at the hands of a new gastroenterology resident? The physician faculty supervising that resident is responsible for calibrating a cautious balance. Intervene too early and take control of the procedure too quickly, and the resident’s learning experience is diminished. Wait too long before taking the hand piece away from the resident, and the patient may experience undue discomfort, or worse, a potentially serious complication. What if that resident had the opportunity to safely learn, practice and repeat the procedure over and over, as often as necessary–so that he could learn from his mistakes and correct them, fine-tune his technique, and master clinical protocols designed to optimize outcomes–before performing a colonoscopy on an actual patient? Today, medical simulation technology makes this a “virtual” reality.

InterAct courses come in many shapes and sizes.

Some InterAct courses include video on CD, some come with an audio track with PowerPoint presentations, and others are completely Web-based text courses. No matter what the format, InterAct courses can be taken on virtually any home or office computer.

Full InterAct courses include online sessions with faculty. These sessions are 3 to 6 weeks in length, but you don’t ever have to be online at a particular time of day. The discussions and case studies that take place during the scheduled online sessions are required for graduate degree or board certification credit.

InterAct Express courses do not include a scheduled online session. These are complete, self-study courses that you take at your own pace as your schedule permits.

Graduate degree and board certification credit

Most InterAct courses provide credit toward graduate management degrees with our university partners: Carnegie Mellon University, Tulane University, University of Massachusetts and University of Southern California.  The credit can also be used toward board certification with the certifying commission in medical management.

ACPE InterAct Courses

Here’s a catalog of our current InterAct courses and a brief course description.

Ethical Challenges of Physician Executives

** How much treatment is too much when a patient is terminally ill?

** When an HIV patient practices risky behavior, how do you balance the patient’s right to privacy against public welfare?

** Informed consent, confidentiality, ethics in managed care and the physician and organization’s roles are the focus of this course.

In letter ruling 200521003, the IRS held that tuition paid to a school program to help dyslexic children deal with their condition was an IRC section 213(a) deductible medical expense. The ruling broadens–albeit slightly–the definition of the kinds of payments that qualify as deductible medical costs. CPAs, however, should be aware of the ruling’s inherent limits and be prepared to address the other restrictions on the medical deduction.

OVERVIEW

In the ruling, the taxpayers’ two children were diagnosed with disabilities caused by medical conditions (including dyslexia) that handicapped their ability to learn. The taxpayers enrolled the children in a school that provided them with special education designed to enable them to cope.

HOLDING AND ANALYSIS

The IRS first explained that “normal education” is not medical care, because it is not designed to overcome a medical disability. For education to be considered medical care, a physician or other qualified professional must diagnose a medical condition that requires special education to correct it. Although a school need not hire doctors, it must have professional staff-competent to design and supervise a curriculum providing such care. Overcoming the disability must be a primary reason for the child’s attending the school; any ordinary education received must be incidental to that.

The IRS ruled that the children were attending the school principally to receive medical care in the form of special education in the years they were diagnosed as having a medical condition that hindered their ability to learn. Thus, the taxpayers can deduct tuition as a section 213(a) medical expense for the years the children continue to be diagnosed as medically handicapped. Citing revenue ruling 69-607, the IRS further held that dyslexia could be sufficiently severe as to be such a handicap.

This ruling expands the types of tuition payments that may be deductible as medical expenses. It refutes the presumption that educational institutions must be “special schools” for their tuition to be deductible. It confirms that tuition for programs designed to enable dependents to deal with a diagnosed medical handicap–such as dyslexia–qualifies as a medical deduction, as long as other requirements are met.

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of January 2003. This issue has been reviewed and is acceptable for up to 4 Prescribed credit hours. Thirty minutes of these credit hours conform to AAFP criteria for evidence-based CME content. When reporting CME credit hours, AAFP members should report total Prescribed credit hours earned for this activity. It is not necessary for members to label credit hours as evidence-based or Prescribed for CME reporting purposes.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 4 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

Sponsored by the University of Nebraska Medical Center, Center for Continuing Education

To obtain CME credits, complete the test below, following these guidelines:

1. Read each article carefully.

2. Choose the most appropriate response to each of the following questions and record these on the registration form. Unanswered questions are considered incorrect.

3. Send the completed registration form and your payment (check, money order. VISA, MasterCard, American Express) to the Center for Continuing Education, University of Nebraska Medical Center (UNMC).

4. After your test has been graded, you will receive a receipt, a copy of the correct answers, and a credit statement certifying completion from the UNMC. Questions about the test should be addressed to UNMC Center for Continuing Education (402-559-4152).

Credit: The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Nebraska Medical Center, Center for Continuing Education designates this educational activity for a maximum of 3 hours in category 1 credit towards the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

This CME activity was planned and produced in accordance with the ACCME Essentials.

AIM: To introduce palliative care into undergraduate medical and nursing education, and to ascertain if such training improved students’ knowledge of palliative care. MATERIALS AND METHODS: Third year nursing students and fourth year medical students at the St John’s National Academy of Medical Sciences, Bangalore had five weekly lectures in palliative care. A 20 item questionnaire was administered to 4th year medical students before and after the educational intervention, and again after one year. The same questionnaire was administered to the control group of final year medical students. The questionnaire for 3rd and 4th year nursing students had 15 questions. RESULTS: The mean scores for medical students was 9.08 (S.D 2.5) in the pretest, 10.43 (S.D 1.63) in post-test I, and 8.43 (SD 1.36) in post test 2. The control group scored 8.36 (SD 2.52). The mean scores for nursing students was 8.7 (S.D 1.8) in the pretest, 10.73 (SD 2.63) in post test 1 and 8.23 (SD 4.1) in post test 2. The control group scored 8.13 (SD 2.39). CONCLUSION: There was no lasting improvement in knowledge scores in both groups of students. Inclusion of palliative care in the undergraduate teaching of medical and nursing students in India is feasible, but thought needs to be given to the curriculum content, teaching methods and evaluation techniques.

Introduction

Palliative care is now included in undergraduate medical and nursing training in many western countries. Although palliative care came to India nearly two decades ago, till recently no medical or nursing college had palliative care teaching for undergraduate students. The introduction of palliative care into undergraduate medical and nursing training is a necessary step in the development of a formal system of education and registration of palliative care in India. St.John’s National Academy of Health Sciences first introduced palliative care into undergraduate medical and nursing curriculum in 2001.This paper is an evaluation of the first year of our programme.