Isolation and identification of a diuretic hormone from Zootermopsis nevadensis.

A diuretic hormone (DH) was isolated from extracts of heads of Zootermopsis nevadensis, a dampwood termite. The peptide has 46 residues, M(r) = 5,328.2 Da, with the sequence TGAVPSLSIVNPLDVLRQRLLLEIARRRMRQSQDQIQANREMLQTI-NH(2,) showing it to be a CRF-related DH. This peptide increases cyclic AMP production in Malpighian tubules of Manduca sexta. We detected another factor in the head extracts which behaved as a more basic peptide on ion exchange chromatography. The latter factor also stimulated cyclic AMP production in the bioassay, but two large scale attempts to isolate this peptide were unsuccessful. We believe the second peptide is acid labile.

Professionalism and professional values in orthopaedics.

During a consensus conference in Fall, 1998, the Academic Orthopaedic Society identified the values and qualities of professionalism as defined by its members. One hundred eighty-six respondents rated 20 characteristics and values describing professionalism, based on the extent to which they believed each item was appropriate. The five items receiving highest average ratings were: integrity, trustworthiness, responsibility, reliability, and accountability. Principal components analysis yielded five factors that captured 62% of the total variability. These factors were labeled respect and relationships, altruism, accountability and reliability, integrity, and excellence. The authors anticipate that the Academic Orthopaedic Society will find these data useful, and incorporate this information into their decisions concerning evaluation of current residents and applicants to their programs. An additional challenge will be to develop a values curriculum (formal curriculum) and a learning environment (informal curriculum) that will encourage residents and faculty to aspire to the highest in professional values and professional conduct.

Moral reasoning, professionalism, and the teaching of ethics to orthopaedic surgeons.

Moral reasoning is not the only component of moral behavior, but it is an important and measurable constituent. Eighty orthopaedists, who took a standardized test of moral reasoning, showed marked heterogeneity in scores, ranging from the level of junior high students to the level of moral philosophers. This variability poses difficulty for those who plan educational courses in ethics, but is not an insurmountable difficulty.

The virtuous orthopaedist has fewer malpractice suits.

It generally is believed that physicians who have poor relationships with their patients are more likely to be sued. We studied certain physician characteristics and related them to their number of malpractice suits and the amount paid to settle those claims. Physicians with better rapport with their patients, who took more time to explain, and who were available had fewer malpractice suits. The most significant correlation was found in time spent with the patient. As the time spent increased, the number of suits decreased.

Can professional values be taught? A look at residency training.

Although medicine has long valued and reinforced certain behaviors, collectively labeled "professionalism," among its members, it is not clear if or how these behaviors might be conveyed to physicians in training. Despite this, teachers are required to assess and at times to act on their perceptions of their charges' professionalism. Surgery residents at a large metropolitan hospital were tracked during a 50-month period. They were evaluated on objective criteria, such as clinical abilities and performance, and more subjective qualities, including ethical standards and interpersonal skills (professionalism). Analysis of the data indicated that residents who scored above the mean on professionalism also scored significantly higher than their classmates on every dimension of skills and knowledge performance evaluated. This convergence suggests that those qualities comprising professionalism are important elements in resident's training, and tend to produce better overall clinical performance. This finding, and previous research in this area, should encourage investigators to explore the relationship between professionalism and clinical competence.

Should moral reasoning serve as a criterion for student and resident selection?

The aim of medical school and residency training is to produce well-trained physicians. One problem has been in knowing which applicants to select. Academic criteria have not correlated well with clinical performance. The current study suggests consideration of an important variable that has been found to be associated with exemplary clinical performance. In recent studies a significant relationship between moral reasoning skills and clinical performance has been found for medical students and residents and dental and nursing students. A similar relationship has been found between levels of moral reasoning and malpractice claims among practicing orthopaedic surgeons. Rest has developed the Defining Issues Test, as a paper and pencil, objective test for assessing moral reasoning. With it being deemed appropriate to assess applicants' scientific reasoning, the authors support the development of an assessment of moral reasoning as a selection criterion for medical school and residency training. More research is required. If additional research confirms the relationship of moral reasoning and superior clinical performance, then the results of moral reasoning tests might legitimately be used in the selection process.

