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Private equity (PE) firms have been acquiring physician practices at an increasing rate, raising concerns about such firms' penetration at the physician level into local markets and the impact on health care quality and prices. However, limited knowledge exists about the extent of PE firms' control in local markets. By linking data on PE acquisitions to physician data and using full-time-equivalent physicians as the base of assessment, we estimated the local market share of each PE firm within ten physician specialties at the Metropolitan Statistical Area (MSA) level. PE-acquired physician practice sites increased from 816 across 119 MSAs in 2012 to 5,779 across 307 MSAs in 2021. Single PE firms had significant market share, exceeding 30 percent in 108 MSA specialty markets and exceeding 50 percent in 50 of those markets. The findings raise concerns about competition and call for closer scrutiny by the Federal Trade Commission, state regulators, and policy makers.

Introduction: Comprehending scientific information have been reported as a barrier in evidence-based practice (EBP) adoption. This survey research aimed to verify the preferred sources of information for acquiring knowledge about physiotherapy and the association between types of information source and barriers in EBP implementation., Methods: A total of 610 physiotherapists were included and answered an online questionnaire about the preferred sources for searching physiotherapy-related information and possible barriers in EBP implementation., Results: Physiotherapists reported scientific resources as the preferred source of information, scientific databases (31%), followed by scientific articles (25%). The main barrier cited in EBP implementation was the difficulty in obtaining full-text articles (34%), followed by lack of statistical knowledge (30%). The use of peer-reviewed resources as the most preferred source of information is associated with the presence of issues in comprehending scientific information., Discussion: Although the positive attitude toward the use of scientific information, the findings raised question regarding the proper translation of scientific information to clinical practice. The importance of scientific information seems to be a well-established attitude among physiotherapists. However, there is a clear need for strategies aiming to improve the understanding of scientific information and consequently facilitate EBP implementation., Competing Interests: Disclosures: The authors declare no conflict of interest., (Copyright © 2023 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

Purpose: In 1974, Dr. Herbert Freudenberger coined the term burnout. With the creation of the Maslach Burnout Inventory in 1984, burnout went from a pop psychology term to a highly studied phenomenon in medicine. Exponential growth in studies of burnout culminated in its adoption into the International Classification of Diseases-11 in 2022. Yet, despite increased awareness and efforts aimed at addressing burnout in medicine, many surveys report burnout rates have increased among trainees. The authors aimed to identify different discourses that legitimate or function to mobilize burnout in postgraduate medical education (PGME), to answer the question: Why does burnout persist in PGME despite efforts to ameliorate it?, Method: Using a Foucauldian discourse analysis, this study examined the socializing period of PGME as an entry point into burnout's persistence. The archive from which the discourses were constructed included over 500 academic articles, numerous policy documents, autobiographies, videos, documentaries, social media, materials from conferences, and threads in forums including Reddit., Results: This study identified 3 discourses of burnout from 1974-2019: burnout as illness, burnout as occupational stress, and burnout as existentialism. Each discourse was associated with statements of truth, signs and signifiers, roles that individuals play within the discourse, and different institutions that gained visibility as a result of differing discourses., Conclusions: Burnout persists despite effort to ameliorate it because it is a productive construct for organizations. In its current form, it depoliticizes issues of health in favor of wellness and gives voice to the challenge of making meaning from the experience of being a clinician., (Copyright © 2023 by the Association of American Medical Colleges.)

