The present research explored the dynamics of competitive advantages in intercollegiate athletics by investigating the contribution of intangible resources  on the generation of more tangible resources , which in turn influence the athletic performance  and academic performance , and gender equity. The research was based entirely on archival data of 324 NCAA Division I member institutions. The results of the SEM supported the study’s basic arguments that tangible resources are the sources of competitive advantages in Division I intercollegiate athletics, and that intangible resources contribute to the generation of tangible resources. The importance and impact of intercollegiate athletics governed by the National Collegiate Athletic Association (NCAA) in America are enormous in every aspect of American society. Apart from the fact that millions of people attend the NCAA contests , and thaThe public image and the prestige of universities are altered by the successes and failures of their athletic programs ,6. MediaDespite these efforts, only a few of the 324 Division I institutions in the NCAA and 115 Division I-A  member institutions are thriving while others are struggling in terms of athletic, financial or educational success . For exaAside from financial successes, there are other performance differences among the universities. In terms of the Learfield Sports Directors’ Cup rankings , several Division I members such as Stanford, UCLA, and Michigan have produced winning programs over competing institutions . In termThese differences in the effectiveness among institutions of similar sizes and types beg the question of why some athletic departments are successful in achieving some of their goals while others fail to do so. In other words, why are some departments achieving competitive advantages over others in different spheres of endeavor? One explanation for the successes of some departments and failures of others can be gleaned from the recently advanced strategic approach of resource-based view of organizations.The main focus of the field of strategic management is on “how firms achieve and sustain competitive advantage” (p. 509) . In regaresource heterogeneity and imperfect mobility make some of those resources valuable, rare, imperfectly imitable, and hardly substitutable  is an important determinant of player evaluation and of “in-game” tactics (p. 113). Wolfe et al. [Even more recently, Wolfe, Wright, and Smart  have empe et al.  suggest Cunningham  investigWhile these studies represent pioneering efforts in employing the resource-based view in investigating competitive advantage in professional sports and collegiate athletics, they are rather narrow in their scope. Either the studies focus on a single athletic program ,23 or thphysical capital resources , human capital resources , financial capital resources , and organizational capital resources .A useful first step in the study of resources as sources of competitive advantage is to categorize the resources and assess the status of an organization in terms of those categories , 29–32. tangibility [While Barney’s classification has been well received, there is also the suggestion that resources be classified on the basis of their gibility –36. Examgibility ,35. The Based on empirical studies, Hall  argued “contributing resources in the sense they facilitate the garnering of the more tangible resources. For instance, the good will toward the university (an intangible and contributing resource) would be reflected in the endowments (tangible resource) bestowed by well-wishers. In fact, studies in alumni donations have suggested that alumni contributions are, to a great extent, the function of the institutional characteristics [The foregoing analysis of intangible resources leads to the suggestion that the intangible resources of the organization may indeed be the eristics . Thus, ceristics  perspecteristics  categoryWe have followed Barney’s  originalAthletic reputation. Reputation is defined as “the evaluation of a firm by its stakeholders in terms of their affect, esteem, and knowledge” (p. 1093). This reAcademic reputation. This variable concerns academic excellence of institutions in which athletic departments are housed. Academic reputation and standing has been the basis for classification of universities . It is not uncommon to gauge the academic reputation of universities by the difficulty of gaining entrance to them. For instance, the Peterson’s College Guide provides entrance difficulty data for all institutions associated with NCAA Division I.Tradition (History). The position and behavior of the organization is often decided by the past experience of the organization ,17. LikeFinancial and physical resources are fundamental to any organization in any context. In the context of ICA, these resources are required to run the athletic program in general, operate individual athletic teams, organize athletic events, recruit athletes, and offer scholarships to them. Some of the resources such as financial resources are more transferable. Financial resources are easily transferable to physical resources. We used the following as the indicators of financial resources.Sports Expenses. According to the U.S. Department of Education, sport expenses are defined as all expenses attributable to athletic activities, including athletically related student aid, recruiting expenses, salaries and benefits for coaching staff, and team expenses.Non-Sports Expenses. The expenses not allocated by sport refer to expenses such as administrative costs, appearance guarantees and options, contract services, fundraising activities, promotional activities and salaries for administrative staff members .Number of coaches. The term is defined as the total number of coaching staffs associated with each athletic department. While the greater numbers of employees do not always indicate a better quality of human resources at an organization, universities tend to hire coaches with expertise, experience and diverse perspectives on coaching.Number of athletes. The term is defined as the total number of student-athletes in each athletic department. Although the rules of a particular sport specify the number of athletes on the roaster for an event, universities are at liberty to carry more or less number of athletes. The larger the number of athletes, the greater is the possibility of the emergence of high performers. This is particularly true in collegiate ranks as the athletes are still in their growth and development stage. It is not uncommon to see substitutes and benchwarmers from one year becoming superstars in the next year.The emphasis on resources is based on the notion that these resources are required to attaining organizational goals. Accordingly, the relevance or criticalness of a given resource varies across prioritized organizational goals or mission of a given organization. For instance, the critical resources of a manufacturing firm  would be different from those of a service firm . In our context, some of the critical resources required by an intercollegiate athletic department would differ from those required by, for example, a city recreation department. A profit-oriented professional sport franchise would require certain critical resources that may be different from those required by an intercollegiate athletic department.An extension of the above perspective would suggest that even within a single organization (or a group of organizations), different resources would become critical to achieve different goals it may pursue. In our context, ICA departments have two sets of goals, namely educational and athletic goals –46. TraiFor the purposes of the present study, we identified three critical goals for intercollegiate athletics—overall athletic success of the program, the overall academic success of the program, and the success in fostering gender equity within the program. While the former two goals  have garnered most attention, the goal of gender equity is equally important. The emphasis on gender equity as a goal for NCAA athletic departments was greatly increased with the promulgation of Title IX. Subsequently, university administrators and the NCAA have touted the virtue of gender equity and have strived continuously to foster it. Given the trimodal foci of ICA goals, the study was concerned with identifying the resources that were more associated with attainment of each of the three goals.organizational, financial, and human resources), and three outcomes . The model suggests that organizational resources are the driving force behind the generation of the other two forms of resources—financial and human resources. The latter two forms of resources are said to influence both the performance and developmental outcomes.The proposed model for empirical verification is shown in The alternative model included in the present study takes a different conceptual approach in which intangible resources  are placed parallel with tangible resources . That is, organizational resources are not considered as contributing resources. Rather, the alternative model sees both tangible and intangible resources independently influencing the attainment of intercollegiate athletic goals see .From a different angle, it is also plausible that tangible resources are building blocks of intangible resources given that some of the tangible resources are transferrable while organizations can deploy more strategic moves with affluent tangible resources. However, in the context of intercollegiate athletics, it is more plausible and reasonable to suggest that intangible resources are much more critical in achieving sustainable competitive advantages and success over time  because This study was approved by the Institutional Review Board of the Office of Responsible Research Practice at The Ohio State University through the expedited review procedure because this study falls under the exempt research categoryThe 326 universities and colleges that are associated with the NCAA at the Division I level constituted the study population. In that the data on the study variables for all schools in the NCAA Division I were available, the target and accessible populations were identical . HoweverPeterson’s Guide to Colleges and Universities [Sperling’s Best Places [The necessary data of 324 institutions for the current study were obtained from several archival records to collect the relevant data for the 2003–2004 season. The data regarding athletic operations were drawn from Equity in Athletics surveys for 2003 [ersities  and Spert Places . The numt Places . Thus, at Places  who emplt Places  who reliAs shown in An organization’s physical resources consist of, but not limited to, plants, equipment, facilities, and buildings , 51 wherHuman resources in athletic departments were operationalized by (a) Number of Coaches, and (b) Number of Athletes. The information was collected from the U.S. Department of Education website .Achievement of athletic goals was operationalized by Sears Cup scores and Winning Rate. The Sears Cup scoring is a well-accepted measure of cumulative successes of an athletic program which takes into account the relative successes of all the teams within the athletic program. In addition, winning rates of each athletic department  were utilized as an indicator since a ‘winning program’ is often used as a criterion of athletic success.The success in achieving the academic goals was operationalized as Graduation Rate. Gender equity was measured by the percent of females in an athletic program. The information about graduation rate, gender equity, Sears Cup scores, and winning rates was collected from the NCAA website , the U.SIn terms of normality of the data, there were instances of true outliers. For example, four athletic departments earned more than 1,000 Sears Directors’ Cup (now known as Learfield Directors’ Cup) points in 2003 while 60 out of 324 athletic departments did not earn a single point as well as the mean score was about 176 points. In so far as such outliers in the data were accurate observations , they weIn order to assess the extent of multicollineairity in the data, we computed the correlations among the summated means of each latent variable and single-item indicators. These correlations ranging from .50 to .79 are lower than the critical value of .85 indicative of multicollinearity problems .First, descriptive statistics were calculated to present the basic characteristics of data as well as to prepare data for structural equation modeling (SEM). Both the hypothesized and alternate models were tested through SEM techniques.n = 218; 67.3%). On average, each athletic department has 254 male and 203 female student-athletes. Each athletic department reported $9.31 million and $4.44 million as the mean sport expenses and non-sport expenses, respectively .In terms of correlations, Athletic Performance was significantly and positively correlated with all other variables in the study while Gender Equity was significantly and positively correlated only with Academic Reputation and Athletic Reputation. Academic Performance was significantly correlated with almost all variables except Athletic Reputation and Non-Sport Expenses.