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Abstract Background Sub-Saharan Africa suffers a disproportionate share of the world's burden of disease while having some of the world's greatest health care workforce shortages. Doctors are an important component of any high functioning health care system. However, efforts to strengthen the doctor workforce in the region have been limited by a small number of medical schools with limited enrolments, international migration of graduates, poor geographic distribution of doctors, and insufficient data on medical schools. The goal of the Sub-Saharan African Medical Schools Study (SAMSS) is to increase the level of understanding and expand the baseline data on medical schools in the region. Methods The SAMSS survey is a descriptive survey study of Sub-Saharan African medical schools. The survey instrument included quantitative and qualitative questions focused on institutional characteristics, student profiles, curricula, post-graduate medical education, teaching staff, resources, barriers to capacity expansion, educational innovations, and external relationships with government and non-governmental organizations. Surveys were sent via e-mail to medical school deans or officials designated by the dean. Analysis is both descriptive and multivariable. Results Surveys were distributed to 146 medical schools in 40 of 48 Sub-Saharan African countries. One hundred and five responses were received (72% response rate). An additional 23 schools were identified after the close of the survey period. Fifty-eight respondents have been founded since 1990, including 22 private schools. Enrolments for medical schools range from 2 to 1800 and graduates range from 4 to 384. Seventy-three percent of respondents (n = 64) increased first year enrolments in the past five years. On average, 26% of respondents' graduates were reported to migrate out of the country within five years of graduation (n = 68). The most significant reported barriers to increasing the number of graduates, and improving quality, related to infrastructure and faculty limitations, respectively. Significant correlations were seen between schools implementing increased faculty salaries and bonuses, and lower percentage loss of faculty over the previous five years (P = 0.018); strengthened institutional research tools (P = 0.00015) and funded faculty research time (P = 0.045) and greater faculty involvement in research; and country compulsory service requirements (P = 0.039), a moderate number (1-5) of post-graduate medical education programs (P = 0.016) and francophone schools (P = 0.016) and greater rural general practice after graduation. Conclusions The results of the SAMSS survey increases the level of data and understanding of medical schools in Sub-Saharan Africa. This data serves as a baseline for future research, policies and investment in the health care workforce in the region which will be necessary for improving health.

Abstract Background The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States. Methods This is a secondary data analysis of the 1996–1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week. Results Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs. Conclusion There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

Editorial. Focuses a series of articles to begin with this issue entitled, `Profiles in Primary Care.' The series being drawn from oral histories of general practitioners; Historical context for the series; Reason for choosing the oral history genre; The method for selecting physicians to profile.

Objective: To evaluate pharmacy, dental and dental therapy undergraduate students' perceived competence of interprofessional working before and after attending an interprofessional education (IPE) Gerodontology workshop., Background: Whilst there is international recognition of the importance of collaboration between the dental profession and systemic healthcare providers to enhance patient care, there remains a paucity of research into IPE in Gerodontology., Materials and Methods: Pharmacy, dental and dental therapy undergraduate students attended a 2-hour Gerodontology case-based workshop. Students completed anonymised Interprofessional Collaborative Competencies Attainment Surveys (ICCAS) before and after attendance., Results: 108 questionnaires were received, 7 were withdrawn (1 incomplete with only pre-workshop side completed, 6 did not identify degree programme). From 101 included questionnaires, 37 were from pharmacy, 56 dental and 8 dental therapy students resulting in response rates of 84%, 82% and 67%, respectively. Each student group recorded an increase in positive reflective competence median (IQR) after taking part in the workshop. Overall median (IQR) reflective competence before the workshop was 6 (1), 5 (2) and 6 (2) for pharmacy, dental and dental therapy students, respectively, which increased to 7 (1) for all groups. There was variability in reflective competence before attending the workshop between dental and pharmacy students for two questions, and dental and dental therapy students for two different questions., Conclusion: All students reported increased reflective competence of interprofessional working following the workshop. These findings suggest that introduction of IPE events into Gerodontology curricula may improve student understanding and appreciation of interprofessional working when providing care for older people., (© 2022 The Authors. Gerodontology published by Gerodontology Association and John Wiley & Sons Ltd.)

