Showing papers in "Academic Medicine in 1989"

Medical ethics education: Coming of age.

Abstract: Medical ethics education is instruction that endeavors to teach the examination of the role of values in the doctor's relationship with patients, colleagues, and society. It is one front of a broad curricular effort to develop physicians' values, social perspectives, and interpersonal skills for the practice of medicine. The authors define medical ethics education as more clinically centered than human values education and more inclusive of philosophical, social, and legal issues than is interpersonal skills training. The authors review the history of the emergence of medical ethics education over the last 20 years, examine the areas of consensus that have emerged concerning the general objectives and premises for designing medical ethics programs, and describe teaching objectives and methods, course content, and program evaluation used in such programs on both preclinical and clinical levels. The four interrelated requirements for successful institutionalization of medical ethics education programs are defined and discussed, and the paper ends with an overview of the uncertain future of medical ethics education, an accepted but still not fully mature part of physician training in the United States. An extensive reference list accompanies the article.

The New Mexico experiment: educational innovation and institutional change.

Abstract: Over the past ten years the University of New Mexico School of Medicine has conducted an educational experiment featuring learner-centered, problem-based, community-oriented learning. The experiment was introduced into an established institution by means of an innovative educational track running pa

The McMaster M.D. program: a case study of renewal in medical education.

Abstract: This paper presents four aspects of health professions education at McMaster University: (1) a review of the key elements of the history and distinctive approach of the Doctor of Medicine (M.D.) program; (2) a description of the process and substance of curriculum change over the past decade, focusing on a major revision of the M.D. program that began in 1983; (3) a summary of the findings of follow-up studies of McMaster M.D. program graduates; and (4) an analysis of the current context within which the Faculty of Health Sciences (of which the M.D. program is a part) is operating and a description of strategies for renewal that are being implemented. The evidence and experience to date support the assertion that satisfactory--and in some ways special--physicians can be prepared using the "McMaster approach" to medical education, but that continuous review and periodic major revisions of the educational program are both necessary and possible; they must occur in concert with developments in other sectors of Faculty of Health Sciences activities.

The effect of teaching medical ethics on medical students' moral reasoning.

Abstract: A study assessed the effect of incorporating medical ethics into the medical curriculum and the relative effects of two methods of implementing that curriculum, namely, lecture and case-study discussions. Results indicate a statistically significant increase (p less than or equal to .0001) in the level of moral reasoning of students exposed to the medical ethics course, regardless of format. Moreover, the unadjusted posttest scores indicated that the case-study method was significantly (p less than or equal to .03) more effective than the lecture method in increasing students' level of moral reasoning. When adjustment were made for the pretest scores, however, this difference was not statistically significant (p less than or equal to .18). Regression analysis by linear panel techniques revealed that age, gender, undergraduate grade-point average, and scores on the Medical College Admission Test were not related to the changes in moral-reasoning scores. All of the variance that could be explained was due to the students' being in one of the two experimental groups. In comparison with the control group, the change associated with each experimental format was statistically significant (lecture, p less than or equal to .004; case study, p less than or equal to .0001). Various explanations for these findings and their implications are given.

Present activities of 1989 U.S. medical graduates.

Abstract: To determine whether control of work hours (controllable lifestyle) was becoming an increasingly important factor in choices of specialties by medical students, data from three medical schools over the past ten, ten, and six years, respectively, were reviewed for the types of specialty training entered by students in the top 15% of their classes. Since students in the upper 15% of the class are likely to obtain the specialties of their choice, any change in the pattern of their specialty preferences probably reflects a general trend. Specialties that feature a controllable lifestyle (CL) were defined as anesthesiology, dermatology, emergency medicine, neurology, ophthalmology, otolaryngology, pathology, psychiatry, and radiology. Non-CL specialties were surgery, medicine, family practice, pediatrics, and obstetrics-gynecology. The results showed that the percentages of students entering CL specialties increased significantly at all three schools, the percentages of students entering non-CL specialties decreased significantly at all three schools, and there was no significant change in the percentage of students entering surgical specialties.