Objectives: Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full-day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients., Methods: The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model., Conclusions: The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high-quality, and evidence-based care for patients, including those with OPD., Competing Interests: Dr Friedlander is the Chief Medical Officer and Co-Founder of EvoEndo, Inc. He is an employee, stockholder, and on the board of directors of EvoEndo, Inc. He is co-inventor on several University of Colorado and EvoEndo, Inc patents and patent pendings related to virtual reality, endoscope design, endoscopic methods, endoscopic training methods, and its associated technologies. Dr Prager is a cofounder of EvoEndo, Inc. The remaining authors report no conflicts of interest., (Copyright © 2023 by European Society for European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Aim: Although the number of global studies on ECMO, which is an important support system in the treatment of COVID-19 related respiratory failure, has increased in recent months, there is still no bibliometric study on the use of ECMO in COVID-19 in the literature. The aim of this study is to analyze the scientific articles on the use of ECMO in COVID-19 by statistical and bibliometric methods., Method: Articles published between 2019-2022 about the use of ECMO in COVID-19 were obtained from the Web of Science (WoS) database and analyzed using statistical and bibliometric methods. Spearman correlation coefficient was used for correlation studies. Network visualization maps were used to identify effe analysis and trending topics., Results: A total of 1197 publications were found. 758 (63.3%) of these publications were articles. The top 3 contributing countries to the literature were USA (257, 33.9%), Germany (102, 13.4%) and Japan (87, 11.5%). The top 3 most active institutions were League of European Research Universities (90), Harvard University (50), and Udice French Research Universities (39). The top 3 journals with the highest count of publications were ASAIO Journal ( n = 36), Frontiers in Medicine (22), and Perfusion-UK ( n = 20). According to the average count of citations per article, the most influential journals were JAMA (1319), Intensive Care Medicine (327), and Lancet (95.7), respectively. We have shared a summary of 758 articles in this comprehensive bibliometric study on the use of ECMO in COVID-19., Conclusion: It can be said that the use of ECMO in COVID-19 has been the trending topic recently and most of the studies are from countries in the ELSO Awards of Excellence list which indicates that the follow-up of ECMO in certain centers and teams can also be influencing the publications. This article can be a useful resource for clinicians, scientists, and students concerning global output for ECMO use in COVID-19.

Asclepiades of Bithynia (124-40 BC) was a Greek physician who practised and taught Greek medicine in Rome. Among his many contributions, Asclepiades challenged the long-standing Hippocratic doctrine of the four humours. Influenced by Epicurean philosophy, he sought to construct a new theory of human disease, derived in part from atomic theories of chance and evolution earlier described by Democritus and Epicurus. In clinical practice, Asclepiades's approach to physical and mental illnesses was reasoned, humane, and, in many ways, ahead of its time. As a result of his many contributions and his overall approach to care, Asclepiades is now considered a pioneer of modern physical therapy, the progenitor of a more humane approach to mental illness, and, as highlighted by Yapijakis, the father of modern molecular medicine., (© 2022. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Background: With the elimination in 2021 of the United States Medical Licensing Examination Step 2 Clinical Skills test, it is incumbent upon U.S. medical schools to develop local validated assessments of clinical reasoning. While much attention has been paid to summative exams for graduating students, formative exams for pre-clerkship students have not been well studied., Methods: We applied the University of Illinois at Chicago College of Medicine (UIC-COM) Patient Note (PN) Scoring Rubric to templated PNs written by 103 pre-clerkship students for two cases in an objective structured clinical examination (OSCE) at the Yale School of Medicine. The rubric consists of four section scores (Documentation, Differential Diagnosis, Justification, and Workup, each scored 1 to 4) and a composite score (scaled 23 to 100). We calculated item discrimination for each section score and Cronbach's alpha for each case. We surveyed students about their experience writing the templated PN., Results: Mean Documentation, Differential Diagnosis, Justification, Workup, and composite scores for case A were 2.16, 1.80, 1.65, 2.29, and 47.67, respectively. For case B, the scores were 2.13, 1.21, 1.60, 1.67, and 40.54, respectively. Item discrimination ranged from 0.41 to 0.80. Cronbach's alpha for cases A and B was 0.48 and 0.25, respectively. A majority of the students felt that the exercise was useful and appropriate to their level of training., Conclusions: Despite performing poorly, pre-clerkship students found the note-writing task beneficial. Reliability of the scoring rubric was suboptimal, and modifications are needed to make this exercise a suitable measure of clinical reasoning., (© 2023. The Author(s).)