χ2/df (101.77/ 37) = 2.75; RMSEA = .074, 90% C: .057, .091; GFI = .95; NFI = .95; IFI = .97; and CFI = .97. These values cumulatively indicated that the model fit the data well.The results of SEM provided good support for the model (2 difference between two models of 79.87 with 1 degree of freedom was significant (p < .001). The fit indices for the alternative model were χ2/df = 5.05; RMSEA = .11; GFI = .91, NFI = .91, and CFI = .93. As these values indicate a poor fit, it was discarded, and the hypothesized model was accepted as tenable.As noted, the alternative model specified direct effects of the three types of resources on the three dependent variables see . The χ2 Three sets of path coefficients shown in  were calβ = .91, p < .001). Tangible resources directly influenced Academic Performance of student-athletes  as well as Gender Equity . Tangible Resources had the greatest positive effect on Athletic Performance .Intangible resources were strongly predictive of greater tangible resources . That is, Intangible Resources had a positive indirect influence on Athletic Performance. Intangible resources also indirectly increased Academic Performance of student-athletes  as well as Gender Equity of female student-athletes .Tangible Resources mediated the relationship between Intangible Resources and Athletic Performance  contributed to the tangible resources in the form of financial and human resources. Our results showed that intangible resources consisting of academic and athletic reputation explained more than 83% of the generation of tangible resources in the collegiate sports context. As Deephouse  noted, sβ = .86, p < .001) than its human resources . In this regard, it must be noted that the NCAA rules and regulations place some constraints on the number of personnel  for a given team. From this perspective, athletic departments are more restricted from having larger pools of human resources while such restrictions are not imposed on financial resources. A counterpoint to the above reasoning is that the NCAA does not place any restriction on the number of teams an athletic department may support. That is, athletic departments with higher levels of intangible resources could support a relatively larger number of teams than the departments with less intangible resources.We also found that the intangible resources were more predictive of an athletic department’s financial resources (R2 = .91). As noted, intangible resources had an indirect influence on athletic performance (R2 = .75). However, the effects of tangible and intangible resources on academic performance were not as large . The effects of tangible and intangible resources on gender equity were the weakest .As hypothesized, tangible resources were significantly predictive of the amount of athletic performance  is, to a great extent, dependent on the efforts and decisions made by athletic department. For example, the recruitment of student-athletes, the number of athletic scholarships, the number of coaches and their salaries, the budget allotted to different teams is all under the control of the athletic department. Therefore, it should not be surprising that the resources had greater impact on athletic performance than on academic performance.It was surprising, however, that the level of resources was weakly related to gender equity. It must be noted that the goal of achieving gender equity is entirely in the hands of the athletic department while athletic and academic performances are largely in the hands of the athletes themselves. Further, gender equity is a relatively more stable attribute than the other two performance outcomes that fluctuate from year to year. One explanation for our results could be that due to the strict enforcement of Title IX provisions, most, if not all, athletic departments would have achieved or approaching the necessary gender equity. Any additional resources at hand would not affect gender equity, which is a finite attribute  in the context of intercollegiate athletics in the U.S.The distinction between intangible and tangible resources underscores the fact that generation of tangible resources is a short-term affair while intangible resources accrue over time. In addition, generation of measurable tangible resources which require concerted efforts from year to year is also dependent on the athletic success of the teams from year to year. In contrast, cultivating athletic and academic reputation is a long-term phenomenon and the success of the efforts in this regard cannot easily be judged. Despite these differences, both forms of resources and the outcomes are highly interrelated in a cyclical manner. As noted, intangible resources accrue to an athletic department over the long run as a function of the continued and consistent success from year to year in the generation of tangible resources which is largely dependent on how successful the athletic teams are in successive years in both the athletic and academic arenas. Stated otherwise, continued non-attainment of the desired outcomes (both athletic and academic) over the years may tarnish the reputation  of the athletic department. But even more perilous is the fact that the attainment of the athletic goals through improper means may drastically reduce the tangible and intangible resources. Given that it takes a long time to build valuable intangible resources in the context of intercollegiate athletics, hence the administrators of athletic department have to be vigilant in promoting the long-term intangible reputation (both academic and athletic) of the university athletics while maintaining athletic integrity.As Carmeli  noted, tOne of the differences between RBV and the traditional economics theory is that the RBV includes critical resources that do not comply with mathematical formulas of economics. Simply put, the RBV emphasizes the importance of unobservable factors that are not shown in the balance sheets of organizations , 54. EspWhile most of the indicators of the variables in the model were direct measures, one of the indicators of institutional reputation was a proxy measure to refer to “tradition” or “history” of an athletic department. While our use of “years since establishment” may be considered a good proxy for tradition and history, future studies need to explore if there are other direct measures or even better proxy measures.Because we were interested in testing the hypothesized structural model, we included all Division I schools  in the analyses to meet the minimum number of observations required for SEM procedures. This overlooks fundamental differences among the three levels of schools within Division I. For instance, schools with a football program (as is the case with Division I-A or FBS schools) are likely to differ considerably in the magnitude of resources they have, and the dynamics of competitive advantage thereof. Future studies may use different statistical approaches which can test subgroup differences in regard to gaining competitive advantages. Also, this study used only a single year data. Future studies should also consider analyzing multi-year composite data or conducting time series analyses.Future studies may also test the model of resources in other sport settings such as the professional sport leagues. However, it must be noted that professional sport franchises are concerned with only one sport whereas intercollegiate athletics deal with several sports. Further, intercollegiate athletics is also concerned with the dual and at times contradictory goals of performance and development of athletes.While the present study has shown the influence of the various resources on attainment of the dual goals of athletic department goals, it did not address the issue of how well the available resources were utilized. It is one thing to say that a university has such and such resources and it is another thing to say how the managers of a university put those resources to different uses, and exploited the advantages accruing from those resources. The ability to exploit the available resources and reap the potential competitive advantage has been labeled “organizational capability” . Future


Large numbers of vulnerable patients are in need of palliative cancer and dementia care. However, a wide gap exists between the knowledge of best practices in palliative care and their use in everyday clinical practice. As part of a European policy improvement program, quality indicators (QIs) have been developed to monitor and improve the organisation of palliative care for patients with cancer and those with dementia in various settings in different European countries.A multidisciplinary, international panel of professionals participated in a modified RAND Delphi procedure to compose a set of palliative care QIs based on existing sets of QIs on the organisation of palliative care. Panellists participated in three written rounds, one feedback round and one meeting. The panel’s median votes were used to identify the final set of QIs.The Delphi procedure resulted in 23 useful QIs. These QIs represent key elements of the organisation of good clinical practice, such as the availability of palliative care teams, the availability of special facilities to provide palliative care for patients and their relatives, and the presence of educational interventions for professionals. The final set also includes QIs that are related to the process of palliative care, such as documentation of pain and other symptoms, communication with patients in need of palliative care and their relatives, and end-of-life decisions.International experts selected a set of 23 QIs for the organisation of palliative care. Although we particularly focused on the organisation of cancer and dementia palliative care, most QIs are generic and are applicable for other types of diseases as well. Europe faces a huge challenge with a population that is rapidly aging in the coming decades. It is estimated that the incidence and prevalence of cancer will increase by about 20% and the prevalence of dementia will double before 2050 –4. AlthoAs a first step in bridging this gap, it is important to assess current performance of palliative care in relation to its desired performance. Such an assessment of health care can be achieved by using quality indicators (QIs). QIs are evidence based, explicitly defined and measurable items that evaluate and describe structures, processes and outcomes of health care . As suchIMplementation of quality indicators for PAlliative Care sTudy) [The objective of this study was to integrate existing sets of QIs into one generic set that can be used to assess and improve the organisation of palliative care in different services and countries. The study was conducted within the framework of the European IMPACT project (e sTudy) .A modified RAND Delphi procedure was used to develop a set of QIs,  which isThe IMPACT consortium consists of experts of the pan-European research group on detection and timely INTERvention in DEMentia (Interdem) and the European Association for Palliative Care (EAPC), all of whom are stakeholders in their country in palliative cancer and/or dementia care. The research team was invited to use their networks to purposefully select panellists for the modified RAND Delphi procedure. A key selection criteria was that the expert had to have extensive knowledge about palliative care, cancer care or dementia care. Additionally, experts had to be able to communicate in English  and were planning to attend the 2012 Congress of the European Association of Palliative Care (EAPC) in Trondheim, Norway. Project partners nominated national and international experts in palliative cancer and dementia care. All nominated experts were approached via email (n = 50), forty experts from twelve countries agreed to participate in the modified RAND Delphi procedure , as well as (“and”) the assessment of care using QIs (combined using “or”). Synonyms and medical subheading terms were used to fully include relevant literature  subsequently reviewed all of the identified QIs independently to determine if the QIs assessed the structure and process of palliative care and to structure them according to the domains of the recommended