Nationwide disparities in managing neurological patients have rarely been reported. We compared neurological health care between the population who reside in a Health and Social Care Trust with a tertiary neuroscience center and those living in the four non-tertiary center Trusts in Northern Ireland. Using the tertiary center Trust population as reference, neurodisparity indices (NDIs) defined as the number of treated patients resident in each Trust per 100,000 residents compared to the same ratio in the tertiary center Trust for a fixed time period. NDIs were calculated for four neurological pathways-intravenous thrombolysis (iv-tPA) and mechanical thrombectomy (MT) for acute ischemic stroke (AIS), disease modifying treatment (DMT) in multiple sclerosis (MS) and admissions to a tertiary neurology ward. Neurological management was recorded in 3,026 patients. Patients resident in the tertiary center Trust were more likely to receive AIS treatments (iv-tPA and MT) and access to the neurology ward ( p < 0.001) than patients residing in other Trusts. DMT use for patients with MS was higher in two non-tertiary center Trusts than in the tertiary center Trust. There was a geographical gradient for MT for AIS patients and ward admissions. Averaged NDIs for non-tertiary center Trusts were: 0.48 (95%CI 0.32-0.71) for patient admissions to the tertiary neurology ward, 0.50 (95%CI 0.38-0.66) for MT in AIS patients, 0.78 (95%CI 0.67-0.92) for iv-tPA in AIS patients, and 1.11 (95%CI 0.99-1.26) for DMT use in MS patients. There are important neurodisparities in Northern Ireland, particularly for MT and tertiary ward admissions. Neurologists and health service planners should be aware that geography and time-dependent management of neurological patients worsen neurodisparities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 McCarron, Clarke, Burns, McCormick, McCarron, Forbes, McCarron, Mullan and McVerry.)

The social mission, which is focused on advancing social justice and health equity, has gained recognition as an important aspect of health professions education. However, there is currently no established method to measure a school's commitment to these activities. In this Perspective, the authors describe the development of a new tool to measure the social mission at dental, medical, and nursing schools across the United States, and they reflect on the implications of using this tool to deepen discussions around the social mission and strengthen progress toward health equity.From 2016 to 2019, the authors created and field tested the online social mission metrics survey for health professions schools to identify their level of engagement in social mission activities, track that level over time, and compare their progress with that of other schools. The survey measures a school's social mission values, programs, and activities across 6 domains and 18 activity areas. The authors also developed a scoring system based on stakeholder priorities, which they used to provide customized, confidential feedback to the schools that participated in the field tests.Going forward, the authors recommend that schools complete the survey every 3 to 5 years to track their social mission over time, and they plan to expand the survey process to additional dental, medical, and nursing schools as well as to schools in other health professions. The social mission metrics survey is meant to be a useful tool for improving the level and quality of social mission engagement at health professions schools, with the goal of improving the awareness, skills, and commitment of health professionals to health equity.

