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Assessing medical student competence in non-traditional domains can be challenging. Conventional methods of assessment are generally unsatisfactory. The authors discuss the approach taken at the Brown Medical School, USA to assess students at the beginner, intermediate, and advanced levels in the social and community contexts of health care - one of the nine abilities that comprise Brown's competency-based curriculum. At the beginner level, faculty use weekly field notes written by students about their experiences in community practice placements as the means for assessment. At the intermediate level, faculty assess students based on their completion of a project focused on a community health problem. At the advanced level, a screening process is used in which students first meet individually with a member of the assessment committee who determines if the student's efforts appear to meet the expected standards. If success seemed likely, then the student was encouraged to appear before the whole committee. The authors discuss the common use of subjective judgments at all three levels and the importance of diverse perspectives in achieving a consensus. Allowing students wide latitude in expressing themselves and their accomplishments helps to ensure success. [ABSTRACT FROM AUTHOR]

The preservation of small, independent family practices within a changed health care delivery environment is a goal worth pursuing. Properly organized, such practices would maintain the special fiduciary relationship between physicians and patients. Fundholding practices, which are a growing organizational form of general practice in the United Kingdom, are described as a model that could serve as the basis for an American alternative to corporate medicine. [ABSTRACT FROM AUTHOR]

The article suggests ways medical schools in the U.S. can enhance the number of their graduates and produce primary care physicians. One of the alternatives that the author mentions is to enable advanced practice nurses and physician assistants to assume a greater role in offering primary care. He adds that medical schools should recognize the factors that discourage students from pursuing careers in primary care.

Background: The Choosing Wisely campaign encourages physicians to avoid low-value care. Although widely lauded, no study has examined its impact on clinical decisions made in primary care settings., Methods: We compared clinical decisions made for 5 Choosing Wisely recommendations over two 6-month time periods before and after the campaign launch and an educational intervention to promote it at 3 primary care residency clinics., Results: The rate of recommendations adherence was high (93.2%) at baseline but did significantly increase to 96.5% after the launch. These findings suggest primary care physicians respond to training and publicity in low-value care, though further research is needed., Conclusion: Given that even small decreases of physician test ordering can produce large cost savings, the Choosing Wisely project may help achieve the health care triple aim., (© Copyright 2015 by the American Board of Family Medicine.)

Automated external defibrillators (AED) have been recommended for use in outpatient dialysis clinics to improve outcomes from cardiac arrest, the most common cause of death in patients with ESRD. The effectiveness of this policy is unknown. The study cohort consisted of 43,200 hemodialysis patients in the US Gambro Healthcare System from 2002 to 2005. Of these, 729 patients who sustained an in-center cardiac arrest were identified. Baseline characteristics at the time of the event were compared between patients who underwent hemodialysis in clinics with and without an AED on site. Unadjusted survival and survival adjusted for potential confounders was measured using Cox proportional hazards regression models. Unadjusted survival at 30 d was 19 versus 15% (P = 0.12) and 9.5 versus 7.8% at 1 yr (P = 0.39) in the AED-present and AED-absent groups, respectively. AED presence was not associated with outcome in unadjusted analysis (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.78 to 1.07; P = 0.26). Univariable analysis identified age (HR 1.07 per decade; 95% CI 1.01 to 1.13), serum albumin (HR 0.91 per 0.7-mg/dl increase; 95% CI 0.82 to 1.01), and indwelling dialysis catheters (HR 1.21; 95% CI 1.02 to 1.42) as potential confounders. Medications including angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, calcium channel blockers, other BP medications, aspirin, antibiotics, and antiarrhythmics were associated with survival and considered confounders. After controlling for case mix and confounders, AED presence was not associated with outcome (HR 0.98; 95% CI 0.82 to 1.18; P = 0.83). Presence of AED in the dialysis clinic is not sufficient by itself to improve the abysmal outcome from in-clinic cardiac arrest in hemodialysis patients in the United States.