Objective: To determine whether gender and racial inequities exist among Lasker Award recipients., Design: Observational, cross sectional analysis., Setting: Population based study., Participants: Recipients of four Lasker Awards from 1946 to 2022., Main Outcome Measures: Gender and race (non-white categorized as racialized v white categorized as non-racialized) of all Lasker Award recipients. Personal characteristics of award recipients were categorized by four independent authors using previously established methods and consistency of categorization among authors was analyzed. Women and non-white people were thought to be underrepresented among Lasker Award recipients compared with professional degree recipients overall., Results: Among 397 Lasker Award recipients since 1946, 92.2% (366/397) were men. Most award recipients were identified as white (95.7%, 380/397). One non-white woman was identified as having received a Lasker Award over the course of seven decades. The proportion of women among award recipients in the most recent decade (2013-22) is similar to the first decade of awards (1946-55; 15.6%, 7/45 v 12.9%, 8/62). The median timeframe from terminal degree receipt to Lasker Award conferral for all award recipients is 30 years. The proportion of women who received a Lasker Award between 2019 and 2022 (7.1%) was less than would be expected based on the proportion of life science doctorates awarded to womenin 1989 (30 years previously; 38.1%)., Conclusions: The number of women and non-white people in academic medicine and biomedical research continues to increase, yet the proportion of women among Lasker Award recipients has not changed in more than 70 years. Additionally, time from terminal degree receipt to Lasker Award conferral does not appear to fully account for the observed inequities. These findings establish the need for further investigation of possible factors that could hinder women and non-white people from entering the pool of eligible award recipients, potentially limiting the diversification of the science and academic biomedical workforce., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study characterizes the US clinical genetics workforce to inform workforce planning and public policy development., Methods: A 32-question survey was electronically distributed to American Board of Medical Genetics and Genomics board-certified/eligible diplomates in 2019. We conducted a descriptive analysis of responses from practicing clinical geneticists., Results: Of the 491 clinical geneticists responding to the survey, a majority were female (59%) and White (79%), worked in academic medical centers (73%), and many engaged in telemedicine (33%). Clinical geneticists reported an average of 13 new and 10 follow-up patient visits per week. The average work week was 50 hours and the majority (58%) worked over half-time in clinical duties. Providers indicated that 39% of new emergency patients wait 3 days or more, and 39% of nonemergency patients wait over 3 months to be seen. Respondents were geographically concentrated in metropolitan areas and many reported unfilled clinical geneticist job vacancies at their institution of more than 3 years., Conclusion: With the rapid expansion of genomic medicine in the past decade, there is still a gap between genetics services needed and workforce capacity. A concerted effort is required to increase the number of clinical geneticists and enhance interdisciplinary teamwork to meet increasing patient needs., (© 2021. The Author(s).)