Background: The epidemiology of multiple sclerosis (MS) is important for planning disease modifying therapy (DMT). Secular changes in the use of DMT in MS can guide future service development., Methods: A population study of the prevalence of multiple sclerosis was completed in the west of Northern Ireland - a defined geographic area making up the Western Health and Social Care Trust (WHSCT). The use, category and cost of DMT for the MS population in the WHSCT were measured over 11 years., Results: The WHSCT had a recorded prevalence of MS of 238.4/100,000 (95%CI 221.5-256.5) in 2018. DMT use increased over threefold in 11 years. Four hundred and nine (57%) of 720 MS patients were taking a DMT by 2018. The annual expenditure of DMT drugs had increased sixfold over ten years to £5,301,198 in 2018 (using 2018 prices), reflecting both an increase in DMT use and a switch to more intensive DMTs. Younger MS patients were more likely to be taking a DMT (P<0.001)., Conclusion: DMT use and cost have been increasing among the MS population in the Northern Ireland. There has been a temporal switch to more efficacious DMTs. Future research should monitor the cost-effectiveness and equity of treatment of MS patients., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The ideals of health equity continue to be constrained by the conditions in which people live, learn and work. But to what extents are nursing schools strengthening the preparedness of nurses to extend their reach and help individuals and communities achieve their highest level of health? A culture of health and health equity is built on a framework of social mission. The authors believe that social mission is not new to the nursing profession. However, a clear understanding of the historical evolution of social mission as it relates to nursing education could provide a solid foundation for understanding the extent to which nursing curricula aligns with a commitment to advancing healthcare outcomes. This manuscript is a commentary that outlines the foundational understanding of the history of social mission in nursing education through the present time and amplifies that educators should consider how adopting a social mission lens could help schools more effectively align their curricula, policies and practices with health equity. Social mission refers to the school's commitment to advance health equity in everything it does from admissions and faculty hiring policies, to curriculum development, the extent of community based experiential learning, and, ultimately measured in their graduates' outcomes (Mullan, 2017). It is the authors' view that the rich history, the magnitude of the sector, and the current transformational conversations occurring in the nursing profession, all call for a deeper analysis and engagement of nursing leaders in this topic., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Social mission refers to a set of concepts and perspectives that promote health equity in health care delivery and within health professions. Little is known about social mission within the context of nursing education. This article clarifies the role of social mission in nursing education, offers current applications, and identifies future opportunities to maximize social mission within nursing to foster a more just culture of health., Method: A multidisciplinary advisory board of experts in nursing education convened to review pertinent literature, current case exemplars, and craft a conceptual framework of social mission in nursing education., Results: The resulting framework consisted of three action-oriented domains to implement social mission into nursing education: board accreditation, curriculum building and faculty training, and developing institutional culture., Conclusion: Successful implementation of social mission into nursing education, and subsequently the nursing workforce, offers the opportunity to further embed equity into health care. [J Nurs Educ. 2020;59(8):433-438.]., (Copyright 2020, SLACK Incorporated.)

Objective: The National Health Service Corps (NHSC) is a federal program to increase the supply of health professionals in underserved communities, but its role in enhancing the capacity of community health centers (CHCs) has not been investigated. This study examined the role of NHSC clinicians in improving staffing and patient care capacity in primary, dental, and mental health care in CHCs., Methods: Using 2013-2016 administrative data from CHCs and the NHSC, we used a generalized estimating equation approach to examine whether NHSC clinicians [staff full-time equivalents (FTEs)] complement non-NHSC clinicians in CHCs and whether their productivity (patient visits per staff FTE) was greater than that of non-NHSC clinicians in primary, dental, and mental health care., Results: Each additional NHSC clinician FTE was associated with a significant gain of 0.72 non-NHSC clinician FTEs in mental health care in CHCs and an increase of 0.04 non-NHSC FTEs in primary care in CHCs with more severe staffing shortages. On average, every additional NHSC clinician was associated with an increase of 2216 primary care visits, 2802 dental care visits, and 1296 mental health care visits per center-year. The adjusted visits per additional staff for NHSC clinicians were significantly greater in dental (difference=992) and mental health (difference=423) care, compared with non-NHSC clinicians., Conclusions: The NHSC clinicians complement non-NHSC clinicians in primary care and mental health care. They help enhance the provision of patient care in CHCs, particularly in dental and mental health services, the 2 major areas of service gaps.