Specialty choices at one medical school: recent trends and analysis of predictive factors.

Abstract: Recent reports have raised the concern that personal care specialties, especially primary care specialties, are attracting fewer medical school graduates. In the present study, the authors evaluated the proportions of University of California, San Francisco (UCSF), medical school graduates entering personal care specialties and technology-oriented specialties from 1982 through 1988 and found no significant trend away from personal care specialties such as internal medicine, family practice, pediatrics, and psychiatry during these years. For the graduating class of 1988, admissions and questionnaire data were used to evaluate the importance of pre-admission, medical school, and postgraduate factors as determinants of specialty choice. The group entering personal care specialties (66% of all 1988 graduates) was significantly older and included more women and fewer minority students than the group entering technology-oriented specialties. Students rated income and lifestyle factors as being less important determinants of specialty choice than are medical school experiences and intrinsic qualities of the chosen specialties. However, compared with the students who entered personal care specialties, those who chose technology-oriented specialties over an alternate choice in personal care rated as significantly more important the opportunity to do procedures (p less than .001), income (p less than .005), the lesser degree of diagnostic uncertainty (p less than .005), and the rejected specialty's allowing less time for family (p less than .005) and for other interests (p less than .008). Exposure to acquired immunodeficiency syndrome and loan indebtedness were rated the least significant influences on specialty choice.(ABSTRACT TRUNCATED AT 250 WORDS)

Teaching medical ethics: some persistent questions and some responses.

Abstract: &NA; No abstract available.

Teaching and Learning in the Ambulatory Setting.

Abstract: Changes in how and where health care is delivered have had an adverse effect on the traditional inpatient-based clinical education of medical students. Increasingly, medical educators are turning to ambulatory-based educational experiences as viable and useful adjuncts to the inpatient wards. However, when planning and developing an ambulatory clerkship, careful attention must be paid to the desired outcomes from the experience, the appropriate site, and instructional model to use to best meet the objectives. This report explores (1) the major differences between ambulatory and inpatient educational settings, (2) potential educational outcomes of clinical teaching in the ambulatory setting, (3) instructional models that can be used to meet educational objectives, (4) the potential barriers and critical issues that must be considered when implementing ambulatory educational experiences, and (5) evaluation strategies for measuring the educational outcome.

Effects of sleep deprivation on cognitive ability and skills of pediatrics residents.

Abstract: The stress and long working hours of medical residency have become the basis for controversy over whether current training structures and processes adversely affect residents' skills and well-being and the quality of patient care. The authors measured cognitive and skills performances of 45 sleep-deprived pediatrics residents by using questions like those on the pediatrics board certification examination and using patient-care tasks that required coordination and dexterity. The residents were randomly divided into two groups--one stayed awake for 24 hours, the other for 34 hours--and were tested on cognitive and skills performances before and after sleep deprivation. Sleep deprivation did not have a significant effect on cognitive performance. Of the three skills tested, the residents overall needed more time to perform umbilical artery catheterization, but the group deprived of sleep for 34 hours performed vein cannulation more quickly than the group deprived for 24 hours. Implications for these findings are discussed in the context of the ongoing controversy over the structure and process of medical education.

The legal context for evaluating and dismissing medical students and residents.

Abstract: Medical school faculty often cite the fear of litigation as a reason for their reluctance to offer candid evaluations of students' and residents' performances and to dismiss them when necessary. This article is written to reassure faculty that they have nothing to fear from the courts and that they should uphold high academic standards. Three legal issues of concern to faculty are addressed: What does fair and equitable treatment entail? What are the due process requirements for academic dismissals? Are negative performance evaluations libelous and defamatory? Recommendations are made to meet legal requirements and to promote academic excellence.

Evaluation of clinical instructors by third-year medical students.