Purpose: To report trends in the number and types of applicants and matched trainees to radiation oncology in comparison to other specialties participating in the National Resident Matching Program (NRMP) between 2010 and 2020., Methods and Materials: Data from the NRMP and Electronic Residency Application System (ERAS) were obtained for 18 medical specialties between 2010 and 2020. We assessed the numbers and types of applicants and matched trainees relative to available positions in the NRMP and Supplemental Offer and Acceptance Program (SOAP)., Results: In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from a median of 187 between 2010 to 2019 (interquartile range [IQR], 170-192; P < .001). Across all 18 specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010 to 2019, in both the number of ERAS applicants from the United States and Canada (-31%) and the percentage of positions filled by US MD or DO senior graduates (-28%). Of 189 available positions, 81% (n = 154) filled in the NRMP prior to the SOAP, of which 65% (n = 122) were "matched" by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, representing a significant decrease from a median of 92% between 2010 to 2019 (IQR, 88%-94%; P = .002). The percentages of radiation oncology programs and positions unfilled in the NRMP prior to the SOAP were significantly increased in 2020 compared with 2010 to 2019 (programs: 29% vs 8% [IQR, 5%-8%; P < .001]; positions: 19% vs 4% [IQR, 2%-4%; P <.001]). Despite >99% (n = 127 of 128) of US MD or DO senior applicants preferring radiation oncology successfully matching to a radiation oncology position in the 2020 NRMP, 16 of 35 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top user of the SOAP across all specialties participating in the 2020 NRMP, filling 15% of total positions versus a median of 0.9% (IQR, 0.3%-2.3%; P <.001)., Conclusions: The supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The structure of preventive medicine residency training in the U.S. warrants serious examination. U.S. public health and general preventive medicine residencies have suffered a 17% decline in the number of residency programs since 2000, and current residency programs are, on average, half-empty. The required clinical year is not unique to preventive medicine, a basic, undifferentiated MPH for preventive medicine doesn't distinguish the preventive medicine specialist, and practicum year requirements are overly broad and not necessarily specific to the specialty, leaving the specialty vulnerable to equivalence by most other specialties. Strategies including creation of an additional preventive medicine-specific clinical year, developing a new public health degree for the specialty, and more specific practicum rotations, as well as potentially changing the specialty's name and altering the annual structure of training, are proposed along with an equivalence test., Competing Interests: Declaration of competing interest The views expressed in the article are solely the opinions of the authors and do not necessarily reflect the official policies of the U.S. Department of Health and Human Services (HHS) or the Health Resources and Services Administration (HRSA), nor does mention of the names of HHS or HRSA imply endorsement by the US government. Paul Jung and Boris D. Lushniak are both Fellows of the American College of Preventive Medicine. Dr. Lushniak is a Regent on the Board of the American College of Preventive Medicine., (Published by Elsevier Inc.)

Competing Interests: Competing interests: None declared.

Objective: To measure self-valuation, involving constructive prioritization of personal well-being and a growth mindset perspective that seeks to learn and improve as the primary response to errors, in physicians and evaluate its relationship with burnout and sleep-related impairment., Methods: We analyzed cross-sectional survey data collected between July 1, 2016, and October 31, 2017, from 5 academic medical centers in the United States. All faculty and medical-staff physicians at participating organizations were invited to participate. The self-valuation scale included 4 items measured on a 5-point (0-4) Likert scale (summative score range, 0-16). The self-valuation scale was developed and pilot tested in a sample of 250 physicians before inclusion in the multisite wellness survey, which also included validated measures of burnout and sleep-related impairment., Results: Of the 6189 physicians invited to participate, 3899 responded (response rate, 63.0%). Each 1-point score increase in self-valuation was associated with -1.10 point lower burnout score (95% CI, -1.16 to -1.05; standardized β=-0.53; P<.001) and 0.81 point lower sleep-related impairment score (95% CI, -0.85 to -0.76; standardized β=-0.47; P<.001), adjusting for sex and medical specialty. Women had lower self-valuation (Cohen d=0.30) and higher burnout (Cohen d=0.22) than men. Lower self-valuation scores in women accounted for most of the sex difference in burnout., Conclusion: Low self-valuation among physicians is associated with burnout and sleep-related impairment. Further research is warranted to develop and test interventions that increase self-valuation as a mechanism to improve physician well-being., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objective: Pediatric aerodigestive programs appear to be rapidly proliferating and provide multidisciplinary, coordinated care to complex, medically fragile children. Pediatric subspecialists are considered essential to these programs. This study evaluated the state of these programs in 2017 by surveying their size, composition, prevalence, and the number of patients that they serve., Methods: The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Aerodigestive Special Interest Group leadership distributed an 11-question survey to the Pediatric Gastroenterology International Listserv. The mean time of the programs' existence, number of half-day clinics, number of procedure days, number of patients evaluated, and the lead primary specialty were evaluated., Results: Thirty-four programs responded. Twenty-five were based in academic centers. Thirty-one programs were located across the United States. The average time of program existence was 5.3 years (standard deviation [SD] = 4.3; range 1-17 years). Approximately 64.7% were started in the past 5 years. Twelve programs were based in the division of gastroenterology. The average number of gastroenterologists serving aerodigestive programs was 2 (SD = 1.1). The mean number of half-day clinic sessions and procedure days were 2.8 (SD = 2.9) and 2.6 (SD = 2), respectively. New and follow-up visits per year in each program averaged 184 (SD = 168; range 10-750)., Conclusions: Pediatric aerodigestive programs are prevalent, proliferating, and serve a large number of complex patients across North America and the world. This survey demonstrated that programs are predominantly based in academic settings. The number of patients cared for by aerodigestive centers varies widely depending on size and age of program.

