Medical Students' Exposure to Ethics Conflicts in Clinical Training: Implications for Timing UME Bioethics Education.

While there is significant consensus that undergraduate medical education (UME) should include bioethics training, there is widespread debate about how to teach bioethics to medical students. Educators disagree about course methods and approaches, the topics that should be covered, and the effectiveness and metrics for UME ethics training. One issue that has received scant attention is the timing of bioethics education during medical training. The existing literature suggests that most medical ethics education occurs in the pre-clinical years. Follow-up studies indicate that medical students in their clinical rotations have little recall or ability to apply ethics concepts that were learned in their pre-clinical training. Trainees also report a desire for medical ethics to be taught in the context of practical application, which would suggest that the timing of pre-clinical ethics education is flawed. However, moving bioethics training to the clinical years should not be assumed to be the solution to the problems of recall and theory application. We argue that the effectiveness of timing bioethics education will depend on when medical students witness or experience particular categories of ethical dilemmas during their training. Our overarching hypothesis is that ethics education will be most effective when the bioethics training on a particular topic correlates to experiential exposure to that ethical issue. The purpose of our current study was to describe medical students exposure to particular categories of ethical conflicts, dilemmas, or issues. Our results may help bioethics educators better strategize about the most effective timing of medical ethics training in UME.

Use of inpatient seclusion at a community mental health center.

Little research has been done on the use of seclusion in community mental health centers. The authors studied 56 seclusion room placements for 25 inpatients at a community mental health center and found that use of seclusion may more frequently be a function of staff than of patient need. Evening and night shifts made more frequent use of seclusion than did day shifts. Shifts staffed primarily with female employees used seclusion more than shifts where male staff predominated. Shifts with both a low staff-patient ratio and a larger number of female staff tended to use seclusion the most. The authors urge other CMHCs to critically examine their seclusion practices to ensure that they are humane and appropriate.

Goal attainment and satisfaction scores for CMHC clients.

The purpose of this study was to explore the psychometric properties of goal attainment scales and client satisfaction measures. The findings revealed that goal attainment results, like other types of self-report psychotherapy outcome measures, are directly related to (a) indicators of a client's social class, and (b) the manner of treatment termination (unilateral dropout vs. mutual consent). The extent of client--therapist agreement on goal scores was relatively low thereby supporting the necessity of obtaining both perspectives in evaluating treatment outcome. Furthermore, because measures of client satisfaction were found to be sufficiently independent from goal outcome scores, it was concluded that they provide a unique source of program evaluation data. Finally, it was concluded that Goal Attainment Scaling is best considered to be a quality assurance tool for individual client/therapist dyads rather than a mechanism for the determination of the effectiveness of specific mental health programs and services.

Governing board and management staff attitudes toward community mental health center citizen participation.

The present study investigated the attitudes and values of community and mental health center board and management staff of four Community Mental Health Centers and one mental health clinic toward the recent federal mandate calling for increased citizen involvement in center evaluation activities. Three related areas were address: (a) general attitudes toward citizen participation, (b) types of program-evaluation activities in which citizen input would be most useful; and (c) types of individuals who would best serve on citizen review groups. The results indicated that although board members are somewhat more optimistic about benefits received from citizen involvement, overall there was close agreement between the board and staff respondents in the three areas studied. These results were interpreted as substantiating the view that community mental health center boards typically reflect a provider orientation in their approach to mental health governance. A missing evaluation component in most centers is citizen participation as it reflects the values of its service consumers. It is advocated that only by developing consumer participation mechanisms will centers more readily achieve the goal of responsiveness to community needs.

A method of evaluating the impact of services at a comprehensive community mental health center.

Efforts of one community mental health center to develop a system of program evaluation designed to meet criteria mandated by recent Federal legislation are described. This approach represents a comprehensive evaluation system with the capability of objectively assessing: (a) patterns of utilization of services, (b) satisfaction with services as well as the availability, accessibility, and acceptability of services, and (c) the quality of direct mental health services as measured by attainment of individualized treatment goals. A rationale for the development of this system as well as a description of the modifications and automatization of the procedure are included. Initial results are presented which pertain to 2,900 goals written for 1,250 clients receiving treatment within five of the Center's direct service elements.

The acces system: a procedure for evaluating children's services at community mental health centers.

This paper describes the efforts made by one community mental health center to develop a system of program evaluation for children's treatment services. The approach described has the capability of objectively assessing (1) patterns of utilization of children's services; (2) satisfaction with services as well as the availability, accessibility, and acceptability of services; and (3) the quality of children's mental health services as measured by the attainment of individualized treatment goals. A rationale for the development of this system as well as a description of the modifications and automatization of the procedure are included. By way of illustration, initial results are presented which pertain to 500 goals written for 208 child clients receiving treatment within any one of three of the center's child direct-service programs.

Demographic data and mental health planning.

The use of readily available demographic data in mental health planning is discussed and illustrated. Four indices are identified as important in setting priorities for mental health services: social class, family organization, population mobility, and population heterogeneity.