MEPI was a $130 million competitively awarded grant by President's Emergency Plan for AIDS Relief (PEPFAR) and National Institutes of Health (NIH) to 13 Medical Schools in 12 Sub-Saharan African countries and a Coordinating Centre (CC). Implementation was led by Principal investigators (PIs) from the grantee institutions supported by Health Resources and Services Administration (HRSA), NIH and the CC from September, 2010 to August, 2015. The goals were to increase the capacity of the awardees to produce more and better doctors, strengthen locally relevant research, promote retention of the graduates within their countries and ensure sustainability. MEPI ignited excitement and stimulated a broad range of improvements in the grantee schools and countries. Through in-country consortium arrangements African PIs expanded the programme from the 13 grantees to over 60 medical schools in Africa, creating vibrant South-South and South-North partnerships in medical education, and research. Grantees revised curricular to competency based models, created medical education units to upgrade the quality of education and established research support centres to promote institutional and collaborative research. MEPI stimulated the establishment of ten new schools, doubling of the students' intake, in some schools, a three-fold increase in post graduate student numbers, and faculty expansion and retention.Sustainability of the MEPI innovations was assured by enlisting the support of universities and ministries of education and health in the countries thus enabling integration of the new programs into the regular national budgets. The vibrant MEPI annual symposia are now the largest medical education events in Africa attracting global participation. These symposia and innovations will be carried forward by the successor of MEPI, the African Forum for Research and Education in Health (AFREhealth). AFREhealth promises to be more inclusive and transformative bringing together other health professionals including nurses, pharmacists, and dentists., Competing Interests: The authors have no competing interests to declare., (© 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.)

Background: Despite considerable federal investment, graduate medical education financing is neither transparent for estimating residency training costs nor accountable for effectively producing a physician workforce that matches the nation's health care needs. The Teaching Health Center Graduate Medical Education (THCGME) program's authorization in 2010 provided an opportunity to establish a more transparent financing mechanism., Objective: We developed a standardized methodology for quantifying the necessary investment to train primary care physicians in high-need communities., Methods: The THCGME Costing Instrument was designed utilizing guidance from site visits, financial documentation, and expert review. It collects educational outlays, patient service expenses and revenues from residents' ambulatory and inpatient care, and payer mix. The instrument was fielded from April to November 2015 in 43 THCGME-funded residency programs of varying specialties and organizational structures., Results: Of the 43 programs, 36 programs (84%) submitted THCGME Costing Instruments. The THCGME Costing Instrument collected standardized, detailed cost data on residency labor (n = 36), administration and educational outlays (n = 33), ambulatory care visits and payer mix (n = 30), patient service expenses (n =  26), and revenues generated by residents (n = 26), in contrast to Medicare cost reports, which include only costs incurred by residency programs., Conclusions: The THCGME Costing Instrument provides a model for calculating evidence-based costs and revenues of community-based residency programs, and it enhances accountability by offering an approach that estimates residency costs and revenues in a range of settings. The instrument may have feasibility and utility for application in other residency training settings., Competing Interests: Conflict of interest: The authors declare they have no competing interests. The opinions expressed are those of the authors and not necessarily those of the Health Resources and Services Administration or the US Department of Health and Human Services.

Objectives: To assess the precision of optical profilometry for characterising the 3D surface roughness of natural and polished human enamel in order to reliably quantify acid mediated surface roughness changes in human enamel., Methods: Forty-two enamel samples were prepared from extracted human molars and either polished flat or left unmodified. To investigate precision, the variability of thirty repeated measurements of five areas of one polished and one natural enamel sample was assessed using 655nm Confocal Laser Profilometry. Remaining samples were subjected to forty-five minutes orange juice erosion and microstructural changes were analysed using Sa roughness change (μm) and qualitatively using surface/subsurface confocal microscopy., Results: Enamel surface profilometry from the selected areas revealed maximal precision of 5nm for polished enamel and 23nm for natural enamel. After erosion, the polished enamel revealed a 48% increase in mean (SD) Sa roughness of 0.10 (0.07)μm (P<0.05), whereas in contrast the natural enamel revealed a 45% decrease in mean (SD) roughness of -0.32 (0.42)μm (P<0.05). These data were supported by qualitative confocal images of the surface/subsurface enamel., Significance: This study demonstrates a method for precise surface texture measurement of natural human enamel. Measurement precision was superior for polished flat enamel in contrast to natural enamel however, natural enamel responds very differently to polished enamel when exposed to erosion challenges. Therefore, thus future studies characterising enamel surface changes following erosion on natural enamel may provide more clinically relevant responses in comparison to polished enamel., (Copyright © 2017 The Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.)