framework for the organisation of palliative care of the Council of Europe .For the first written Delphi-round (April 2012), panellists received a personal invitation for an online questionnaire. To reduce the large number of identified QIs, panellists were asked to nominate one QI per domain of palliative care . Those QIn the second round (May 2012), also via an online questionnaire, panellists were asked to rate QIs on a 9-point Likert scale for clarity , usefulness , to rephrase unclear and to add missing QIs. They were instructed to rate a QI high on usefulness if it: 1) corresponded with a basic quality level; 2) referred to a higher quality level that would be met only in very good practices; or 3) was associated with an innovative quality level which is exceptional at the moment, but could become the optimal quality level in the near future . They weA consensus meeting was organised during the EAPC Congress June 7, 2012 in Trondheim, Norway. The meeting was chaired by an independent researcher with the aim to reach consensus on the QIs on which there was disagreement or where the median score was between 4 and 6 in the second Delphi round. Participants received a rating sheet on which the median ratings of the second Delphi-round of all experts were visible. Participants were given 30 minutes to rate the adapted QIs for usefulness. Next, per QI, participants were asked to raise their hand if they had rated usefulness 6 or less. If at least nine (30%) participants raised their hand, [After the consensus-round, the remaining indicators were fed back to the panellist with the purpose to validate the changes that were made (September 2012).In the final step of the QI development process, QIs were operationalised by the research team into questions that could be used by healthcare professionals to assess their organisation of palliative care and identify areas for improvement. During this process, it appeared that some QIs were inappropriate or not measurable (e.g. too time consuming to answer them appropriately). All QIs were therefore rated for necessity by the IMPACT research team (October 2012), representing both clinicians and researchers that also took part in the modified RAND Delphi procedure. QIs that were considered not necessary after this round, were omitted from the list.QIs with a median rating on the usefulness scale of 7, 8 or 9 without disagreement were considered to have face validity. Disagreement was defined as: 30% or more of the panellists rated a single QI in the 1–3 tertile and more than 30% in the 7–9 tertile. QIs scored with a median of 1–3 without disagreement were not considered to have face validity. Because panellists had rated QIs high on usefulness, only QIs with median ratings of 8 or 9 were considered face valid for the second Delphi-round. Only QIs that were rated valid by all panellists were included in the final set .The Medical Ethics Committee of the district Arnhem-Nijmegen has declared that this study doesn’t fall within the remit of the Medical Research Involving Human Subjects Act (WMO) (registration number 2012/075). This means that this study can be carried out without an approval by an accredited medical ethics committee.650 QIs were selected from literature , 24–54. In the second Delphi-round, 27  of the 40 invited panellists participated. Sixteen QIs were considered to have face validity, 28 were invalid, and six QIs were added to the list based on suggestions made by the panellists. The 40 QIs on which there was no agreement on, were included into the third Delphi round.In the third Delphi-round, a consensus meeting, 29  of the 40 panellists participated. After having rated 40 QIs, one was excluded and 10 were discussed. Of the QIs that were discussed, six were accepted and four were excluded. Panellists also agreed to merge 11 QIs. Round three therefore resulted in 24 accepted QIs. The total list of QIs  comprised 40 QIs.In the fourth Delphi-round, panellist provided feedback to the remaining set of QIs. This resulted in minor linguistic changes and the exclusion of three QIs because they were considered inappropriate by the majority of panellists. The resulting set of QIs, therefore, consisted of 37 QIs. This list was critically assessed by members of the IMPACT consortium for their necessity (round five). Fourteen QIs were considered to be overlapping, inappropriate, or not measurable in palliative care. The final list of QIs, therefore, consisted of 23 QIs, covering seven domains . Furthermore, specific elements of palliative care were considered important, such as the availability of opioids and anticipatory medications for symptom control, as well as the availability of bereavement support.Almost all panellists also rated important the accessibility of the medical record to health care professionals, timely transfer of information between settings (including when transferring or discharging patients). Panellists also considered an assigned contact person, who maintains regular contact with patients and their families, useful.The infrastructure of the place where palliative care is provided, such as a single bed hospital room, was rated important. Access to equipment , required to provide palliative care, was considered important. Panellists also rated high consensus for facilities for relatives to visit, stay overnight, and a private area for saying goodbye to the deceased. There was no agreement on QIs that aimed to control waiting time or waiting list, i.e. these aspects were not considered to be unique for palliative care and therefore not important.Regular assessment of pain and other symptoms was rated as a valid quality criterion, though it was commented that a validated instrument might not always be available, particularly for specific patient groups (e.g. for persons with advanced dementia).There was agreement on the need for a multidisciplinary team, which should consist of at least a physician and nurse, and have access to a range of supporting disciplines, such as: physiotherapist, psychologist, occupational therapist, social worker, dietician, and chaplain. Panellists also rated a regular multidisciplinary team meeting important.Panellists recognized the importance of having a well-structured medical record. However, a QI about the structure of the medical record was not considered important by the panellists. Panellists only considered the inclusion of a medication regimen in the medical record important. They also considered a timely assessment (within 48 hours) of pain and other symptoms, psychosocial and spiritual needs, patient preferences, wishes and needs, and the patient's capacity to be involved in the decision making process as important.Furthermore, almost all panellists rated the documentation of communication on the medical condition, goals of treatment, physical, psychosocial, and spiritual needs of the patient and their relatives, intention to return home, advanced directive, and end-of-life decisions as important.Panellists rated the QI about assessing the experiences of care givers with the palliative care service important. Secondly, a QI about the quality of care, assessing the use of an end-of-life care pathway within the last three days of life, was also considered useful.QIs about the staff’s learning objectives and a program for specialised and/or continuing medical education about the physical, psychosocial, and spiritual needs of a patient in need for palliative care were not rated important. There was also no agreement on disease-specific education for staff members, but panellists considered palliative care training specified to the professiona’ls background important.Family members and friends are able to visit the dying person without restrictions of visiting hours), [Family and caregiver experiences of the palliative care service are assessed/evaluated/recorded and An end-of-life care pathway (such as the Liverpool Care Pathway) was used for the last 3 days of life of a person in need of palliative care) and 20 were rephrased QIs. Panellist agreed not to formulate disease-specific QIs for the organisation of palliative care, since our set of QIs provide information about the organisation of services and not about the care provision itself. This might explain why so many QIs were rated face-valid for as well the organisation of cancer as dementia palliative care: regarding aspects as access to and 24 h availability of specialist palliative care or transferring information between settings, the specific condition of the patient  is not relevant, making our set of QIs much more broadly applicable. Therefore, these QIs are generically applicable and can be used in different settings. Thereby, they can also be used for (cross-)national comparisons and to identify best practices regarding the organisation of palliative care in other services and countries.With the help of a modified five-round RAND Delphi-procedure, we were able to develop an internationally validated set of QIs for the organisation of palliative care with high face validity as judged by experts in the field of cancer and dementia care. The final set provides 23 quality aspects regarding the accessibility of the service, its infrastructure, the use of symptom assessment tools, management of personnel, documentation of clinical data, quality of care, and education. Of these 23 QIs, one was identical to the original one ( hours),  two wereIn the recent literature several sets of QIs for palliative care have been identified , 38, 55.A recently published White paper defining optimal palliative care in older people with dementia,  describeAnother quality indicator, suggested by the World Health Organization as part of the framework programme on non-communicable diseases has been the focus of attention recently. This QI is being proposed to describe access to palliative care by assessing morphine equivalent consumption per death from cancer , 58. HowUsing our QIs as an external quality assessment tool will therefore make them unfit for their task . BerwickStrengths of this study were that we used a large international group of panellists for our Delphi procedure, who were actively involved in palliative care . Secondly, by organising our consensus meeting during the EAPC Congress in Trondheim, Norway, key persons active in the fields of palliative care and dementia care were able to contribute extensively to the discussion of the Delphi procedure. Thirdly, the multidisciplinary character of palliative care was represented by the panellists  involved in the Delphi procedure. Furthermore, half of them were professionals active in dementia care. Fourth, combining QIs for the organisation of services that provide care to palliative patients with cancer and those that provide such care to patients with dementia is unique. Our QIs can therefore be used in different settings.A limitation of this study is that this set of QIs might not be comprehensive. Because an international, generic set of QIs was developed, some QIs that were important in only one or a few countries were excluded from the list. For that reason, important national or setting-specific QIs must be added when the set is used in a specific country. Secondly, this set of QIs is only related to the organisation of palliative care. Outcome and patient-related outcome measures were not included because they address a distinct purpose in measuring quality of palliative care. Thirdly, participants of the modified RAND Delphi procedure were selected because of their knowledge about palliative care, cancer care or dementia care. Because some experts of two large European networks (EAPC and InterDem) are part of the IMPACT consortium, they were also selected as participant for the modified RAND Delphi procedure (n = 18). Although not all countries were represented (like France) and others were overrepresented (like the Netherlands), the experts covered 12 countries from three continents, covering different health care systems and types of organisation of palliative care. Pilot testing the set of QIs in those countries and continents that were not represented in this study will reveal whether they are applicable in these countries too. Fourthly, unfortunately, there were no patient representatives involved as panellist. Testing the final set of QIs will therefore also have to incorporate their views on the basic quality level or higher quality level that would be met only in very good services.International experts selected a set of 23 QIs for the organisation of palliative care that can be implemented in daily practice in order to demonstrate that organisations are providing high quality and effective palliative care or to identify areas for improvement.