Importance: National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined., Objective: To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians., Design, Setting, and Participants: This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics., Exposures: Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%)., Main Outcomes and Measures: Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit., Results: Overall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services., Conclusions and Relevance: Overuse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.

The aim of this brief review article is to help to reconcile medicine with evolutionary biology, a subject that should be taught in medical school. Evolutionary medicine takes the view that contemporary ills are related to an incompatibility between the environment in which humans currently live and their genomes, which have been shaped by diferent environmental conditions during biological evolution. Human activity has recently induced acute environmental modifications that have profoundly changed the medical landscape. Evolutionary biology is an irreversible, ongoing and discontinuous process characterized by periods of stasis followed by accelerations. Evolutionary biology is determined by genetic mutations, which are selected either by Darwinian selective pressure or randomly by genetic drift. Most medical events result from a genome/environment conflict. Some may be purely genetic, as in monogenic diseases, and others purely environmental, such as traffic accidents. Nevertheless, in most common diseases the clinical landscape is determined by the conflict between these two factors, the genetic elements of which are gradually being unraveled Three examples are examined in depth:--The medical consequences of the greenhouse effect. The absence of excess mortality during recent heat waves suggests that the main determinant of mortality in the 2003 heatwave was heatstroke and old age. The projected long-term effects of global warming call for research on thermolysis, a forgotten branch of physiology.--The hygiene hypothesis postulates that the exponential rise in autoimmune and allergic diseases is linked to lesser exposure to infectious agents, possibly involving counter-regulatory factors such as IL-10.--The recent rise in the incidence of obesity and type 2 diabetes in rich countries can be considered to result from a conflict between a calorie-rich environment and gene variants that control appetite. These variants are currently being identified by genome-wide analysis. Biological evolution should be taken into account in future holistic health policies.

On the basis of 3 surveys conducted among French physicians in 1967, 1977 and 2007, the study aims at identifying the current state and the developments during the recent decades of certain aspects related to medical practice: distribution of physicians according to the place of work, their weekly working time, the time they devote to medical readings, the means they utilize for continuing education. In 2007, out of 100 active physicians, 60 are in private practice, 19 work in university hospitals, 23 in other hospitals, 19 in health centers, 6 in the expertise societies or the control departments of sickness insurance funds, 17 in other medical activities and 11 carry out non-medical activities. Each of these figures includes the professionals having other activities elsewhere. These physicians in poly-practice are 47 percent of the medical profession nowadays, they were 58 percent 3 decades earlier. In other words, mono-practice, or exclusive practice, is fastly expanding. The weekly working time of medical doctors in 2007 is 47.9 hours, as compared to 37.9 hours in the whole active population in France. The working time of female doctors (42.4 hours) is much shorter than that of their male colleagues (52.3 hours). However, during the period 1977-2007, the salient feature was that physicians reduced sharply their time of work, from 52.9 hours to 47.9 hours. The decrease was an affair of men, as female doctors have not shortened their own time. Similarly, time shortening was mostly an affair of young and middle-aged physicians, whereas their senior colleagues have performed only a slight reduction. As a result, in 2007, the physicians aged 55 years and over have the longest working time (48.7 hours) as compared to the work week of 46 hours of physicians aged under 40. During the last 3 decades, the time devoted to medical readings has also decreased: 4.3 hours a week in 1977, and only 2.9 hours in 2007, a rhythm 3 times faster than the reduction of the working time. The time devoted to medical readings was equivalent to 8 percent of the working time in 1977 but the ratio decreased to 6 percent nowadays. However, surprisingly, the medical journals and textbooks remain today among the most popular tools quoted by French physicians among the means they utilize for their continuing education. The fact does not hide the spectacular expansion of the medical congresses which were less frequently quoted in the past, and the brutal emergence of internet on the stage of medical continuing education.