What terminally ill patients care about: toward a validated construct of patients' perspectives.

BACKGROUND: Citizens have conveyed to professionals that care at the end of life is less than optimal. Efforts to improve matters have tended to work in piecemeal fashion, on tangible more than personal aspects of care, and without the benefit of documented perspectives of those who face dying. Policy initiatives and clinical interventions need guidance from a broad framework that is validated by patients' perspectives. PURPOSE: Our goals were to: (1) assess the construct validity and stability over time of the portions of a conceptual framework that concern patients' subjective experiences; (2) develop a foundation for measurement of these personally meaningful factors; and (3) examine these factors' associations for potential clinical or policy significance. POPULATION: Patients were from six diverse geographical areas whose physicians judged their survival prognosis to be 6 months or less. Physicians who referred the patients were randomly selected from state and specialty association lists. METHODS: We used in-person survey methodology and multivariate analysis of patient responses. The analysis fell into two parts. Using exploratory factor analysis, we looked for evidence of discrete dimensions of experiences. Using regression analysis, we examined associations among them. RESULTS: Of 1,131 eligible patients, 988 were interviewed (87.4% response rate). Of 682 patients who survived to follow-up interview 4-6 months later, 650 were interviewed (95.3% response rate). Exploratory factor analysis identified 12 discrete factors (accounting for 55% of variance; maximum Spearman's p = 0.24), 8 of which met criteria for representing measurable dimensions (accounting for 46% of variance). These 8 were: patient-clinician relationship; social connectedness; caregiving needs; psychological distress; spirituality/religiousness; personal acceptance; sense of purpose; and clinician communication. Eigenvalues ranged from 1.45 to 6.30 and Cronbach's alpha from 0.63 to 0.85. The concordance between these dimensions and those in the proposed framework indicated that two dimensions required minor modifications and six were confirmed, providing evidence of good construct validity for this portion of the framework. The same dimensions were also evident at follow-up except that the first two above-listed loaded on one combined factor, clinician interaction (eigenvalues 1.83-7.92; Cronbach's alpha from 0.64 to 0.86). This provides evidence of the construct's stability over time. Clinical communication and patient-clinician relationship were associated (odds ratio [OR] 2.79, 2.31-3.36). Better clinician communication correlated with somewhat better personal acceptance (OR 1.10,1.02-1.19), and a better patient-clinician relationship correlated with less psychological distress (OR 0.84, 0.75-0.95). CONCLUSIONS: We conclude that: (1) Personally meaningful aspects of patients' experience of terminal illness can be represented in valid, multidimensional constructs that are stable over time; (2) They are measurable; and (3) Aspects of the therapeutic relationship appear to correlate with patients' experience of the dying process.

Physician substance use by medical specialty.

Self-reported past year use of alcohol, tobacco, marijuana, cocaine, and two controlled prescription substances (opiates, benzodiazepines); and self-reported lifetime substance abuse or dependence was estimated and compared for 12 specialties among 5,426 physicians participating in an anonymous mailed survey. Logistic regression models controlled for demographic and other characteristics that might explain observed specialty differences. Emergency medicine physicians used more illicit drugs. Psychiatrists used more benzodiazepines. Comparatively, pediatricians had overall low rates of use, as did surgeons, except for tobacco smoking. Anesthesiologists had higher use only for major opiates. Self-reported substance abuse and dependence were at highest levels among psychiatrists and emergency physicians, and lowest among surgeons. With evidence from studies such as this one, a specialty can organize prevention programs to address patterns of substance use specific to that specialty, the specialty characteristics of its members, and their unique practice environments that may contribute risk of substance abuse and dependence.

Unethical and unprofessional conduct observed by residents during their first year of training.