In addition, there was a high overall internal consistency for thequestionnaire  and for the factors found .  the Portuguese version has good psychometric characteristics; therefore, it isadequate to obtain reliable information on the perception of nursing studentsconcerning the type of supervision that is provided in clinical practice, and thisversion is adequate to improve teaching practices. The monitoring of nursing students in clinical teaching (CT) is demanding for allinvolved. The CT program of the Graduate Studies in Nursing (GSN) has become law inPortugal since September 18, 1999 by Ordinance No. 799-D/99The study plan of the GSN from the Nursing School of Coimbra (Escola Superior deEnfermagem de Coimbra-ESEnfC), Portugal, follows the European Credit Transfer System(ECTS). It lasts four years/eight semesters and requires 240 credits that aredistributed in the areas of Theory (T), Theory and Practice (TP), Laboratory Practice(LP), and Clinical Teaching (CT). The practical component constitutes approximately 50%of the total credits and includes CT, which is considered, at the European level, "thatpart of nurse training in which trainee nurses learn, as part of a team and in directcontact with a healthy or sick individual and/or community, to organise, dispense andevaluate the required comprehensive nursing care, on the basis of the knowledge andskills which they have acquired"When considering the number of credits that are allocated to CT in the GSN, itsimportance is evident. CT is regarded as a significant opportunity to confront studentswith actual work situations. In addition, CT contextualizes and consolidates theoreticalknowledge and constructs new knowledge and learning through critical reflection,creative thinking, and problem-solvingNursing Fundamentals is the first hospital-based CT in ESEnfC and is taught in thesecond year. It is supervised by guest assistants and comprises active nurses, who, inturn, are supervised by the university's professors. The workload that is establishedfor supervising students is 8 hours per day, 35 hours per week, per student group. Thegroup has 4-6 students and at least two supervisors in each CT. In the other CTs,student supervision is ensured primarily by the faculty of the School.--The epistemological value of this practice, which was advocated by Schӧn, is that thepractice of CT requires a practical rationality that is based on knowledge or supervisedpractice, which is opposed, somewhat, to the basis of the traditional culture of highereducation teachers that is epistemologically sustained by a positivist root calledtechnical rationality-Therefore, the Ministerial Order No. 1/87 from April 21, 1987, which was reinforced byDecision No. 8/90 from February 28, 1990The mobilization of the knowledge and the replacement of individual thought for aninterconnection of all knowledge will facilitate the resolution of situations thatarise; in addition, in education, what students learn, not what teachers teach, isessentialThe training of a nurse is deeply dependent on the quality of learning in the clinicalsetting. Training in this complex interface that involves teaching, learning, andpersonal transformation facilitates the psychological process of adherence to workactivities and allows the reflexive rationalization of the various dimensions of healthproblems. This training also provides the basis for the establishment ofself-consciousness as a future professional in a game of adjustment of roles and iscrucial to social and moral development through a combination of logics in the students'entire dimensionThe skill-based model of education that is used in CT at ESEnfC allows teachers andsupervisors to become facilitators of learning and allows students to become theconstructors of their own knowledge. Students are taught that "learning to learn" shouldbe a voluntary and autonomous process in the construction of knowledge and learning;therefore, they must become responsible for their education. However, the implementationof this model faces some difficulties, including the choice of the most suitablestrategies for acquiring specific knowledge and expertise. In this context, not allstudents respond equally in terms of motivation and learning, particularly in largegroups. Therefore, students should understand their role and the role of teachers andinstitutionsTo ensure the quality of the assessment that is made by the education community, ESEnfCstudents are asked to comment on their satisfaction with the supervision in CT, althoughsome teachers consider student evaluations as unfair and unacceptableConcerning the supervision of CT by guest assistants, the school should know thestudents' degree of satisfaction with the supervision that is provided. We reviewed theliterature on nursing students' opinions of CT supervision by using all EBSCO databasesand the descriptors of 'student evaluation of teaching' and 'clinical learningenvironment'. We selected the Nursing Clinical Facilitator Questionnaire (NCFQ), whichwas created by the Centre for Learning and Teaching at the University of Technology inSydney, AustraliaThe objectives of this study were to perform the cultural adaptation to Portuguese ofthe Nursing Clinical Facilitators Questionnaire (NCFQ) and to validate theinstrument.For the creation of the Portuguese version of the Nursing Clinical FacilitatorQuestionnaire (NCFQ), a methodological study of cultural adaptation and validation wasconducted. Although this instrument has been published and has no restrictions on itsuse, we petitioned for an authorization to use this instrument, but the authors neverreplied. Therefore, we initiated the process of cultural and linguistic adaptation andsearched for similar instruments that were written in languages other than the original,including translation, back-translation, semantic comparison, and idiomatic andconceptual equivalenceIn the questionnaire translation stage, we intended to obtain a version in Portuguesethat was linguistically correct and equivalent to the original version. This stage beganwith the creation of two Portuguese versions and was performed independently by twotranslators who were native in the Portuguese language and fluent in English. This stepwas followed by the stage of reconciliation between the two translations, and theircontents were analyzed and compared. This phase included the presence of the twotranslators and two study researchers. The identified discrepancies were minimal andrelated solely to the words that can have different translations in Portuguese.Therefore, the first Portuguese version was obtained and was subjected toback-translation by a native English-speaking translator. Later, the researcherscompared this version with the original version. This stage was followed by thesubmission of the project to the Ethics Committee (Opinion No. 224-09/2014).In a later phase, we asked a group of five nursing professors, who were experts inclinical supervision, to make a critical assessment of the content of the questionnaireconcerning its technical, linguistic, and semantic aspectsThe next stage was the pilot test, which involved the completion of the questionnaire bya group of 21 students; in addition, these students were asked to evaluate the contentof the questionnaire items to assess their clarity and adequacy. Later, thequestionnaire was discussed. There were no difficulties in understanding or ambiguitiesin the interpretation of the questionnaire. Considering the need to obtain more detailed responses for the evaluated items and tomake them consistent with the responses of other ongoing studies, in the Portugueseversion, we decided to include seven possible answers to each item . Theobtainment of a Portuguese version was followed by the development of a set ofreliability and validity tests by using international statistical standards. Regardingvalidity, a value of 0.50 was accepted as the minimum factor loading for each scaleitem. The questionnaire was applied to a convenience sample of 767 students from the secondyear of the GSN program of the ESEnfC, who were enrolled in hospital-based CT inCoimbra, Portugal, in the academic year of 2013/2014. The inclusion criteria were beinga second-year student and having completed one of the CT modules on the fundamentals ofhospital-based nursing. Each student completed a questionnaire concerning eachsupervisor. The questionnaires were voluntarily self-completed by using an electronicplatform, and participant anonymity was ensured. The data were processed by using IBMSPSS software version 22.The