You may think that this is silly, but it’s one of those “essential” techniques you don’t learn in the classroom.  Have you ever struggled to tear off a strip of adhesive tape to apply a dressing?  If you’re not in the medical profession, how about tearing duct tape?  Can you do it?

It seems like it takes three hands to hold and cut tape with scissors, and scissors are not always available or accessible.  Typically they are in the wrong pocket and you can’t easily reach them with your free hand.

I don’t know when it was in med school that a tiny little nurse embarrassed me by deftly tearing off a strip from a roll of wide adhesive tape.  I had made a mess of trying and she got a kick out of making fun of me.  Then she taught me how to do it.

It’s simple but not intuitive.  Most people will hold the tape in both hands and try to twist and tear it.  That feels like the natural way to do it, but it bunches up the tape at the top edge and makes the tear hard to start.

The “correct way” is to grasp the tape between the thumb and index fingers of both hands and then pull apart the top edge without twisting the tape.  Think of turning the palms from the palm-down into the palm-up position (i.e. supinating them) while pulling the top edge of the tape apart.  If you can’t pull hard enough without some leverage, you can roll your hands outward leveraging on the backs (dorsal aspects) of the otherwise unused long, ring, and small fingers.  Just don’t twist it.

You can do this.  It just takes a little practice.  Then you can enjoy embarrassing your co-workers and some novice medical student yourself.

Tearing apart telephone books is a different matter.  Maybe we’ll address that sometime in the future.

Dr. Hundley is a retired orthopaedic surgeon living in Wilmington.  He is the founder and president of OrthopaedicLIST.com a resource website for orthopaedic and other surgeons and related professionals.

Graduate medical education, still in the process of being born, was not mentioned in Flexner’s 1910 landmark treatise on medical education.  The existence now of 8500 residency programs and 127 specialties and subspecialities would, a century ago, have seemed preposterous.

Movement in GME prior to 1985 was largely academic and specialty specific. Curriculum, accreditation and certification, and duration of training were issues for resolution within the house of medicine.  Since the mid-1980s, influences outside of medicine, fueled by explosive population growth, technologic innovation, and social concerns have become dominant players, threatening the foundations of the educational bridge between student and practitioner.  An expanding and aging population and a panoply of therapeutic options have created overriding problems of access and expense.

Among the major challenges facing contemporary graduate medical education are issues related to teaching and learning, evaluation, professionalism, supervision, research training, funding, and manpower.  This book considers the issues in these areas and offers options for their resolution.

Following are excerpts from a few of these topics:

Teaching and Learning

“The search for ways to improve medical education should include a re-examination of the values underlying the profession.  Values shape the world; they should hold pride of place in the intellectual community and drive the educational enterprise.  Unfortunately the ethos that determined them in the past has been blurred by contravening trends of the present.  Propelled by the explosive escalation of knowledge and technology, too little attention has been given to the humanistic values that should determine their use.”

Professionalism

“Among the core competencies, professionalism is the most critical and among the most difficult to quantify. It is the competency which, possessed in full measure, gives rise to the others.  A professional possesses and maintains a unique body of medical knowledge and uses it to provide effective, safe, compassionate and ethical patient care, including the communication skills necessary to help patients navigate through a complex health care system.”

… “professionalism is founded on the pillars of science and service, upon possession of a specialized body of knowledge and skills, and the obligation to use that expertise to serve others before self.”  … “at the heart of this obligation is ethics, and at the heart of ethics is the welfare of the patient.”

“Professionalism is not just a philosophical ideal, nor can it be marginalized by the need for efficiency or productivity. It should be defined according to its characteristic traits, its cognitive base made clear, and opportunities provided to gain experience in its application to daily medical care.”

Manpower: Supply and Distribution

“With specialty choices determined largely by issues of income and lifestyle, fewer students are choosing careers in primary care.  High-tech specialities offer exciting opportunities for cure; but older patients having chronic conditions, are often more in need of care than cure – for someone to be there to guide them through the complex world of health care and to manage multiple diseases and depression. Despite the fact that most of the problems for which a physician is consulted can be handled by generalists, they have become an endangered species.”

“Medical care for the aged drives and will continue to drive, health care in the U.S. for the foreseeable future. By 2020, some 20% of Americans will be over 65, and people over 85 constitute the most rapidly expanding segment of the population, for which all physicians must be prepared.”

“Population trends must be studied, and planning for anticipated growth closely coordinated with the capacity of the U.S. health care system for expansion.  Since resources are finite, and expansion of the physician pool is very costly and time consuming, joint planning…is essential to meet short- and long- term needs for medical services.”

****

 In his Foreword to the book, David C. Leach, Executive Director Emeritus of the ACGME, said: “This is an important book about this most formative time in a physician’s life, the history of graduate medical education, the key issues that consume present interests of medical educators, and the options that the profession and society have for going forward.  It is timely.  Workforce shortages, financial constraints, new knowledge and technologies, and dramatically changing demographic patterns in society pose challenges.  Changes are needed; will wisdom or reflex actions inform the changes?”

