Moral education in medical schools.

The present report summarizes challenges in teaching medical ethics, defines its goals, describes theoretical frameworks for moral education, and reviews strategies for teaching medical ethics to serve as guidelines in developing medical ethics instruction. Medical teachers should clarify the instructional goals in cognitive, attitudinal, and behavioral domains. The cognitive developmental and behavior-analytic theories called for ethical instruction using a series of discussions based on real-life ethical dilemmas while pointing out all the basic rules related to medical practice. Ethical courses for medical students should be student-centered, problem-based, and integrative. Ethical instruction should be systematically taught to every student, but additional elective courses could also be used. Moral education for residents should be more focused to issues specific to their specialties. Medical researchers need both formal ethical training and informal teaching, and role modeling. Finally, experienced staff could use small group discussions of shared ethical problems to maintain their ethical knowledge and skills.

Predicting academic achievement in the medical school with high school grades.

OBJECTIVE: The present study investigated whether high school grades can predict medical school grades after controlling for the effects of demographics and entrance examination scores. MATERIAL AND METHOD: The authors used hierarchical multiple regression analyses to predict medical school grades of 223 medical students in the 1997 entering class of the Faculty of Medicine Siriraj Hospital, Thailand, using age, gender, entrance examination scores, and high school grades as predictors. RESULTS: After controlling for demographics and entrance examination scores, high school grades provided significant prediction only for premedical grades. The type of entrance examination that students took and the type of high school curriculum that the students studied were significant predictors of medical school grades in every level. CONCLUSION: Measures of cognitive abilities in academic content were good in predicting short-term academic achievement. Long-term academic achievement in the medical school could be better predicted from academic orientation, commitment to the medical study, and demographic traits.

The validity and reliability of clinical performance assessment of residents in the general surgery residency program.

A retrospective study of clinical performance assessment of residents in the general surgery residency program at the Department of Surgery,Faculty of Medicine Siriraj Hospital, during the 200-2001 and 2001-2002 academic years was done to evaluate the inter-rater reliability, internal structure, and ducational discriminant validity of the assessment. The inter-rater reliabilities were determined by using the intraclass correlation. Correlations between individual performance ratings were checked to determine how well faculty members differentiate their ratings with individual clinical skills. Finally, the percentage of marginal or unsatisfactory ratings was checked to demonstrate how sensitive the ratings were in identifying performance deficiencies among residents. From the evaluation of 42 residents in the 2000-2001 academic year, inter-rater reliability coefficients of individual ratings ranged from 0.06 to 0.93 with an average of 0.51. From the evaluation of 47 residents in the 2001-2002 academic year, inter-rater reliability coefficients ranged from 0.04 to 0.85 with an average of 0.49. Inter-rater reliabilities of performance ratings of third-year residents were at an acceptable standard for a medium-stake assessment. However, those of first and second-year residents should need some improvement. Tasks performed by first and second-year residents seem to have been inadequate for faculty members to evaluate their performance reliably. The correlation study between individual performance ratings demonstrated the lack of discrimination between many clinical skills in faculty ratings. Faculty members need some guidelines to differentiate between many items including relationship with patients, relationship with other doctors, and relationship with other workers; knowledge and judgment; work concentration and work effectiveness; and punctuality and responsibility. About ten percent of ratings were marginal or unsatisfactory which indicated that these ratings were sensitive enough to identify performance deficiencies among residents.

Predictive power of resident selection criteria for clinical performance in general surgery residency.

To evaluate the ability of the resident selection criteria to predict clinical performance of general surgery residents, the application files and resident evaluations of 35 general surgery residents who were in the residency program of the Department of Surgery, Faculty of Medicine Siriraj Hospital during the 2000- 2001 and 2001- 2002 academic years were reviewed. A correlation study was done using scores from three selection criteria (medical school grades, letters of recommendation, and interview) predictors and clinical performance ratings as outcomes. The interview scores were the best predictor for overall performance of residents in the first and second years. The GPA scores were the best predictor for overall third–year performance. Each selection criterion contributed unique predictive ability for resident performance. The combination of interview scores, scores from letters of recommendation, GPA scores, and ages at admission could predict 60.5% of the total variance in the overall first-year performance scores (R=0.778, p=0.012). The combination of interview scores and score from letters of recommendation could predict 31.4% of the total variance in the overall performance score in the second year (R=0.56, p=0.049). None of the multiple regression models demonstrated statistically significant prediction for the third-year overall performance.