assessment of the validity and reliability of the questionnaire revealed thefollowing results. To analyze construct validity, a factorial analysis was conducted byusing principal component analysis followed by orthogonal varimax rotation. According tothe original versionSubsequently, the Kaiser-Meyer-Olkin (KMO) measure was determined, and Bartlett's testof sphericity was conducted. Solutions with eigenvalues greater than 1.00 were found.The KMO measure was 0.976, which allowed the performance of a factor analysis. The valueof Bartlett's test of sphericity was χ 2 = 19013.04 at p <0.001, where H0 wasrejected, and we concluded that the variables were significantly correlated. The initialcommonalities were 1, and for the extracted factors, the percentage of variance of eachexplained variable was greater than 0.50. By using the rule of retention for the factorswith eigenvalues that were greater than 1.00, which was confirmed by the Scree plot,two factors that explained 69.86% of the total variance were extracted. The first factorexplained 37.180% of the variance, and the second factor explained 32.686% of thevariance. Therefore, the factorial solution that was found was favorable fromstatistical and significance viewpoints.Factor I consisted of 13 items, and factor II consisted of 12 items. No items wereeliminated. Item 8, 'The supervisor encourages me to be responsible for my learning',predominates in the two factors, which indicates that learning can be explained by thesupport and stimulation of learning. We maintained the item in the dimension where itsfactor weight was higher. Despite slight differences in some items relative to the original proposal, therepresentation of the results that were obtained allowed maintaining the identical namesfor the factors after analyzing the number and content of the items. Factor 1  was designated "learning-supportingbehavior" and factor 2  wasdesignated "learning-stimulating behavior". In the original version, factor 1  wasdesignated "supportive behavior", and factor 2  was designated "challenging behavior". Internal consistency was determined to assess reliability by calculating Cronbach'salpha, which is one of the most commonly used coefficients to evaluate this variable inLikert scalesThe adaptation of the NCFQ to Portuguese proved to be very useful because given itspsychometric properties, this instrument fills an assessment gap of the staff of theCouncil for Quality and Evaluation that is the same as the objective of thequestionnaire, namely, to measure the degree of satisfaction of students with thesupervision that they received during CTNo difficulties in the process of cultural adaptation were detected; on the contrary, atext as close as possible to the original was obtained, and no semantic changes wererequired.Regarding validation, the questionnaire showed a strong internal consistency , which was higher than that found by the authors. Factor analysis withvarimax rotation indicated the presence of two factors that were very similar to thefactors in the original version. However, the original version had a third factor withtwo items (1 and 2), which were designated preparatory behavior; however, these itemswere not found in this study. Furthermore, in the original study, three items  had the same weight in the two factors; the weight of these factors was lower than0.50, and therefore, they were removed by the authors. In this study, this weight wasnot found, except for item 8, and the items were maintained.Therefore, these factors represented learning-supporting and -stimulating behaviors andhad a high internal consistency ; however, these valueswere higher than the values that were found in the study by Espeland and IndrehusThe first factor contained items such as "My supervisor discusses my learning needs withme", "My supervisor gives me a clear idea of what is expected of me in clinicalpractice", and "My supervisor gives me enough learning opportunities for my independencein clinical practice." These items help to identify strategies that facilitatecontextual learning, i.e., learning that involves theory and practiceThe second factor has items such as "My supervisor helps me link theory with clinicalpractice", "My supervisor encourages me to consider a range of alternative methods ofuser care", and "My supervisor encourages me to reflect on my clinical learning". Theseitems promote the ability to think, analyze, and seek explanations in different learningsituationsThe small differences in the distribution of the items in the factors compared with thescale that was used by Espeland and IndrehusThe evaluation of the psychometric properties of the questionnaire indicated that theyare similar to those of the translated version; thus, the questionnaire is adequate toassess the degree of satisfaction of students with their supervision in CT.Therefore, this instrument allows the development of future studies on this topic andthe comparison with the results that are obtained in other countries where thisinstrument has been or will be used.We believe that this validation increases the number of valid instruments to assessstudents' satisfaction with their supervision in CT. Our research team will performconfirmatory factor analysis in the near future.


Tap watDisinfection and treatment practices, as well as the environmental regulation of water pollutants, have substantially improved domestic water quality during the past century and have led to a marked decrease in the incidence of waterborne diseases such as typhoid fever –5. DespiNew challenges to the U.S. water supply include deteriorating drinking water infrastructure, the impact of climate change on water availability and quality, chemical contamination of water sources, emerging pathogens, and the development of new ways to obtain and use water.Drinking Water Week is a time to highlight the importance that providing safe drinking water and protecting and reinvesting in water infrastructure has to U.S. public health.


Malaria is a climate-sensitive disease with a significant socio-economic impact. As monthly and seasonal dynamical climate prediction systems have improved their skill in the tropics over recent years, there is now the potential to use these forecasts to drive dynamical malaria modelling systems to provide early warnings of climate-related transmission hazards in holo and hyper endemic settings.A new pilot dynamical malaria prediction system was introduced. Multiple temperature and precipitation forecasts from the ECMWF monthly and seasonal prediction systems were used to drive the spatially explicit, dynamical malaria model VECTRI that accounts for population density and climate to produce forecasts of up to 4 months ahead. The malaria forecasts were started from realistic initial conditions derived from climate observations. The parameter predicted is the logarithm of the entomological inoculation rate (EIR). Forecasts are made on a grid mesh with a spatial resolution of 25km, but are then aggregated at the administrative district level, and normalized to be evaluated using normalized district level crude incidence data or sentinel site cases (suspected or confirmed) for three countries: Uganda, Rwanda and Malawi. The forecasts are evaluated over a period of approximately a decade, depending on the length of the data record available.The results show that for a number of districts in which interventions have been limited over the evaluation period, the forecasts were statistically significantly correlated with observed malaria outcomes, with the forecasts predicting the years of anomalous transmission and the sub-seasonal anomalies well. This was true for districts of both low and higher endemicity. However, for the majority of locations, significance levels were lower. The potential reasons for this are numerous, including incorrect climate forecasts, errors or missing physics (e.g. lack of immunity) in the malaria model, inaccuracies in the cases data itself, and interventions that have reduced prevalence and transmission risk as a function of time. We demonstrate, using confirmed sentinel site data, that data inaccuracies in the district statistics can be significant. Interestingly, the analysis and forecast system appear to indicate that the reduction in malaria prevalence in Rwanda over the past decade has been achieved against a backdrop of increasing transmission hazard due to climate. We conclude by discussing the weaknesses in the system that require addressing and the next steps to pilot this system in an operational context.


