Curricular trends in instruction of pathology: a nationwide longitudinal study from 1993 to present.

Medical schools throughout the United States continue to respond to various external and internal challenges and make modifications in their curricula. Responses obtained from 66% (n = 83) of schools on a longitudinal survey conducted during the year 2000 to study trends in instruction of pathology over a 7-year period (ie, for classes entering 1993 to 1999) indicate the following. There have been steady shifts in instruction of systemic and clinical pathology from discipline-based courses to integrated formats from 1993 to 1999. The degree of integration with other disciplines varies among schools, and may take one or more of the following formats: joint course (pathology and another discipline); multidisciplinary systems course; a combination of pathology course and another integrated course; and completely integrated in the form of problem-based or case-based small group discussion. Presently, at least some degree of integration occurs in 51% of schools for instruction of systemic pathology and 65% for clinical pathology, up from 31% and 48%, respectively, in 1993. Although there has been an increased trend toward integration in instruction of general pathology as well, it is still taught predominantly in a discipline-based manner in the vast majority of schools. Although often difficult to identify with certainty, the best estimates indicate that the overall scheduled length of pathology instruction time has stabilized over the years; the mean total for the entering classes of 1999 was 196 hours versus 201 hours for the classes entering in 1993. However, internal rearrangements of time for various components of delivery of instruction continue. The lecture remains unchanged as an important mode comprising the largest component of pathology curriculum time (53% in 1999, 52.2% in 1993) during the 7-year period examined. The mean traditional laboratory instruction time has decreased slightly from 27% in 1993 to 24% in 1999. This decrease may be accounted for by a shift toward use of laboratory materials in various other formats and venues not included in the traditional laboratory instruction (eg, small group sessions, clinicopathologic correlation conferences, study of kodachrome slides, and computer programs). The use of electronic educational resources has increased remarkably, but for the most part it is not measurable because of the lack of any designated hours. Because pathology instruction occurs exclusively or primarily during year 2 in most schools, the classes entering in 1999 would have studied it during 2000 and 2001, which means the present study provides the most updated curricular trends at this time.

The effect of outliers on confidence interval procedures for cost-effectiveness ratios.

Cost-effectiveness ratio (CER) is defined as the ratio of the difference in cost between a test and standard health care programme to the difference in benefit, respectively. Methods to obtain confidence intervals for CERs are either variants of Fieller's method (1954), or bootstrap methods. We study the effect of outliers in cost measures on the precision of confidence interval procedures for CERs. In particular the performance of the procedures under single and multiple case influential deletion diagnostics, respectively, are evaluated. Simulation studies suggest that the bias-corrected percentile bootstrap procedure gives better precision and coverage under either diagnostic.

Life values, resuscitation preferences, and the applicability of living wills in an older population.

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills. DESIGN: Individual structured interviews. SETTING: An independent retirement community. PARTICIPANTS: One hundred thirty-two subjects older than 63 years of age. MEASUREMENTS: Resuscitation preferences were elicited in five hypothetical scenarios. Subjects with living wills were asked whether their living will would play a role in the scenarios. Subjects rated the importance of 13 life value statements. RESULTS: The percentage of subjects desiring CPR in each scenario was as follows: current condition (66%); acute illness (33%); terminal disease (8%); functional impairment (8%); and dementia (7%). The percentage of those with a living will who thought their living wills would play a role in the scenarios was as follows: acute illness (84%); terminal disease (93%); functional impairment with intact cognition (66%); and dementia (91%). Factor analysis of the life value statements revealed five meaningful factors: quality of life; capacity/autonomy; family relations; physical comfort; and treatment philosophy. Multiple correlations were found between four of five life value factors and hypothetical resuscitation preferences or the presence of a living will. CONCLUSION: Subjects misinterpreted the applicability of living wills in nonterminal illness scenarios. A relationship between life values and resuscitation preferences was noted, which emphasizes the importance of eliciting and including life values when discussing advance directives.