PURPOSE: To present residents' personal observations of unethical and unprofessional conduct in medicine during their first year of training. METHOD: Eight hundred and fifty-seven second-year residents who had previously participated in a study of perceived mistreatment as senior medical students were resurveyed by a three-tiered mail process concerning their experiences during their first postgraduate year, including their personal observations of four types of unethical and unprofessional conduct. RESULTS: Surveys were returned by 571 residents, for a response rate of 67%. Personal observations of falsification of patient records by others on at least one occasion were reported by 44.5% of the responding residents, while 73.8% reported direct observations of mistreatment of patients. Nearly half of the residents (46.7%) reported that others had taken credit for their work, and 72.8% said they had observed colleagues working in an impaired condition at least once during their first year of training. Over one fourth of the residents (28.6%) stated that they had been required to do something during the year that they believed was immoral, unethical, or personally unacceptable. There was an inverse relationship between the residents' observations of unethical and unprofessional conduct and their overall satisfaction with their first year of training (p < .001). CONCLUSIONS: The residents reported observing several types of unethical and unprofessional conduct among their colleagues and superiors. These findings confirm similar reports among medical students and residents and raise questions about the possible effect of such observations on the ethical principles and behavior of physicians-in-training.

Clarifying the relationship of medical education and moral development.

PURPOSE: To assess the development of the moral reasoning skills of medical students through the course of their education, and to determine whether their scores would reflect the increases usually found at this age range and education level. METHOD: Using Rest's Defining Issues Test (DIT), the authors assessed the moral reasoning of a total of 95 Texas A&M medical students from the classes of 1991-94 at the beginning of their first semester, at the end of a required first-semester medical ethics course, and at the end of the students' fourth year. RESULTS: The mean score on the first test was 47.7; on the second, 53.7; and on the third, 56.5. The +6.0 change in mean scores from the first to second test was statistically significant (p < .0001), as was the +8.8 change from the first to final test (p < .0001). The +2.8 change from the second to final test was also significant, although at a lower level (p < .0302). Analysis revealed no significant correlation between moral reasoning scores and age; however, there was a significant correlation between moral reasoning scores and sex, with women scoring higher than men on all three tests. CONCLUSIONS: While data from the current study seem to contradict earlier findings that medical education inhibits an increase in moral reasoning skills, the current findings may alternatively be interpreted as resulting mainly from the required first-semester medical ethics course, which involved small-group discussion of moral dilemmas, an educational method shown elsewhere to be effective in enhancing moral reasoning skills.

The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students.

PURPOSE: To examine how much exposure to small-group case-study discussion is necessary to significantly increase moral reasoning skills. METHOD: For the classes of 1991-1998 at Texas A&M, using Rest's Defining Issues Test, the authors tested groups of students for moral reasoning skills both before and after the students participated in small-group case-study discussions of medical ethics. RESULTS: From 960 students asked to participate, the authors collected complete data for 729 students (75.9% response rate). Small-group case-study exposures ranged from 0 to 44 hours. Groups of students exposed to 20 hours or more demonstrated a significant increase in their moral reasoning scores. Groups with less than 20 hours of exposure demonstrated no significant increase in their scores. CONCLUSION: This study indicates that moral reasoning skills are teachable and measurable, and that small-group discussion significantly increases moral reasoning skills. Further studies are needed to increase the generalizability of these findings.

Learning, satisfaction, and mistreatment during medical internship: a national survey of working conditions.

CONTEXT: Concerns about the working and learning environment of residency training continue to surface. Previous surveys of residents have focused on work hours and income, but have shed little light on how residents view their training experience. OBJECTIVE: To provide a description of the internship year as seen by a large cross section of second-year residents. DESIGN: Mail survey conducted in 1991. SETTING: Residency programs in the United States. PARTICIPANTS: Random 10% sample (N=1773) of all second-year residents listed in the American Medical Association's medical research and information database. MAIN OUTCOME MEASURES: What and who contributes most to residents' learning during internships, degree of satisfaction with the internship experience, on-call and sleep schedules, incidents of perceived mistreatment or abuse, observations of unethical behavior, and experiences of harassment or discrimination. RESULTS: A total of 1277 surveys (72%) of 1773 mailed were returned. Overall, respondents reported a moderate level of satisfaction with their first year of residency. On a scale of 0 to 3, residents rated other residents as contributing most (score of 2.3) to their learning, with special patients ranked second (2.1). During a typical work week, residents reported that they spent an average of 56.9 hours on call in the hospital. A total of 1185 (93%) residents reported experiencing at least 1 incident of perceived mistreatment, with 53% reporting being belittled or humiliated by more senior residents. Among women residents, 63% reported having experienced at least 1 episode of sexual harassment or discrimination. A total of 45% of residents reported having observed another individual falsifying medical records, and 70% saw a colleague working in an impaired condition, most often lack of sleep. Regression analyses suggest that satisfaction with the residency experience was associated with the presence of factors that enhanced learning, and fewer experiences of perceived mistreatment. CONCLUSIONS: Residents report significant problems during their internship experience. Satisfaction with internship is enhanced by positive learning experiences and lack of mistreatment.