Abstract: Third-year medical students used 12 descriptive items to evaluate the teaching skills of first-year residents, senior medical residents, preceptors (internal medicine fellows), and attending physicians. Intraclass correlations showed that the students were able to judge their instructors reliably. Further analyses were then carried out to determine whether students differentially evaluated the four instructor groups. Three of the descriptive items that related to overall evaluations, as well as the mean rating of all items, indicated no group differences. However, when the groups were compared on specific teaching characteristics (by means of a multiple-group discriminant function analysis), systematic differences were found. The first function differentiated the groups in terms of the cognitive and experiential characteristics of the instructors, with attending physicians being rated the highest and first-year residents the lowest. In contrast, the third function separated the groups in terms of interpersonal skills; on this function, the senior medical residents were rated the highest and preceptors the lowest. It is concluded that students make sophisticated judgments in evaluating their clinical teachers.

Teaching Medical Ethics during Residency.

Abstract: Because practicing physicians are poorly prepared to resolve many ethical issues that arise in patient care, this article proposes that residencies include practical training in medical ethics. Training in medical ethics helps physicians recognize ethical issues in patient care and resolve those issues wisely. Furthermore, such training has its maximum impact during the professionally formative years of residency. The article specifies key ethical concepts residents should know, including knowing how to obtain informed consent, knowing what to do about incompetent patients, knowing when to withhold or disclose clinical information, and knowing how to use resources properly. The article also points out that the success of residency training in ethics depends on strong commitments from the department: endorsement by the chairman and the residency program director; recruitment of several dedicated faculty; support for adequate ethics training for these faculty; dedication of conferences, rounds, and consultations to teaching ethics; and allocation of sufficient funds.

Internal medicine residents' preferences regarding medical ethics education.

Abstract: Three hundred and twenty-three residents in six internal medicine programs in three states were surveyed concerning what they wanted to learn about medical ethics and how they would prefer to learn it; they were also asked to indicate what medical ethics education they had already received. Specific

Teaching medical students in ambulatory settings in departments of internal medicine.

Abstract: Clinical training in ambulatory settings is an increasingly prominent topic in medical education, but most descriptions of internal medicine programs in the literature concern training for residents The authors undertook a survey of departments of internal medicine to obtain and assess information

An education program to reduce unnecessary laboratory tests by residents.

Abstract: What are often called "little-ticket" items--X-rays and laboratory tests--account for 25-30% of all health care costs. Two such items were the focus of this study, which took place at an inner-city community health center operated by the Department of Family Medicine of Cook County Hospital and involved 20 family practice residents over a period of nine weeks. The first item was the complete blood count (CBC) with differential, a prototype of a low-cost, high-volume test often ordered by reflex; the second, the thyroid stimulating hormone (TSH) test, a high-cost, low-volume test normally associated with a differential diagnosis or clinical reasoning. Through the use of a simple educational intervention based on quality of care, not cost-containment, and an audit feedback system, the authors were able to reduce significantly the rates of ordering TSH tests (p less than .0001) and CBCs (p = .05). This effect on the rates persisted five months after the intervention terminated. In addition, the percentage of TSH tests clinically indicated by explicit criteria increased significantly (p less than .001) during the intervention. However, this effect showed signs of diminishing five months after the intervention ended. The percentage of CBCs clinically indicated did not change significantly as a result of this intervention.

A research methods and statistics journal club for residents.

Abstract: A monthly journal club for residents that focuses on research methods and statistics is described. Detailed discussions and analyses of clinical research articles by the residents are used to teach the important concepts and principles of medical research in a manner useful to the practicing physician. Discussion of research articles is structured by a guide for presenting the research articles to the group and by stimulus questions that address specific methodological issues related to the study being examined. Residents have been enthusiastic in their evaluation of the journal club; the experience has stimulated some of them to conduct their own research studies.

Sex differences in rank attainment among radiology and internal medicine faculty.