Objectives: To investigate the differences in susceptibility of the surface of native and polished enamel to dietary erosion using an in-situ model., Methods: Thirty healthy volunteers (n = 10 per group) wore mandibular appliances containing 2 native and 2 polished enamel samples for 30 min after which, the samples were exposed to either an ex-vivo or in-vivo immersion in orange juice for 5, 10 or 15 min and the cycle repeated twice with an hour's interval between them. Samples were scanned with a non-contacting laser profilometer and surface roughness was extracted from the data, together with step height and microhardness change on the polished enamel samples., Results: All volunteers completed the study. For native enamel there were no statistical difference between baseline roughness values versus post erosion. Polished enamel significantly increased mean (SD) Sa roughness from baseline for each group resulting in roughness change of 0.04 (0.03), 0.06 (0.04), 0.04 (0.03), 0.06 (0.03), 0.08 (0.05) and 0.09 (0.05) μm respectively. With statistical differences between roughness change 45 min in-vivo versus 45 min ex-vivo (p < 0.05). Microhardness significantly decreased for each polished group, with statistical differences in hardness change between 30 min in-vivo versus 30 min ex-vivo (p < 0.05), 45 min in-vivo versus 30 min ex-vivo (p < 0.01), 45 min in-vivo versus 45 min ex-vivo (p < 0.01)., Conclusions: The native resistance to erosion provided clinically is a combination of the ultrastructure of outer enamel, protection from the salivary pellicle and the overall effects of the oral environment. CLINICALTRIALS., Gov Identifier: NCT03178968., Clinical Significance: This study demonstrates that outer enamel is innately more resistant to erosion which is clinically relevant as once there has been structural breakdown at this level the effects of erosive wear will be accelerated., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: To describe the residents who chose to train in teaching health centers (THCs), which are community-based ambulatory patient care sites that sponsor primary care residencies, and their intentions to practice in underserved settings., Method: The authors surveyed all THC residents training in academic years 2013-2014, 2014-2015, and 2015-2016, comparing their demographic characteristics with data for residents nationally, and examined THC residents' intentions to practice in underserved settings using logistic regression analysis., Results: The overall survey response rate was 89% (1,031/1,153). THC resident respondents were similar to residents nationally in family medicine, geriatrics, internal medicine, obstetrics-gynecology, pediatrics, and psychiatry in terms of gender, age, race, and ethnicity. Twenty-nine percent (283) of respondents came from a rural background, and 46% (454) had an educationally and/or economically disadvantaged background. More than half (524; 55%) intended to practice in an underserved setting on completion of their training. Respondents were more likely to intend to practice in an underserved area if they came from a rural background (odds ratio 1.58; 95% confidence interval 1.08, 2.32) or disadvantaged background (odds ratio 2.81; 95% confidence interval 1.91, 4.13)., Conclusions: THCs attract residents from rural and/or disadvantaged backgrounds who seem to be more inclined to practice in underserved areas than those from urban and economically advantaged roots. THC residents' intentions to practice in underserved areas indicate that primary care training programs sponsored by community-based ambulatory patient care sites represent a promising strategy to improve the U.S. health care workforce distribution.

Objectives: To determine if Sa roughness data from measuring one central location of unpolished and polished enamel were representative of the overall surfaces before and after erosion., Methods: Twenty human enamel sections (4x4 mm) were embedded in bis-acryl composite and randomised to either a native or polishing enamel preparation protocol. Enamel samples were subjected to an acid challenge (15 minutes 100 mL orange juice, pH 3.2, titratable acidity 41.3mmol OH/L, 62.5 rpm agitation, repeated for three cycles). Median (IQR) surface roughness [Sa] was measured at baseline and after erosion from both a centralised cluster and four peripheral clusters. Within each cluster, five smaller areas (0.04 mm2) provided the Sa roughness data., Results: For both unpolished and polished enamel samples there were no significant differences between measuring one central cluster or four peripheral clusters, before and after erosion. For unpolished enamel the single central cluster had a median (IQR) Sa roughness of 1.45 (2.58) μm and the four peripheral clusters had a median (IQR) of 1.32 (4.86) μm before erosion; after erosion there were statistically significant reductions to 0.38 (0.35) μm and 0.34 (0.49) μm respectively (p<0.0001). Polished enamel had a median (IQR) Sa roughness 0.04 (0.17) μm for the single central cluster and 0.05 (0.15) μm for the four peripheral clusters which statistically significantly increased after erosion to 0.27 (0.08) μm for both (p<0.0001)., Conclusion: Measuring one central cluster of unpolished and polished enamel was representative of the overall enamel surface roughness, before and after erosion.