Characteristics of surgeons with high and low malpractice claims rates.

We studied the relationship of malpractice claims and the personal, educational, and practice characteristics of a sample of surgeons (n = 427). The surgeons were members of a physician-owned malpractice trust and represented all those who had fewer than 0.13 malpractice claims per year and those with more than 0.54 claims per year. Data are reported separately for orthopedic surgeons (148), obstetrician-gynecologists (115), and a mixed group of other surgeons (164). The last group included otolaryngologists, neurosurgeons, and general, vascular, thoracic, and plastic surgeons. We studied the relationship between the number of malpractice claims (ranging from no history of claims to those terminated from the trust because of high rates of claims) and the surgeon's personal, educational, and practice characteristics. The major differences were between the surgeons who were terminated because of a high number of claims and those with few or no claims. Terminated surgeons were less likely to have completed a fellowship, belong to a clinical faculty, be members of professional societies, be graduates of an American or Canadian medical school, have specialty board certification, or be in a group practice. The data also suggest that orthopedists with high numbers of claims may be less likely to have a religious affiliation or to have a registered nurse working in their office practice. These findings suggest that surgeons with lower claim rates may be more likely to manifest exemplary modes of professional peer relationships and responsible clinical behavior.

Clarifying the relationship of veterinary medical education and moral development.

OBJECTIVE: To clarify the relationship between veterinary medical education and moral development in response to 2 previous studies that presented conflicting evidence that the experience of veterinary medical education may inhibit moral development. DESIGN: The Defining Issues Test (DIT) was used to survey the moral reasoning of veterinary medical students at the beginning and end of their education. SAMPLE POPULATION: First and fourth-year veterinary medical students. PROCEDURE: The moral reasoning of 98 veterinary medical students was assessed at the beginning of their first semester of veterinary medical education and again, 4 years later, at the end of their last semester to determine whether their moral reasoning scores would reflect the expected maturity-related increases usually found at this age range and education level. RESULTS: The DIT scores ranged from 8.3 to 70.0 for first-year students and from 16.7 to 76.7 for fourth-year students. The first-year mean was 44.0 and the fourth-year mean was 45.4. The mean change of +1.45 points was not significant. Statistical analysis did not reveal any significant correlation between the moral reasoning scores and age; however, there was a significant correlation between the moral reasoning scores and gender, with females scoring higher on the first and second test. The difference in the rate of change between tests by gender was not significant. CONCLUSION: This study appears to confirm the findings of an earlier study suggesting veterinary medical education inhibits an increase of moral reasoning in veterinary medical students.

Moral reasoning and malpractice. A pilot study of orthopedic surgeons.

The relationship between moral reasoning and malpractice claims was studied in 53 orthopedic surgeons. Levels of moral reasoning were defined by the percentage of principled responses (P-score) on Rest's Defining Issues Test, while annualized rates of malpractice claims were computed on the basis of data from a regional, physician-owned, interindemnity/liability protection trust. Orthopedic surgeons with fewer than 0.20 claims per year demonstrated significantly (P = 0.04) higher levels of moral reasoning (mean P-score of 43.8) than did those with claims rates higher than 0.40 claims per year (mean P-score of 38.0). Only 1 of 13 orthopedists with P-scores over 50 was found in the higher claims group, suggesting that high levels of moral reasoning may provide a protective element against malpractice claims.