Betting on CPR: a modern version of Pascal's Wager.

Many patients believe that cardiopulmonary resuscitation (CPR) is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrest without CPR (ie, zero). Without realising it, this line of reasoning is strikingly similar to Pascal's Wager, a Renaissance-era argument for accepting the proposition for God's existence. But while the original argument is quite logical-if not universally compelling-the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal's Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal's Wager to code status decisions-and identifying the underlying motivations which the Wager serves to confirm-providers can better ensure that the true values and preferences of patients are upheld.

The Other Side of Medical Student Mistreatment: Teaching Cultural Competency Across the Generational Divide.

Introduction: Medical student mistreatment continues to be a significant problem despite increased awareness and longitudinal efforts to address the issue. Through audience discussions of a previously published film depicting learner mistreatment, we identified challenges created by student behaviors that negatively impact the learning environment. In addition, the need to address cultural competency in a multigenerational clinical environment became apparent. Methods: We created a film of three vignettes based on perspectives shared in focus groups by faculty, residents, nurses, and staff who work with medical students. We used this film to develop student and faculty curricula elucidating generational differences in behaviors and expectations while also exploring the learner's role in creating a more positive learning environment. Results: Our film was presented to medical education professionals at faculty development workshops and meetings, clerkship students at orientation sessions, residents as part of residents-as-teachers curricula, and faculty at departmental grand rounds. Evaluation data from 176 students and 42 faculty showed that a majority of our participants believed the film accurately reflected challenges they faced in the learning environment and felt better equipped to address them. Discussion: Film is an effective way to stimulate discussion about complex interactions in the clinical learning environment. Divergent perspectives on behaviors depicted in the film served as a stimulus to create targeted curricula for faculty and student education. Stimulating dialogue through film may enhance understanding and empathy among disparate groups, which is likely to be a necessary step for lasting change.

The Effectiveness of Standardized Patient Simulation in Training Hospital Ethics Committees.

Clinical simulation using standardized patients has become standard in medical education--and is now being incorporated into some graduate programs in bioethics--for both formative and summative evaluation. In most hospitals, though, clinical ethics consultation is done by the ethics committee (or a subset of it). This study is the first, to our knowledge, to examine the effectiveness of standardized patient simulation in training hospital ethics committees to deal with ethically complex and emotionally fraught clinical situations. Following a substantial revision of the institution's nonbeneficial treatment policy, ethics committee members underwent a simulation to determine whether a specific requested treatment should be withheld on the basis of futility. Pre- and post-intervention surveys showed improvement in all domains, although the small sample size limited the power of the study, with only one measure showing a statistically significant difference. An interesting incidental finding was that one-quarter of committee members voted against a determination of futility, even though the case clearly met the definition set forth in the policy. This highlights the emotional challenges in implementing an ethically rigorous, unanimously accepted policy that ultimately determines the timing and manner of a patient's death.

The detection of premalignant colon polyps during colonoscopy is stable throughout the workday.

BACKGROUND: Recent studies have shown that colonoscopic polyp detection decreases as the workday progresses. This may reflect time-dependent factors such as colonoscopist fatigue and decreased colon cleanliness, which can be addressed through adaptations in colonoscopy practice. OBJECTIVE: To test for time-of-day differences in adenomatous polyp (AP) and sessile serrated polyp (SSP) detection in a practice that uses split-dose bowel preparation and moderated daily colonoscopist procedure loads. DESIGN: Retrospective chart review. SETTING: Community-based, group gastroenterology practice. PATIENTS: This study involved 2439 patients undergoing surveillance or screening colonoscopy. INTERVENTION: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Detection rate of all premalignant polyps (PMPs), and of APs and SSPs, individually. RESULTS: A total of 1183 PMPs were identified in 1486 eligible patients (mean PMP/colonoscopy = 0.80; PMP detection rate = 47%). In univariate and multivariate analyses, PMP detection as well as detection of APs or SSPs individually did not vary significantly in relation to the hour of the day. In a binary comparison of morning (am) versus afternoon (pm) procedures, the total polyp detection rate was 67% and 66%, respectively. For PMPs, APs, SSPs, and hyperplastic polyps (HPs), the am and pm detection rates were 46% and 47%, 41% and 44%, 8% and 8%, and 27% and 24%, respectively. Bowel preparation quality was independent of time of day and was rated excellent or good in 86% to 87% of cases. LIMITATIONS: Retrospective, nonrandomized study. CONCLUSION: Stable PMP, AP, SSP, and HP detection rates throughout the workday occur under certain practice conditions, including the use of split-dose bowel preparation and/or moderated daily colonoscopist procedure loads.