Objective: To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals., Data Sources/study Setting: The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs., Study Design: Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design., Data Collection/extraction Methods: Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items., Principal Findings: After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states., Conclusions: Findings do not support a quality-scope of practice relationship., (© Health Research and Educational Trust.)

Purpose: Shortages of generalist physicians in primary care and surgery have been projected. Residency programs that expose trainees to community-based health clinics and rural settings have a greater likelihood of producing physicians who later practice in these environments. The objective of this study was to characterize the distribution of residency training sites in different settings for three high-need specialties-family medicine, internal medicine, and general surgery., Method: The authors merged 2012 data from the Accreditation Council for Graduate Medical Education Accreditation Data System and 2010 data from the Centers for Medicare and Medicaid Services hospital cost report to match training sites with descriptive data about those locations. They used chi-square tests to compare the characteristics and distribution of residency programs and training sites in family medicine, internal medicine, and general surgery., Results: The authors identified 1,095 residency programs and 3,373 training sites. The majority of training occurred in private, not-for-profit hospitals. Only 48 (of 1,390; 4%) family medicine training sites and 43 (of 936; 5%) internal medicine training sites were community-based health clinics. Seventy-eight (6%) family medicine sites, 8 (1%) internal medicine sites, and 16 (2%) general surgery sites were located in rural settings. One hundred thirty (14%) internal medicine sites were Department of Veterans Affairs medical facilities compared with 78 (6%) family medicine sites and 94 (9%) general surgery sites (P < .001)., Conclusions: Relatively little training occurs in rural or community-based settings. Expanding training opportunities in these low-access areas could improve physician supply there.

Importance: Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns., Objective: To examine the relationship between spending patterns in the region of a physician's graduate medical education training and subsequent mean Medicare spending per beneficiary., Design, Setting, and Participants: Secondary multilevel multivariable analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2851 physicians providing care to 491,948 Medicare beneficiaries)., Exposures: Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers. There were 674 physicians in low-spending training and low-spending practice HRRs, 180 in average-spending training/low-spending practice, 178 in high-spending training/low-spending practice, 253 in low-spending training/average-spending practice, 417 in average-spending training/average-spending practice, 210 in high-spending training/average-spending practice, 97 in low-spending training/high-spending practice, 275 in average-spending training/high-spending practice, and 567 in high-spending training/high-spending practice., Main Outcomes and Measures: Mean physician spending per Medicare beneficiary., Results: For physicians practicing in high-spending regions, those trained in high-spending regions had a mean spending per beneficiary per year $1926 higher (95% CI, $889-$2963) than those trained in low-spending regions. For practice in average-spending HRRs, mean spending was $897 higher (95% CI, $71-$1723) for physicians trained in high- vs low-spending regions. For practice in low-spending HRRs, the difference across training HRR levels was not significant ($533; 95% CI, -$46 to $1112). After controlling for patient, community, and physician characteristics, there was a 7% difference (95% CI, 2%-12%) in patient expenditures between low- and high-spending training HRRs. Across all practice HRRs, this corresponded to an estimated $522 difference (95% CI, $146-$919) between low- and high-spending training regions. For physicians 1 to 7 years in practice, there was a 29% difference ($2434; 95% CI, $1004-$4111) in spending between those trained in low- and high-spending regions; however, after 16 to 19 years, there was no significant difference., Conclusions and Relevance: Among general internists and family physicians who completed residency training between 1992 and 2010, the spending patterns in the HRR in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians for Medicare beneficiaries. Interventions during residency training may have the potential to help control future health care spending.