This essay explores the impact of ‘generalism’ and ‘general practice’ on the specialisation of British medicine using the case of neurology in Britain to reveal characteristics of British ‘generalist medical culture’ from 1870 to 1990. It argues that ‘generalism’ represented a particular epistemological position in Victorian medicine, one that then created a natural bridge between science and medicine over which almost all physicians and scientists were comfortable walking. The legacies of that Victorian ‘generalist preference’ exerted an enduring impact on the specialisation process as physicians experienced it in the twentieth century and as this case of neurology reveals so clearly. Neurologists and general physicians would still be arguing about the relative merits of a general medical education into the 1980s. By then, however, the emergence of government bodies promoting specialist labour conditions would have rendered the process seemingly inexorable. Yet, just as the ‘patrician sensibility’ did not disappear with the advent of medical modernity, the structures and processes of nineteenth-century medicine did not cease exerting palpable influence under the pressures of medical modernisation.2 As modernisation occurred, other patterns of medical culture persisted in appreciable ways. In part, this persistence explains differential experiences of patient care and medical labour in rural and urban general practice, the equitable distribution of health resources across the country, and the slow transfer of scientific, medical, and technical knowledge and skill from the confines of the medical teaching hospital to less august sites of medical work.Ever since Christopher Lawrence's pioneering identification of a patrician sensibility among medical practitioners in Victorian and Edwardian Britain, historians and sociologists of medicine have routinely placed what we shall call for brevity the modernisation of British medicine into the context of the culture it ostensibly replaced.3 This relationship conjured at once the Romantic ideal of the unity of knowledge and faith in the progress of medicine and science. It recalled heroic gentleman of science as well. Illustrious figures populated this imagined world. There Charles Darwin and Michael Foster found ready company with the likes of John Hunter, Edward Jenner, Astley Cooper, Joseph Lister, John Hughes Bennet or Thomas Clifford Allbutt. There was also material evidence for this imagined world in the real one; ‘Fellowship’ in the Royal Society connected in a formidably Carlylian way individual discovery to unified, progressing science; ‘Fellowship’ in one of the Royal Colleges implied acumen in a range medical subjects.In nineteenth-century British medical culture a peculiar relationship had formed between the life sciences and medicine, a relationship filled with Romantic-era resonances. Moreover, the relationship lasted well-beyond the interwar period of the twentieth century.4 For them, achievements of universal value in science and medicine defined excellence in medical practice and research, and thus much that was characteristic of British medico-scientific culture ranging from the Cambridge Natural Sciences Tripos to the creation of the National Institute for Medical Research captures these aspirations.5British physicians and scientists therefore aspired to ‘generalism’, an ethic that held high competence and excellence in many medical and scientific subjects to be the calling of medicine—a definition that shall be used throughout this essay. ‘Generalists’ viewed discoveries in the natural and human sciences as demonstrating truths of transcendental significance; in medical practice they emphasised ‘general clinical observation’ even as they eschewed the laboratory, and in the British hospital they ‘reigned supreme’ until the second decade of the twentieth-century.6 As social processes these developments were quintessential to the cultural experience of late industrial society's upheavals, instabilities, and experience of steady transformation .7 Specialisation foreshadowed advancing bureaucratisation as well, and it thus sat comfortably beside such other innovations as double-entry bookkeeping in the hospital and American-styled Taylorist efficiency in the factory.8 Thus, though the Romantic impulse in Britain inclined towards unitary visions of the progress of science and medical practice, there was a simultaneous, inexorable process of social reification that brought new categories of labour  into existence that possessed no meaningful historical counterpart.9 To be modern, it seems, was to be divided.At the same time a counter-trend developed. Specialisation, discipline formation and the steady appearance of the division of labour characteristically defined the modern appetite to ‘divide and conquer’.10 But for all of that, their resistance to specialisation in Britain (and elsewhere) remains a past curiosity, a seemingly reactionary response to modernity analogous perhaps to William Morris' hostile if famous reply with News from Nowhere (1890) to Edward Bellamy's Looking Backwards (1887).11 There is, accordingly, ample opportunity to consider the multi-faceted dimensions of British resistance to specialisation and to do so in ways that delve somewhat deeper than exploration of the rhetoric against it.12As is well known, many British medical practitioners' responses to these trends took the form of vehemence towards specialisation and its implications.The Practitioner, the continual demand placed on medical schools to train students to be competent general practitioners, and even the notion that there should be such a thing as ‘general medicine’ can all be construed as signs that there was much underpinning generalist attitudes. Being a good general physician did not denote superficiality; neither for that matter did it imply knee-jerk dismissal of specialist knowledge. Rather, to competent general physicians, specialist knowledge meant transferable, usable knowledge—for students, general practitioners, physicians and surgeons, for medical lore writ large. Such knowledge could sell medical monographs and journal subscriptions, and for that matter could justify membership in some societies with special subjects, as, for instance, obstetrics and gynaecology.There are many reasons for believing that even as specialisation became a reality of British medical culture, a culture of medical generalism left a concomitant impression. William Osler's appointment as Regius Professor of Medicine at Oxford, the formation of such organisations as the Royal Society of Medicine and the Association of Physicians of Great Britain and Ireland, the persistent popularity of the medical magazine 13 The study of the diseases of the nervous system and their treatment in the nineteenth century was a pursuit carried on by eminent physicians and scientists (often the same person), many of whom fashioned neurological knowledge in universalistic terms and regarded their subject as the logical development of their general clinical acumen and vice versa. For such physicians and scientists with interests in nervous and mental diseases and in the function of the nervous system, it became a practical commonplace for them to hold forth in published writings and lectures, as well as private conversations, on a range of sociological, anthropological, psychological and philosophical matters, not least of which was the philosophy of mind.14 Often at best agnostic about the process of specialisation, they regarded their studies and practice as specialised only insofar as the nervous system could be construed as integrating the whole of the body and mind together.15 Their clinical method, precise and exacting, was deemed not only difficult, but also of general clinical worth and productive of scientific progress.16 In a lecture in 1900 before the Nottingham Medical Society, Frederick W. Mott offered what was for then a typical view of the role played by the nervous system that captures all such themes:17The nervous system not only serves in maintaining the relation of the individual to his external environment in response to present or past stimuli from without, but also serves to correlate all the internal activities of the tissues and organs of the body by stimulating here, inhibiting there, and distributing the blood to the tissues in proportion to their activity. The nervous system is enabled to control the activities of all the tissues of the body by impressions conveyed to and from them by nerve fibers to and from various centres; but we also know that the nerve centres themselves are bio-chemically sensitive to the state of the blood occasioned by an organ which is diseased, when all the nervous paths from the organ have been interrupted.The formation of the specialty of neurology in Britain provides a particularly clear means of examining the persistence of generalism even as specialisation became a reality.18 Yet physicians with interests in the nervous system could have easily expressed similar conflicts with general medicine and general practice.19 That they did not until the interwar period, and that they thereafter did so half-heartedly, is a significant indicator that for them specialisation entailed real trade-offs. In what follows, we shall draw upon manuscripts and published sources salient to the development of neurology to describe the culture of generalism that permeated the British medical landscape before the introduction of the National Health Service. We shall then consider the ways in which that culture left a significant imprint on the development of specialisation as it was practised within the health service after 1948.In one sense, of course, all-encompassing-views like Mott's existed against a background of competition among specialists.20 The Act, which created the Medical Directory and the General Medical Council, however, followed the pattern of resistance to specialisation that so marked Britain's medical scene throughout the nineteenth century. The registry of practitioners, for example, did not acknowledge specific specialties, and physicians and general practitioners vigorously resisted medical specialisation throughout the period.21 Medical Consultants greeted specialisation with similar scepticism.22 Resistance to specialisation, however, did not prevent them from actively working in specialist hospital environments.23 In 1899, 195 physicians worked in London general hospitals, and only 31 of them did not also hold a position in a specialist hospital.24Rosemary Stevens has observed that the period following the Medical Act of 1858 brought increased specialisation in the hospitals and private practice in Britain.25 Their chief sources of income were benefactions and subscriptions, although increasingly by the early twentieth century grants, State funds, small payments and contributory schemes were also present.26 Altering the arrangements of hospital wards by creating specialist departments ensured increasing expense. Increases in staff, and therefore costs, were a predictable consequence of medical specialisation. There were other reasons too. Hospital administrators and physicians alike worried that increasing the specialised training for medical students would complicate teaching and further overload an already unwieldy medical curriculum. Experience of the general wards, many felt, should mirror the chaos medical students would encounter in general practice.27Resistance to thoroughgoing specialisation developed for several reasons. Nineteenth-century hospitals—poor-law, county, general, voluntary and even specialist ones—throughout Britain were often stretched thin in terms of resources.28There was, too, a further motive. As Abel-Smith described, some felt that general practitioners sent patients to consultant's private practices when they could afford the consultant's fee but not necessarily the costs of hospitalization, in this way ensuring their patients preferential treatment through ‘queue-barging’ ahead of patients in out-patient hospital clinics. Such practices advantaged general practitioners and also the ‘monopoly value’ of Consultants' honorary appointments, and implied, or so we infer, that the advent of hospital beds delimited to specialist cases in special departments implied a corollary decrease  in the amount of beds available for general cases.29 At the same time, there was high turnover in medical labour in special and general hospitals.30 Junior appointments in all hospitals were a means of remaining employed within the medical hierarchy until elected to the status of ‘Assistant’ or ‘Full Physician’ within a larger hospital—an appointment that was rarely a specialist one until the interwar period.31 Terms of junior appointments were brief, and doctors and surgeons in their early careers often held many different appointments simultaneously. Rising to the honorary status of ‘Full Physician’ in a voluntary hospital was viewed as the best path towards growing a large private practice, and individuals' circumstances along that career path, and their appointments in specialist hospitals as part of that journey, was often more happenchance than purposefully sought.Of course, as Stevens and Weisz have made so clear, resistance to specialisation in Britain did not prevent specialisation. Specialists could be prominent figures. Specialist hospitals and specialist private practices had been established even early in the nineteenth century. Stevens describes 128 specialist hospitals scattered across England and Wales by 1900, with those in London designated ‘centres of specialist teaching and research’.32 Early nineteenth-century charitable voluntary associations had established medical care centres for the poor and elderly alike, and one effect of such voluntary associations was that growing numbers of patients began entering hospitals, prompting the formation of new ones.33 Such organisations sought to employ respectable practitioners, and membership in medical societies, especially those founded in provincial centres, provided some practitioners with much-sought legitimacy.34 By the time the Nottingham Medico-Chirurgical Society celebrated its centenary (1928), Humphrey Rolleston (1862–1944) could consequently observe that ‘the uses of a medical society were educational, for unity, peace, and friendship, and in certain circumstances for combined action in medico-political crises’.35Medical societies followed these trends, too.36 But for would-be specialists, research and communication before their peers in general medical societies, as well as the ability to discourse on all medical topics with them, were essential means of demonstrating legitimate membership in a medical community. In fact, adopting a specialty often meant primarily further enhancing an income already generated by general practice. For these reasons medical practitioners brought their own research into public discourse, and thus did such societies become places of ‘friendly discourse’ and ‘agreeable refuge from the daily anxieties of medical practice’.37 For these reasons, too, specialist medical societies were not always aimed specifically towards communities of self-identified specialists. The Edinburgh Obstetrical Society, established in 1840 for example, ‘effectively remained for many years a society open to general practitioners’.38If unity and collegiality were mantras, the division that medical specialists represented in the profession became ever-more commonplace, especially in the rural Victorian world.These trends reached their zenith with the formation in 1907 of the Royal Society of Medicine and also the Association of Physicians of Great Britain and Ireland. While the Royal Society of Medicine had individual specialist sections ranging from neurology to medicine, its founders intended it to function as an umbrella organisation for former specialist societies. Many of London's hitherto autonomous specialist societies thereby gave up some autonomy in order to gain other measurable rewards through consolidation . Similarly, the Association of Physicians, which was founded in the same year and promoted itself as an organisation focused on ‘internal medicine’, cultivated members who dedicated themselves to medical research and teaching. In other words, although both organisations seemingly moved in ways embracing more specialisation and not less, both organisations ultimately sought to curtail the fragmentation caused by specialisation.Munk's Roll as an ‘accomplished general physician’ if with specialist interests as well.39 Members of Neurological Society of the United Kingdom, like many of the specialist societies in London that dissolved with the advent of the Royal Society of Medicine, involved themselves from the beginning in the creation of that organisation. Hutchinson, Hale-White and Humphrey Rolleston were members of that society at the time of its dissolution. Indeed fifty-four members of the former Neurological Society joined the Association of Physicians in its inaugural year and were active participants in its proceedings until the 1920s.40 In short, it seems clear that many active members of the Association of Physicians and the Royal Society of Medicine would have readily agreed in 1907 with Osler's 1897 injunction: ‘that the student of internal medicine cannot be a specialist’.41Members of the Association of Physicians were teachers of medicine and medical researchers. It is therefore noteworthy that their members were those most involved in the creation of both the Royal Society of Medicine and the Association of Physicians, and that they did much to bolster those societies' subsequent scientific proceedings. Richard Douglas Powell, as a leading figure in the creation of both societies, was perhaps exceptional. But like him the founders of the Association of Physicians, which included such medical luminaries as William Osler, John Rose Bradford, Archibald Garrod, Jonathan Hutchinson, William Hale-White, and Humphrey Rolleston too, might well have been described (as Powell was) in 42 Many of these institutions treated conditions that had been differentiated from cases found in asylum medicine.43 All of these hospitals for nervous diseases and epilepsy were small institutions, and for the majority of patients with nervous conditions  the likelihood of receiving in-patient or out-patient care from a specialist was slight. Almost all patients, moreover, preferred to be cared for at home in the years before the First World War.44 The general hospitals  and clinics were therefore the patient's most likely destination. Teaching, voluntary and old poor-law hospitals alike confronted numerous challenges with nerve patients. Primarily there was the issue of determining which cases should be brought to the attention of the specialist in nervous diseases, a rare figure.45 Many patients presented with conditions inclusive of nervous system involvement. Any physician capable of determining which patients should see specialists, and which should not, might well therefore have regarded him- or herself as skilled (or adept) enough to bypass the necessity of a referral to a neurologist. Furthermore, centralisation of nervous patients meant also recognising that ‘more than one-half of the persons who seek relief at the neurological out-patient department of a general hospital are suffering from functional as opposed to organic disease’. There was an obvious solution in 1922: ‘the appointment at each of the large hospitals of a resident medical officer for the department of nervous diseases.’46 The solution, if sensible, was by no means simple to implement. There would be very few departments of nervous diseases before 1945, and it was unlikely that most general hospitals could afford to hire a resident medical officer to differentiate cases for neurology referral only. Whoever was hired for such a job would necessarily have to be a good, young general physician—they could develop specialist interests on the job.Specialist hospitals for nervous diseases had begun appearing in Britain from the late-1850s.47 His was the first department of neurology founded in Britain, and one of very few formed in the pre-First World War years. The 1912 appointment of Herbert Campbell Thomson to a special department for ‘Diseases of the Nervous System’ at the Middlesex Hospital offers another example. As Thomson explained in his history of the hospital, his appointment as a physician and lecturer in nervous diseases occurred because of undergraduates' demand for neurological teaching. Although the re-categorisation of Thomson's clients as ‘nerve patients’ represented an administrative achievement of a kind for neurologists, his primary appointment as Physician-to-Outpatients to the Hospital had not effectively ended. By not creating an in-patient service for nerve patients, the hospital administrators had only recognised officially as a specialist service a general out-patient clinic that he was providing already. Thus, aside from new teaching obligations, the position provided him with little save the ability to justify a further focus on nerve patients.48The organisation of the hospitals did increasingly reflect specialisation around therapeutics, laboratory diagnostics, and surgery by the close of the nineteenth century, a fact most clearly reflected in the voluntary hospitals. An Electricity Department founded at St Mary's Hospital in 1881 converted into a neurological department under Wilfred Harris in 1903. Harris thereby transformed a formerly rehabilitative service for a general medical department into a diagnostic department.esprit de généralité. William Johnson's experiences in Arthur Hurst's out-patient neurological clinic at Guy's Hospital, again another example of a voluntary hospital, captures well the sensibility. Guy's Hospital had recruited Johnson in 1917. Hurst, very much cut from generalist cloth himself, required a Senior Registrar with a talent for treating neurotic patients. Johnson's practical knowledge of the psychoneurosis, gained on the Western Front, meant that he had worked with both cases of mental and nervous diseases and no doubt had seen his fair share of a wide variety of acute injuries as well. Johnson's obituarist later recalled that he had never been ‘an exclusive specialist’ and that he ‘remained one of the lessening band of general physicians, at home in all aspects of medicine and with wide practical interests’.49 This point was one worthy of celebration, even in 1949.Positions like those held by Harris and Thompson would typically have encompassed mental diseases as well. Thus even within worlds of emerging specialism there was an 50 In 1933, Frederick Menzies, then Medical Officer of Health for the London County Council, drafted a report focusing on the appointment of specialists in London County Council hospitals. He claimed that each hospital should hire a ‘gynaecologist; ophthalmic surgeon; ear, nose and throat surgeon; orthopaedic surgeon; dermatologist; pediatrist; urologist; radiologist; obstetrician; tuberculosis officer’. Menzies demurred, however, that while neurologists would be useful: ‘… the amount of time for which he would be required is difficult to estimate, I suggest a panel of neurologists should be formed and their services should be utilised as required, and that they should be paid a fee of £2.12s.6d. per session.’51 Menzies' report, on one hand a bold estimation of the needs for specialist services in London, serves on the other hand as a reminder of how slow were the general hospitals adapted to specialisation. Indeed it is worth nothing that where specialist neurology departments formed they usually did so in those environments where medical teaching took place, and individuals trained in neurology otherwise held visiting appointments to county and municipal institutions.52By the 1930s, many county and municipal hospitals had responded to the emergence of specialisation and begun changing their administrative