 Dr. Wilson is Kenan Professor and  Chief Emeritus of Orthopaedics at UNC.  He is a past President of the American Orthopaedic Association, the American Board of Orthopaedic Surgery, the Association of Orthopaedic Chairmen and the Thomas Wolfe Society.  He received the Thomas Jefferson Award from UNC, and the Distinguished Clinician-Educator Award from the American Orthopaedic Association.  His book, Graduate Medical Education:  Issues and Options, can be found  on OrthopaedicLIST.com.

Medical Librarians CAN save you time AND assist you in making better informed clinical decisions.

Medical Librarians have an essential role in health care.  They provide evidenced-based medical information to health professionals, enabling them to make better informed clinical decisions.

A recent JAMA article (Sept. 25, 2013), “The Evolving Role and Value of Libraries and Librarians in Health Care,” reported on a study of health professionals in which 71% of the respondents said they changed how they managed the care of a particular patient as a result of information provided by the health science library.

At many medical centers, medical librarians are actually going on rounds with physicians and medical residents, then providing evidenced-based medical information on the medical cases studied.  I did this with the Pediatric physicians and residents in a former job.

A landmark study was published in the Journal of the Medical Library Association in January 2013.  It demonstrates the importance, value, and cost savings of medical libraries, and medical librarians.  16,122 physicians, nurses, and other health professionals at 118 hospitals in the US and Canada responded to the survey.  The survey was designed to determine whether information obtained from library services was perceived as valuable and if the information was considered to have impacted patient care.  Here are some of the results:

• 7% felt the impact was significant enough to reduce patient length of stay
• 56% felt the knowledge helped avoid adverse events, such as hospital readmission, patient mortality, and additional procedures
• 92% of health professionals said medical information provided through library services provided new knowledge
• 95% of health professionals said medical information provided through library services resulted in the provider making a better informed clinical decision
• 85% of physicians believed the information from the library saved, on average, 2.5 hours of their time
• 84% of health professionals felt the knowledge contributed to a positive change in patient care, such as advice given to patient or choices of drugs

In Spring, 2013, I completed a user satisfaction survey on the SEAHEC Medical Library in Wilmington, NC.  Of the physicians who responded, 95% agreed that the information the library provided would have been difficult to obtain on their own.  Additionally, 75% agreed that the information the library or the library databases provided influenced decisions on patient care.  Below is a sampling of comments from my user satisfaction survey:

• A physician stated:  “The library has been invaluable for research projects and articles submitted for publication.”
• An OB/GYN resident stated:  “The librarians are very knowledgeable and helpful with journal articles and literature searches.”
• A physician stated:  “The librarians provided excellent, prompt help.”
• A nurse administrator stated:  “I’d never be able to find what I want due to lack of knowledge and/or time constraints.  My job would be so much more difficult without the library services.”
• An administrator of the Emergency Department stated:  “Love our library, we couldn’t do without it.”

I encourage readers of this blog to contact their medical librarians – great things can happen!

Sources:

Sollenberger, J, Holloway, R.  The evolving role and value of libraries and librarians in health care.  JAMA Sept 25, 2013 310 (12): 1231.

Marshall, J, Sollenberger J, Easterby-Gannett S, et al.  The value of library and information services in patient care:  results of a multisite student.  J Med Lib. Assoc 2013 101 (1): 38-46.

Mrs. Flake is Library Director at the SEAHEC Medical Library in Wilmington, NC and renown for her work with libraries around the world.

by Donna Flake, MSLS, MSAS, Director, SEAHEC Medical Sciences Library

The World Health Organization (WHO) has created a tremendously innovative and benevolent program to help physicians, researchers, clinicians, students and health administrators in resource-poor countries.

In a partnership with numerous Scientific, Medical and Technical publishers, WHO provides access to thousands of full-text medical journals and medical books to these constituencies worldwide.  This is done through an internet based program called HINARI (www.who.int/hinari).

The program began in 2002, when WHO contacted key publishers, and requested access to e-journals and other resources.  Today over 150 publishers make their electronic publications available through HINARI.  The program includes access to over 8,500 full text journals, and over 7,000 full text medical books.  This greatly changed the playing field for the health practitioners trying to keep abreast of the medical literature.

Here is how a user from a resource-poor country can obtain access to the HINARI collection of full-text books and journals:

A physician at a medical institution contacts the HINARI program at the World Health Organization and registers for a login and password.

Accesses full-text articles, books and other electronic resources from the HINARI website.

Searches PubMed from the United States National Library of Medicine using the HINARI access code.

Pulls up full text journals and books through PubMed.

Of course there are still some obstacles to using HINARI including irregular supply of electricity, lack of hardware and insufficient bandwidth.