Problem: In many limited resource countries, medical and nursing school faculties are small and understaffed, contributing to the sparse output of physicians and nurses to support the country's health system. The World Health Organization declared that 37 African nations suffer a "critical shortage" of health practitioners., Approach: The Global Health Service Partnership (GHSP) is a new program that sends U.S. physicians and nurses to serve as faculty at medical and nursing schools in low-resource countries to increase the quantity and quality of graduates, thereby strengthening local health systems. The GHSP is a collaboration between the Peace Corps and Seed Global Health, a private nongovernmental organization, and is supported by the President's Emergency Plan for AIDS Relief., Outcomes: In July 2013, the GHSP sent 15 physicians and 15 nurses to serve as faculty at 11 schools in Uganda, Tanzania, and Malawi. These volunteers will serve for one year, working with their African counterparts teaching and building academic capacity. The program aims to help train more physicians and nurses for patient care, some of whom will become faculty in the future., Next Steps: An evaluation program will track and analyze the impact of the GHSP on the schools, the volunteers, and, over time, the impact on local health care. The authors propose a "sabbatical corps" to enable more U.S. academic medical and nursing faculty to participate in the program through the sponsorship of their home institutions. In future years, the GHSP will expand to more countries and include more health professions.

The Medical Education Partnership Initiative (MEPI) supports medical education capacity development, retention, and research in Sub-Saharan African institutions. Today, MEPI comprises more than 40 medical schools in Africa and 20 in the United States. Since 2011, the MEPI Coordinating Center, working with the MEPI schools and the U.S. government, has laid the groundwork and served as a catalyst for the creation and development of MEPI "communities of practice" (CoPs). These CoPs encompass seven components, some of which are virtual while others are tangible. They include technical working groups, principal investigator site visit exchanges, an annual symposium, a MEPI journal supplement, the MEPI Web site, newsletters, and webinars. Despite certain challenges and the question of sustainability, the presence within the MEPI network of an organization focused on promoting group consciousness and facilitating collaborative projects is an asset that is likely to continue to pay dividends for the foreseeable future.

Problem: To quantify the relative prevalence of traditional (education, research, service) and emerging (prevention, diversity, primary care, distribution, cost control) themes in medical school mission statements., Approach: In 2011, the authors obtained and analyzed the mission statements from 136 MD-granting and 34 DO-granting medical schools. They read each for the presence of traditional and emerging themes and then compared the mission statements by category of school (MD-granting versus DO-granting, level of National Institutes of Health funding, public versus private, date of initial accreditation [before or during/after 2000], and community-based versus non-community-based)., Outcomes: Traditional themes were common in medical school mission statements-education (170; 100%), research (146; 86%), and service (150; 88%). Emerging themes were less common-distribution (41; 24%), primary care (32; 19%), diversity (27; 16%), prevention (9; 5%), and cost control (2; 1%). DO-granting and community-based medical school mission statements cited the traditional theme of service and the emerging themes of primary care and distribution more frequently than those of MD-granting and non-community-based schools., Next Steps: The traditional themes of education, research, and service dominate medical school mission statements. DO-granting and community-based medical schools, however, more often have incorporated the emerging themes of primary care and distribution. Although including emerging themes in a mission statement does not guarantee tangible results, omitting them suggests that the school has not embraced these issues. Without the engagement of established medical schools, the national health care problems represented by these emerging themes will not receive the attention they need.

Intussusception is a rare cause of obstruction in adults and has a variable, non-specific presentation. Adult intussusception is usually associated with an underlying organic pathology, such as a benign or malignant tumour which acts as the lead point. Prolapse of the lead-point mass through the anal canal is an extremely rare presentation with very few reported cases in the literature. We describe a case of a 67-year-old man who presented with rectal prolapse of a large soft tissue mass. CT of the abdomen and barium enema revealed partial intussusception of an upper sigmoid lipomatous polyp. Examination under anaesthesia was performed and the prolapse reduced. A laparoscopic sigmoid colectomy was planned. The patient subsequently re-presented clinically unwell with a recurrent necrotic prolapsing mass. Laparotomy and sigmoid colectomy was performed and the patient recovered fully. The resected mass was a 7×4.5×4.0 cm necrotic sigmoid lipoma., (2014 BMJ Publishing Group Ltd.)