Abstract: Overall, the percentage of women attaining the ranks of associate professor and professor remains well below the percentage of men in those ranks. Few studies of women in academic medicine have been conducted that might guide the leaders of medical schools and specialty societies in addressing the reasons for this disparity. The Association of American Medical Colleges (AAMC) Faculty Roster System allows comparison of a cohort of faculty at any selected time following their first faculty appointments. This study examined men and women faculty who received their first appointments in the departments of radiology and internal medicine in 1976 and who were still active in 1986. Disparities between men and women in rank attained were apparent in both specialties but were greater in radiology than in internal medicine. Other variables examined include ethnic-racial self-description and teaching, research, patient care, and administrative responsibilities. The authors pose additional research questions requiring information that the Faculty Roster System is not designed to provide.

A matter of integrity.

Abstract: There may be more aberrations in the moral and ethical behavior of scientists and physicians now than in the past. Fraud and misconduct in research have become a major stress point for both science and medicine. The "premed syndrome" (cheating in medical school and dishonesty during residency training) and fraud in medical practice are well known. Further, studies show that medical students are lenient towards dishonesty in education and practice. One result is that researchers and faculty members may turn to fraud when faced with the pressures to excel, produce, publish, be promoted, and win tenure. Also, physicians' ties to research and commercial endeavors raise questions of conflict of interest that may tarnish the medical image and compromise research findings. An AAMC ad hoc committee on research fraud identified three steps institutions might take: determination of the magnitude of the problem by a formal study; institution of guidelines for research, publication, and promotion; and establishment of policies for investigating allegations of fraud. Because of the problems of dishonesty, fraud, and conflict of interest, academic medical institutions must establish codes of conduct to govern professional life.

Medical students' perceptions of cheating

Abstract: In 1985, 683 students at a large private upper-midwestern medical school were surveyed concerning the appropriateness of traditional cheating behaviors and behaviors related to professional misconduct and dishonesty in patient care. They also rated the acceptability of various rationalizations for these behaviors. The students agreed that traditional forms of academic cheating are inappropriate, but they did not agree about the appropriateness of certain behaviors in the areas of patient care and professional misconduct.

Residents' hours and supervision.

Abstract: One year of graduate medical education, the internship, had become the norm for graduates of most U.S. medical schools by 1920, and subsequently was adopted by most states as a criterion for licensure. The original concept of a "resident physician" carried with it responsibility for patients 24 hours per day, seven days per week. Recent public and media attention to the issues of residents' supervision and working hours has led to governmental efforts to restrict their hours and set minimum requirements for supervision. New York is the first state to impose specific requirements. The New York recommendations have implications for the concept of graded responsibility for residents, for learning the natural course of illness, and for the need to provide service in hospitals. Further, the recommendations raise four objections: they do not recognize differences by type of specialty or year of training; they might affect the length of time needed to acquire aggregate clinical skills; they affect different types of hospitals differently; and they would have a major effect on physician manpower. Hospitals and residency programs will face several difficult choices in responding to the regulations. To provide its members with guidelines for action, the Executive Council of the Association of American Medical Colleges has issued recommendations for residency hours and supervision, including the use of an 80-hour work-week averaged over four weeks, the continued use of graded supervision of residents in emergency rooms and in inpatient and ambulatory settings, and control of housestaff moonlighting.

Impact of a required family medicine clerkship on medical students' attitudes about primary care.

Abstract: A study of 314 medical students before and after a required third-year clerkship in family medicine explored relationships among exposure to the clerkship and changes in attitudes toward primary care. The survey instrument contained 29 statements distinguishing the philosophy of primary care from that of subspecialty-oriented medicine and asked students' to state their future residency plans. The responses of the primary care and subspecialty-oriented groups were the most disparate, whereas the students who were uncertain about residency plans shifted on several items from an alignment with the specialty group toward an alignment with the primary care group. This study shows that experience in a family medicine clerkship may be associated with changes in attitudes that represent development of a more informed image of primary care.

The VA's affiliation with academic medicine: an emergency post-war strategy becomes a permanent partnership.

Abstract: The creation of a cabinet-level department for veterans' programs is an occasion to review medical care of American military veterans, which dates back to colonial times. To meet the medical care crisis caused by large numbers of returning World War II veterans, the Veterans Administration (VA) ente

The Duke University program for integrating ethics and human values into medical education.