arrangements as well—although this was haphazard.53Although neurologists may have been unusually disadvantaged in these patterns, it is clear that the tendency towards general appointments remained firmly ensconced and was only incrementally reforming in London. A 1932 letter from Francis Fraser  to Alan Gregg at the Rockefeller Foundation captures the difficulties. Noting that Cecil Hinds Howell had begun a consultative neurologic clinic for out-patients at the hospital, Fraser observed that there was an otherwise hopeless situation for neurology there: ‘The plans for a neurological department failed to mature last year and will fail again this year … the formation of new special departments does not meet with approval. It is feared that such special departments must in the end mean more specialised instruction for undergraduates with further cramping of the curriculum.’54 In 1934, the General Infirmary at Leeds established a number of specialist departments, and in 1937 the neurologist Hugh Garland became an Assistant Physician there with an interest in Nervous Diseases, although his hospital established a neurological department only in 1947.55 Hospitals in Scotland and Wales were little different from those in England. The Victorian Infirmary in Glasgow had appointed a physician in nervous diseases in 1914.56 The Western Infirmary in Glasgow appointed its first neurologist in 1941, and Aberdeen did not have a neurological department until after the Second World War.57 The Edinburgh Royal Infirmary was a similarly conservative institution.58 In Wales a 1948 government study of specialist services observed scant neurological services.59 Such facts reflected the substantial role general physicians and general practitioners continued to play in treating patients with nervous diseases, both in Wales and across Britain. Indeed, even in 1960, it was an inevitable conclusion that general physicians and general practitioners almost exclusively saw patients suffering from neurological illnesses.60These were the circumstances in all major urban environments throughout England, Scotland and Wales, and stories of the struggle to found departments of neurology or nervous diseases in hospitals abound . In 1927, the Royal Victoria Infirmary in Newcastle appointed George Hall in neurology.61 In Britain universities and hospitals faced highly differentiated circumstances, but hospital managers in particular, were suspicious, as historian Christopher Lawrence noted, of ‘academic medicine’ as ‘part of a real and realizable social order’ that was ‘professional and technocratic’ and had its ‘implicit and explicit accounts of a healthy nation’.62 Until the First World War, faculty in medical schools in London, throughout England, and in Scotland and Wales, thus appear to have fought the incursion of the State into their educational and clinical work. They resisted the allocation of State salaries, block grants and even the recommendations of government bodies to modernise medical training, degrees or scientific research facilities, not least because they claimed to fear the lack of autonomy such financial arrangements might bring. The formation of academic departments and specialist clinical departments run by academic staff, which became more commonplace in the interwar period, thus resulted from many different pressures, including: competition between educational bodies, falling undergraduate and graduate enrolments, recommendations by recognised governing authorities and philanthropic patrons, and even an increased valuation of specialisation.63Throughout the period prior to the formation of the NHS, the academic and clinical institutional relationships among hospitals, medical schools, universities and external examining bodies were highly contingent upon local circumstances and the training of undergraduates in bedside neurology reflected this reality.64 By the interwar period this increasingly meant specialist training in nervous diseases happened at either the National or Maida Vale Hospitals for Epilepsy and Nervous Diseases in London. In a report drafted in 1966, a history of those hospitals explained that they finally began developing professorial units linked to the University of London in 1950:65With the advent of the National Health Service, the National Hospital was linked to the Hospital for Nervous Diseases, Maida Vale, and they are now one hospital. In 1950 the Medical School was incorporated in the British Postgraduate Medical Federation of London University as the Institute of Neurology. We were slow to alter the original internal structure of our old established Postgraduate Medical School to that of an Institute, with the establishment and growth of professorial units.In practical terms, although not in an exclusively academic sense, specialist training, when it happened, occurred in postgraduate educational settings.66 His retirement, however, was recognised there with the creation of a permanent Lectureship in Neurology, to which Bramwell's former Registrar, William Ritchie Russell, was appointed in 1938. Oxford University, later hired Ritchie Russell as a Lecturer in Neurology in 1949. He would eventually hold the first Chair of Clinical Neurology at the University, which was established in 1966.67 More broadly a collective biography of members of the Association of British Neurologists, a body formed in 1933 (and the members of whom were invited by invitation only), identifies 23 professorships held by members across their careers. Of these only five were Professorships of Neurology in Britain (a sixth was at Harvard University). The range of their professorial positions captures Britain's generalist context: five were Professors of Medicine; three Professors of Physiology; two Professors of Pathology; and one was a Professor of Morbid Anatomy, Experimental Neuropathology, Mental Pathology, Bacteriology, Neurophysiology, Neuropathology and The Practice of Medicine.68 Philip Cloake, Professor of Medicine at Birmingham and Arthur Stanley Barnes, Dean of the Faculty of Medicine there (both members of the Association of British Neurologists) typify these figures. They had struggled throughout the interwar period to establish a department for neurology at Birmingham. Cloake sought a tripartite division for the medical school encompassing neurology, neurosurgery, and neuropsychiatry but ultimately failed, despite being made honorary Professor of Neurology when he retired there in 1946.69Of those physicians often remembered as pioneers of neurology, many had held positions as clinical professors of medicine. Edwin Bramwell, very much in the generalist tradition of his pioneer-neurologist father Byrom Bramwell, had been appointed Moncrieff-Arnott Professor of Medicine at Edinburgh University in 1921.70 Neurology was but one specialty among the 22 recognised by the Ministry of Health, and it seems probable that many specialists had experiences matching those of neurologists in the 1950s and 1960s. From the time of the creation of the health service, Ministry officials had recognised the need to increase the number of practising neurologists . In 1948, they had thus presented ‘general physicians with an interest in neurology’ as a temporary necessity—the qualification itself reveals the transformation bureaucratisation brought to the practice of medicine. Ministry officials also recommended that between 100 and 150 beds per million of population be reserved for neurological patients and declared that each regional centre should provide a neurological service.71 Under the new legislation, the Ministry of Health managed the health service through a hierarchical system of Regional Hospital Boards .72 Ministry officials, frequently criticised in the press for over-centralisation, increasingly adopted a hands-off approach and thereby empowered members of the Regional Hospital Boards to undertake local management of health care. By 1953, according to neurologist Walter Russell Brain, then President of the Royal College of Physicians London, the Ministry had significantly diminished its advisory role, especially towards the Regional Hospital Boards. These facts meant that by the mid-1950s medical specialists, especially in non-surgical specialties, while better represented in teaching centres and major urban environments, found it difficult to find employment beyond the teaching hospitals and most metropolitan-bound general hospitals.73 Specialists' difficulties, according to figures at the Royal Colleges, derived from policy tendencies that had become increasingly exaggerated by the mid-1950s. General physicians commonly controlled the Regional Hospital Boards and preferred to hire physicians with some training in specialist subjects rather than exclusive specialists. Some observed also that members of Regional Hospital Boards preferred to hire specialised surgeons over specialised physicians, because, in the words of Dr George E. Godber , surgical specialists could supposedly ‘kill two birds with one stone’ through diagnosis and subsequent intervention.74The National Health Service Act, passed in 1946 and implemented in 1948, transformed patient access to health care.75 Further details supplied by the Ministry of Health, as well as hospital and patient data gathered mainly from London hospitals, added to what they deemed a bleak picture for the state of British neurology.76 Importantly, most physicians and medical administrators who reviewed the Committee's 1954 report, if not agreeing with the neurologists' solutions, nonetheless concluded that their report was a fair representation of the circumstances for all medical specialists beyond the teaching hospitals.77 It seems that hiring practices within the Regional Hospital Boards benefited general physicians with some training in a specialty rather than pure specialists.Some clinical neurologists viewed this situation as a crisis. In a series of reports published by the Committee on Neurology of the Royal College of Physicians London, neurologists endeavoured first to understand and then secondly steer the future development of neurology within the health service. Committee members in the early 1950s, for example, were shocked to discover that the Ministry of Health recognised officially only 38 neurologists for the whole of the country.78 In the early 1960s and as part of that campaign, the Committee surveyed 86 neurologists working across Britain about the circumstances of their labour , they, the neurologists, were therefore the right group to do those procedures and that under the present arrangement the federal government of the United States was being unfairly stingy and anti-progressive. It is interesting to speculate about the resulting consequences should either the US government or primary care providers adopt an approach similar to that found in the UK in the past. Advocates for primary care practitioners in the USA could certainly argue that if they received more training in basic neurology, then they could thereby supplant more expensive neurologists in primary care settings. The American Academy of Neurology has also recently noted a decline in the number of neurologists per capita in the USA. As this study has demonstrated in the case of Britain, it was a continual shortage of specialist labour that ultimately justified training and hiring general physicians with an interest in neurology. That shortage of specialist labour derived primarily from a potent faith, one grounded in an epistemological perspective, in the value of enduring generalism for medicine.But perhaps, too, there are signs pointing in a different direction—here circumstances in neurology in the contemporary United States may well suggest a prospective future. Representatives for the American Academy of Neurology in the comparatively recent past had begun lobbying to have neurology recognised by the US government for primary care incentives under Medicare (which American neurologists can only do if they are accorded primary care status).