In France, ambulatory care is provided to patients mostly by independent physicians, GPs and specialists, paid on a fee-for-service basis. A national agreement between the Sickness Insurance Fund and the medical associations sets the price of different medical services. Due to the numerus clausus imposed upon the medical schools since the 70's, the yearly number of new graduates has sharply decreased and a feeling of manpower shortage has spread throughout the health system, in the public hospitals and the ambulatory care sector as well. Moreover increased dissatisfaction has been perceived among independent practitioners (they were 56 % of all the medical profession in early 2004). In this context, an opinion survey was undertaken among a sample of 3000 independent doctors whose one thousand have answered to the postal questionnaire.

Objective: To determine whether care for children was more consistent with national asthma guidelines when a specialist rather than a generalist was the usual source of asthma care., Design: Cross-sectional survey., Setting: Two large managed care organizations in the United States., Participants: A total of 260 parents of children with asthma., Interventions: None., Main Outcome Measures: Parent reports of the physician primarily responsible for asthma care (specialist, generalist, or both equally) and whom they would call (specialist or generalist) for questions about asthma care were used to define usual source of care. We assessed consistency of care with 1997 National Asthma Education and Prevention Program guidelines using 11 indicators in 4 domains of asthma care: patient education, control of factors contributing to asthma symptoms, periodic physiologic assessment and monitoring, and proper use of medications., Results: In all 4 domains, care was more likely to be consistent with guidelines when specialists were the usual source of care. These differences remained after adjustment for symptom severity, recent care encounters, and parent demographics. Greatest differences for specialist versus generalist management were for use of controller medications (odds ratio [OR] 6.7; 95% confidence interval [CI]: 1.5-30.4), ever having a pulmonary function test (OR 6.5; 95% CI: 2.4-18.1), and having been told about asthma triggers and how to avoid them (OR 5.9; 95% CI: 1.3-26.2)., Conclusions: In these managed care organizations, asthma care in children was more likely to be consistent with national guidelines when a specialist was the primary provider. Greater use of specialists or altering generalist physicians' care may improve the degree to which the care of children with asthma is consistent with national guidelines.

This paper summarizes a communication presented at the Second International Conference of Nuclear Cardiology, held in Cannes on 23-26 April 1995. The general evolution of nuclear medicine in Europe is examined within the context of European Union Directives, and the role of the Union of European Medical Specialists/Section of Nuclear Medicine is discussed. Thereafter consideration is given to the technical aspects of cardiovascular nuclear medicine procedures, and the situation with respect to such procedures in European countries is examined. In most European countries, nuclear medicine is a recognized specialty, while "nuclear cardiology" does not exist in its own right. In general, only nuclear medicine specialists have the responsibility for radionuclide studies, and most cardiovascular studies are performed under the direct responsibility of a licensed nuclear medicine specialist.

For about three years psychotherapy has been introduced as a must for any medical student in the USSR. The author describes the policies behind this important step, its implementation, and first effects in detail. Psychotherapeutical services for the hospitalized, for crisis intervention, ambulant teams, its significance for surgery, and the delivery of psychotherapeutical short term programs in spas are described. The significance of psychotherapeutical work as a link between the specialized medical branches is stressed.