Abstract: In its second year of development, this program blends cognitive and affective approaches to integrating ethics and human values into medical education. The core of this effort is the establishment of direct and continuing relationships between the four advisory deans and their medical student advisees through small groups that continue throughout the four years of medical school. Clinical correlation seminars, lecture/discussions, the humanities, clinical clerkships, and electives are components of this integration process. Both basic science and clinical faculty members have observed positive changes in the degree and depth of participation, discussion, and interest, as well as in the general attitudes of the students.

Physicians' and medical students' knowledge of nutrition

Abstract: A study was conducted to assess the knowledge of nutrition of 184 family practitioners and general internists and 24 first- and second-year medical students before they had received medical school instruction in clinical nutrition. Overall, the physicians answered 69.2% of the questions correctly, a significantly better score than that of the medical students (62.5%, p = .0065). The physicians scored better on topics that have been the most heavily researched (such as diet and coronary heart disease) and worse on less heavily investigated topics (such as diet and cancer, iron absorption). There was no significant difference in overall knowledge in terms of gender or practice. However, a significant negative correlation was found between the number of years since graduation from medical school and respondents' knowledge about nutrition.

A review of medical education and medical informatics.

Abstract: Physicians have considerable difficulty collecting and interpreting information from patients, dealing with the uncertainties associated with diagnosing and treating their patients, communicating precisely with one another, keeping up to date, and applying recommended procedures when indicated. Some of the advances in information technology may help physicians to manage information more effectively through more accessible, validated clinical indexes, data bases of diagnostic test characteristics, computerized audits of clinical activities with feedback, expert systems, on-line access to the medical literature, and other tools of medical informatics. Medical educators can catalyze this process by facilitating the introduction of information technology into academic clinical settings so that students can learn its use first-hand and by promoting the evolution of this and other aspects of medical informatics, a new discipline dedicated to the solution of information problems in health care. The potential roles for computer-aided instruction and centralized computer laboratories in medical schools are much less clear.

Assessing correlations between black and white students' perceptions of the medical school learning environment, their academic performances, and their well-being.

Abstract: From 1982 to 1985, first-year students at a medical school were invited to participate in a longitudinal study that assessed the correlations between their perceptions of the learning environment, their academic performances, and their perceptions of their own well-being. Differences between black and white medical students' perceptions of the medical school's learning environment and the predictors of their academic success and mental and social well-being were determined at the end of their first year. Black and white students had similar perceptions of the learning environment's quality. Black students experienced more stress but found more support from faculty, class advisors, and administrators. Although black and white students shared some predictors of academic performance and well-being, there were important differences that should be considered when resources are developed to assist students with their academic performance and the maintenance of their social and mental well-being.

Assessing Research Productivity: Evaluating Journal Publication across Academic Departments.

Abstract: Publications produced by faculty over a three-year period are used in analyzing the relative research productivity of basic and clinical science departments in a college of medicine. The citation ratings of the journals, the number of authors, and the byline position of the faculty member are used in various publication evaluation schemes. The departments vary almost tenfold in research productivity per faculty member. Results of the analysis demonstrate that the number of authors and the byline position influence departmental productivity rankings very little. Rankings are substantially affected, however, when the journals are weighted based heavily on citation ratings.

Improving the Preparation of Preclinical Students for Taking Sexual Histories

Abstract: The authors evaluated human sexuality training programs at two California medical schools. In one program, students had no experience taking a sexual history. In the other, students were randomly assigned either to conduct or to observe a brief sexual history interview with a community volunteer. The students who conducted an interview showed more significant improvements in knowledge of human sexuality, perceived appropriateness of taking a sexual history and perceived personal skill in taking a sexual history than did the students who neither observed nor took a sexual history and also developed more critical views of practicing physicians' skills in taking such histories. The students who observed an interview improved more in knowledge and perceived personal skill than did the students who had no interview experience.