A decision analysis of the treatment for uncomplicated acute cholecystitis.

Laparoscopic cholecystectomy has replaced an open procedure for elective treatment of symptomatic gallstone. However, its use in the management of acute cholecystitis is still controversial. The traditional approach of initial medical treatment followed by delayed laparoscopeic cholecystectomy has been challenged by many recent studies that demonstrated success with early laparoscopic cholecystectomy. In this report, a decision tree was used to analyze treatment alternatives for uncomplicated acute cholecystitis comparing between early and delayed laparoscopic cholecystectomy based on probability estimates and patient utilities data from current medical literature. From the decision tree, the expected value of delayed laparoscopic cholecystectomy in patients with acute cholecytitis was slightly higher than the expected value of early laparoscopic cholecystectomy (0.8634 versus 0.8520). Generally, delayed laparoscopic cholecystectomy seems to have a slight more preferable outcome than early laparoscopic cholecystectomy in patients with uncomplicated acute cholecystitis. However, this decision is sensitive to the change in the rate of conversion from a laparoscopic to an open procedure. Sensitivity analysis revealed that early laparoscopic cholecystectomy was a batter choice of treatment as long as its conversion rate was below 16.98%. From the conversion rates reported in current medical literature, early laparoscopic cholecystectomy should be done within 48-72 hours after the onset of symptoms. However, each surgeon should make appropriate decision for individual case based on individual laparoscopic experience, duration of patient’s symptoms, and hospital policy in scheduling an emergency laparoscopic cholecystectomy. If early laparoscopic cholecystectomy can be performed with a conversion rate lower than 16.98%, it is a better choice of treatment for patients with uncomplicated acute cholecystitis. Otherwise, delayed laparoscopic cholecystectomy should be considered.

Left paraduodenal hernia presenting as intestinal obstruction: A case report.

A case report of left paraduoenal hernia in an 18-year-old man presenting with complete small intestinal obstruction. This patient suffered from intermittent colicky abdominal pain for 10 days. The pain worsened over the 2 days before admission. He also had bilous vomiting and obstipation. He was diagnosed with complete small intestinal obstruction and sent for an emergency exploratory laparotomy. At operation, he was found to have a left paraduodenal hernia. The small bowel could be reduced manually into the normal position and the neck of the hernial sac was closed. He made an uneventful recovery after the operation and was discharged from hospital 4 days later. Although paraduodenal hernia is a rare cause of small intestinal obstruction, it should be taken into account in the differential diagnosis of small intestinal obstruction especially in a patient with no previous abdominal exploration. Early surgical intervention could prevent the possible complication of gangrenous bowel.

Malignant mesothelioma.

A 27 year old Thai male presented with progressive abdominal distension without leg edema, low grade fever and 10 Kgs weight loss over 2 months. Physical examination revealed cachexia,a markedly distended abdomen, with a fluid thrill, but no hepatosplenomegaly. An abdominal tap produced serosanguinous fluid. Analysis of the ascitic fluid demonstrated white blood cell 300 /mm3, red blood cell 270,000 /mm3, SAAG 0.9 gm/dl, ascites protein 3 gm/dl, AFB stain no organisms seen. Cytology showed a few mesothelial cells but no malignant cells. A chest X-ray was normal. The patient underwent laparoscopy. The peritoneum was studded with whitish miliary nodules and fibrin plaques. Peritoneal biopsy revealed chronic inflammation with fibrosis, no granuloma or specific organism. Abdominal CT images demonstrated a large multiseptated cystic mass with a thick wall, occupying almost the entire abdominal cavity. Abdominal exploration demonstrated a huge intraabdominal cystic mass, with multiple discrete white nodules on the surface of the cystic wall and the liver. Histology demonstrated most of tumor cells were deeply embedded in collagenous tissue with a biphasic pattern and high mitotic figure.Immunoperoxidase staining demonstrated tumor markers as follow vimentin, cytokeratin (AE1/AE3), epithelial membrane antigen (EMA) and neurospecific enolase (NSE). The final diagnosis was biphasic malignant mesothelioma. Up to now, no standard treatment is available. Surgery for localized tumors has been reported. Other treaments, such as external radiation, intraperitoneal instillation of radioactive gold and chemotherapy have generally failed to improve overall survival. The median survival is 2 to 12 months after diagnosis with a total duration of about 1 year from the onset of symptoms.