Improved competence after a palliative care course for internal medicine residents.

Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of residents in internal medicine. Before and after the course, we carried out a questionnaire survey and knowledge test in 91 residents. The results show that many residents felt they had limited competence or were incompetent when taking care of patients in the palliative care phase. This was particularly true with respect to communication concerning euthanasia and physician-assisted suicide or hastened death (86% and 85% respectively reported limited competence or incompetence). Participants reported that they received inadequate training in palliative care and believed that specific education would make them feel more competent. The number of times that residents were engaged in palliative care situations and the years of clinical experience had a positive influence on perceived competence. Participating in the course improved perceived competence and knowledge in palliative care. No correlation was found between perceived competence and knowledge of palliative care.

Who does become an internist?

Internal medicine is a broad medical speciality and choosing the residency programme opens up a variety of career tracks. Despite this broad choice of subspecialities, we found that within our residency programme for internal medicine in the Nijmegen region between 1981 and 2000, 29% of the residents did not become internists but switched to other medical specialities. To further complicate the efficiency of the residency programme, about 20% of the residents who became internists did not finish within six years, but had a delay of two years due to combined internal medicine/PhD tracks (the training for internist/clinical investigator). In another 20% there is a delay of six to 12 months due to part-time training tracks as well as to (multiple) pregnancies of female residents and parental leave of both sexes. Our data imply that nationwide data are urgently needed to re-evaluate the manpower planning for internal medicine by taking into consideration not only the number of residents starting in the residency programme but also to include the number of residents who actually do become internists.

Why don't medical textbooks teach? The lack of logic in the differential diagnosis.

Medical textbooks are an important aid in the process of diagnosing and treating patients. Medical students use these books to acquire the skills necessary for this process, while medical teachers and experienced doctors use them for teaching these competences. We posed the question whether medical textbooks are structured in such a way that medical students are taught to structure knowledge and to make a differential diagnosis in a logical way. Five major textbooks were compared with regard to four clinical problems (gastrointestinal bleeding, anaemia, oedema and heart failure). The presentation appeared to be very variable in respect of logic and systematic arrangement. In fact, it was disappointing that even in well-reputed textbooks, a systematic approach is lacking. We feel there is a need for improvement, in order to facilitate the learning of medical students and to enhance their abilities in clinical problem solving.

[Broader indication for treatment with statins; the 'heart protection study']. / Ruimere indicatie voor behandeling met statinen; de 'heart protection study'.

The introduction of statins has been a breakthrough in the treatment of hypercholesterolaemia. Statins are safe and effective in reducing the risk of coronary heart disease in the general population. The 'Heart protection study' has provided evidence for the benefit of statin treatment in much broader populations than is presently indicated in the Dutch national guidelines, i.e. also in high-risk persons with diabetes mellitus, and irrespective of age or cholesterol level. The use and cost of statins, which have been referred to as 'lifestyle-drugs' in the lay press, have risen enormously. Recently, the Dutch College of Healthcare Insurers issued a report in which recommendations concerning the reimbursement of the costs for cholesterol-lowering drugs are based on 'generally accepted insights into the appropriate use of these drugs'. Lifestyle and/or age are not exclusion criteria for treatment with statins. The expiration of patents of some statins and modifications to the reimbursement system in 2003 could lead to cost reductions.