Graduate medical education (GME) determines the overall number, specialization mix, and geographic distribution of the US physician workforce. Medicare GME payments-which represent the largest single public investment in health workforce development-are allocated based on an inflexible system whose rationale, effectiveness, and balance are increasingly being scrutinized. We analyzed Medicare cost reports from teaching hospitals and found large state-level differences in the number of Medicare-sponsored residents per 100,000 population (1.63 in Montana versus 77.13 in New York), total Medicare GME payments ($1.64 million in Wyoming versus $2 billion in New York), payments per person ($1.94 in Montana versus $103.63 in New York), and average payments per resident ($63,811 in Louisiana versus $155,135 in Connecticut). Ways to address these imbalances include revising Medicare's GME funding formulas and protecting those states that receive less Medicare GME support in case funding is decreased and making them a priority if it is increased. The GME system badly needs a coordinating body to deliberate and make policy about public investments in graduate medical education.

Purpose: Graduate medical education (GME) plays a key role in the U.S. health care workforce, defining its overall size and specialty distribution and influencing physician practice locations. Medicare provides nearly $10 billion annually to support GME and faces growing policy maker interest in creating accountability measures. The purpose of this study was to develop and test candidate GME outcome measures related to physician workforce., Method: The authors performed a secondary analysis of data from the American Medical Association Physician Masterfile, National Provider Identifier file, Medicare claims, and National Health Service Corps, measuring the number and percentage of graduates from 2006 to 2008 practicing in high-need specialties and underserved areas aggregated by their U.S. GME program., Results: Average overall primary care production rate was 25.2% for the study period, although this is an overestimate because hospitalists could not be excluded. Of 759 sponsoring institutions, 158 produced no primary care graduates, and 184 produced more than 80%. An average of 37.9% of internal medicine residents were retained in primary care, including hospitalists. Mean general surgery retention was 38.4%. Overall, 4.8% of graduates practiced in rural areas; 198 institutions produced no rural physicians, and 283 institutions produced no Federally Qualified Health Center or Rural Health Clinic physicians., Conclusions: GME outcomes are measurable for most institutions and training sites. Specialty and geographic locations vary significantly. These findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs.

The Patient Protection and Affordable Care Act of 2010 created the Teaching Health Center Graduate Medical Education (THCGME) program to provide graduate medical education (GME) funding directly to community-based health centers that expand or establish new primary care residency programs. The THCGME program was the legislation's only new investment in GME, and it represents a significant departure from the Medicare GME funding system. It provides payments to ambulatory care centers for both direct and indirect GME expenses, and mandates a level of reporting from recipients that is not required for Medicare GME support. This initial look at the 11 inaugural teaching health centers (THCs) shows that they are training primary care residents in relevant delivery models (e.g., interprofessional teams, patient-centered medical homes), developing educational initiatives that address primary care practice in underserved areas, and transforming organizational and funding structures to support community-based training. The THCs plan to evaluate and report resident performance, patient quality of care, and graduate outcomes. The work of the first THCs has implications for primary care training, the GME system, and future policies and legislation aimed at strengthening the health care workforce.

The early success of the President's Emergency Plan for AIDS Relief (PEPFAR) in delivering antiretroviral medications in poor countries unmasked the reality that many lacked sufficient health workers to dispense the drugs effectively. The 2008 reauthorization of PEPFAR embraced this challenge and committed to supporting the education and training of thousands of new health workers. In 2010 the program, with financial support from the US National Institutes of Health and administrative support from the Health Resources and Services Administration, launched the Medical Education Partnership Initiative to fund thirteen African medical schools and a US university. The US university would serve as a coordinating center to improve the quantity, quality, and retention of the schools' graduates. The program was not limited to training in the delivery of services for patients with HIV/AIDS. Rather, it was based on the principle that investment in medical education and retention would lead to health system strengthening overall. Although results are limited at this stage, this article reviews the opportunities and challenges of the first year of this major transnational medical education initiative and considers directions for future efforts and reforms, national governmental roles, and the sustainability of the program over time.