WHO is reaching out to teach members how to access the HINARI collection.  There are many trainers all over the world.  I received HINARI training at a conference of the Medical Library Association in 2009.  The purpose of the training was to instruct individuals from industrialized countries so that they could train partners from low-income ones.  In June 2009, I traveled to Moldova in Eastern Europe, and trained 23 health professionals at the Medical University of Moldova, and 20 health practitioners from the Free International University of Moldova. The class participants were very grateful for the HINARI program, and my training.  My SEAHEC Medical Library in Wilmington, NC has an international partnership with the Medical University of Moldova.  Silvia Ciubrei, Deputy Director of this library, is now a HINARI super trainer for the World Health Organization and travels to Eastern Europe and Russia for the purpose of providing training to health practitioners.  She speaks Romanian, English, and Russian, so her language skills are highly valued.  Silvia is also an excellent teacher.

The WHO divides the countries of the world into 3 categories:

In low-income countries, health practitioners have free access to HINARI.  (One example is Haiti).  More than 5,000 institutions in these countries have HINARI access.

In emerging countries, each institution must pay $1,000.00 per calendar year.  One example of a country in this category is Ukraine.  More than 1,388 institutions in these countries have access.

Richer countries – no access to HINARI.

Orthopedic materials in HINARI include:

Acta Ortopedica Brasileira

Advances in Orthopedics

BMC Musculoskeletal Disorders

Case Reports in Orthopedics

Chiropractic & Osteopathy

Chiropractic and Osteopathy

Clinical Medicine:  Arthritis and Musculoskeletal Disorders

Indian Journal of Orthopaedics

Internet Journal of Orthopedic Surgery

Internet Journal of Rheumatology

ISRN Orthopedics

Journal of Indian Rheumatology Association

Journal of Orthopaedics

Open Access Rheumatology:  Research and Reviews

Open Rheumatology Journal

Revista Brasileira de Reumatologia

Revista Colombiana de Reumatologia

Revista Cubana de Ortopedia y Traumatologia

Romanian Journal of Rheumatology

For more information on HINARI – www.who.int/hinari

Mrs. Flake is the Director of the SEAHEC Medical Library in Wilmington, NC, USA.  She has received numerous awards for her accomplishments including being named a Distinguished Member of the Academy of Health Information Professionals.

by Donna Flake, MSLS, MSAS, Director, SEAHEC Medical Science Library

Physicians can save time and obtain current, evidence-based medical information from their medical librarians.  Many physicians feel compelled to seek medical information on their own, even though they are always pushed for time.  Many physicians simply “google” the topic.  However, Google contains fewer than 30% of the medical literature much of which is out of date and incorrect.  Some physicians use PubMed from the National Library of Medicine.  PubMed is a great database but contains very few full text journal articles.

I encourage physicians to contact the medical library nearest to them, and check out what is available.  I am Library Director at a SEAHEC Medical Library in Wilmington, N. C.  Our library has integrated its digital library inside the Electronic Health Record (HER) of New Hanover Regional Medical Center in Wilmington, N. C.  Physicians can go into the EHR, click on my library’s digital library and use:  over 2000 full-text journals, 60 full-text books, the evidence-based product DynaMed, the Cochrane Database of Systematic Reviews, and much more.  My local orthopedists can use this method to access these journals FREE OF CHARGE:

• Clinical Orthopedics and Related Research
• Clinical Journal of Sport Medicine
• Journal of Bone and Joint Surgery (both American and British)
• Journal of Orthopaedic Trauma
• Spine
• and more

A few other U. S. medical libraries that also have integrated their digital libraries inside the EHR of the hospitals they serve include:

• Vanderbilt University Medical Center in Nashville
• University of Pittsburgh Medical Center
• Oregon Health and Science University Hospital in Portland
• University of Washington Medical Center in Seattle

If your local medical library has not integrated its digital library into its hospital’s EHR, there are other methods of accessing your library’s digital content.  Many hospital libraries and university medical libraries put their digital content on the hospital’s or university’s intranet, and physicians can access it this way.

Your medical library can save you time, money and effort.  A 2011 survey of U. S. health practitioners revealed

• 75% of survey respondents said “I handled an aspect of a clinical situation differently as a result of having information provided by a librarian, or the library”.
• 1 hour to 2 hours 30 minutes of time was saved by health professionals using the librarian or the medical library rather than seeking the information on their own.

I also conducted a medical library-user survey at my hospital.  Doctors and other health care providers responded.

• 59% of survey respondents indicated that information from library services influences decisions in patient care.
• 73% of survey respondents indicated that information from the library would have been difficult to obtain on their own.

In summary, I encourage you to contact your medical library to see how you can use its services!  A medical librarian could be your best friend!

Mrs. Flake is the Director of the SEAHEC Medical Library in Wilmington, NC, USA.  She has received numerous awards for her accomplishments including being named a Distinguished Member of the Academy of Health Information Professionals.