UK geriatricians' attitudes to active voluntary euthanasia and physician-assisted death.

AIM: To describe the views of British geriatricians on active voluntary euthanasia and physician-assisted death. METHOD: Postal questionnaire to 742 consultant members of the British Geriatrics Society. RESULTS: 81% considered active voluntary euthanasia never to be justified ethically, although 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations. With regard to physician-assisted death, 68% opposed it on ethical grounds and 24% supported its legalization in some instances, with 12% stating they would be willing to provide such assistance in some situations. Free text comments frequently cited good palliative care as an important response to such issues in clinical practice.

Prior aspirin use in unstable angina predisposes to higher risk: the aspirin paradox.

BACKGROUND: Aspirin is the most widely prescribed agent used in prevention of coronary thrombosis. Thus, many patients presenting with acute coronary syndromes have a history of aspirin usage. METHODS: To assess response to medical therapy in patients taking aspirin prior to admission with an acute coronary syndrome, we reviewed outcomes data from the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Events (ESSENCE) and Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) studies. RESULTS: Patients with acute coronary syndromes who had taken aspirin prior to enrollment were less likely to have non-Q-wave myocardial infarction on admission (ESSENCE: 16.0% vs. 29.2%, p<0.001; PRISM-PLUS: 34.2% vs. 57.7%, p<0.001). However, prior aspirin users were more likely to be failed by standard medical therapy with unfractionated heparin than non-prior aspirin users (ESSENCE: 21.5% vs. 16.5%, p=0.017; PRISM-PLUS: 23.5% vs. 12.1%, p<0.001). Prior aspirin users received greater benefit from both enoxaparin (21.5% vs. 16.8%, p=0.009) and tirofiban with unfractionated heparin (23.5% vs. 16.0%, p=0.007) than from unfractionated heparin alone. Non-prior aspirin users presented with higher rates of non-Q-wave myocardial infarction. CONCLUSIONS: Prior aspirin users admitted with acute coronary syndromes may have a more benign presentation, but are more likely to be failed by medical therapy with unfractionated heparin and should be considered as a high-risk group. Enoxaparin or the combination of tirofiban and unfractionated heparin are both more effective than unfractionated heparin in this group.

The incremental value of internet-based instruction as an adjunct to classroom instruction: a prospective randomized study.

PURPOSE: Computer-based methods of instruction offer the possibility of helping medical students to learn clinical skills and professionalism. Without rigorous documentation of its pedagogic advantages, the utility of Internet-based teaching is not solidly grounded. The authors carried out a prospective, randomized study of educational outcomes, comparing a traditional classroom course in clinical ethics with the same course supplemented by Internet-based discussion. METHODS: Introduction to Clinical Ethics is a sophomore medical school course that teaches a specific method for analyzing clinical ethical problems. One sophomore class was randomly assigned to either classroom teaching alone (traditional group; n = 65) or classroom teaching supplemented with Internet-based discussions of cases illustrating ethical issues (Internet component group; n = 62). A final case analysis comprehensively evaluated students' understanding of the analytic method taught in the course. Grades for both groups on the final case analyses, which were rated by two external reviewers, were compared. RESULTS: The students' understanding of ethical analysis, as measured by grades of external reviewers on the final paper, was significantly higher for those in the course with the Internet component than it was for those in the traditional course (3.0 +/- 0.6 and 2.6 +/- 0.7, respectively; p <.005). CONCLUSION: The study documents the incremental value of Internet-based teaching of clinical ethics to sophomore medical students.

Detached concern and death anxiety of first-year medical students: before and after the gross anatomy course.

The purpose of this study was to gather data from first-year medical students prior to their taking gross anatomy and again at the end of the course to determine if changes occur regarding death anxiety and detached concern toward patients. Chi-square and t-tests were used to assess statistical significance. From the 84 students for whom we had data both prior to and after gross anatomy, only the sociodemographic variable of sex was consistently related to the two dependent variables. Women reported more death anxiety prior to and after the gross anatomy course and were more likely to disagree with the need for detached concern.

Influence of medical school applicants' demographic and cognitive characteristics on interviewers' ratings of noncognitive traits.

BACKGROUND: Interviews are commonly used to measure noncognitive traits of medical school applicants. The present study investigated the influence of knowledge of applicants' cognitive abilities on interviewers' ratings of noncognitive traits. METHOD: Academic and demographic predictors of interview ratings of applicants' noncognitive traits were examined at the Medical University of South Carolina College of Medicine during two years: 1992, when applicants' Medical College Admission Test (MCAT) total scores and undergraduate grade-point averages (GPAs) were available to interviewers; and 1993, when MCAT and GPA data were not available. In 1992, 226 applicants met study criteria (i.e., they received ratings from three interviewers in addition to having MCAT and GPA data on file); in 1993, 245 applicants met the criteria. Step-wise regression analyses were conducted to measure the influences of seven independent variables on applicants' interview ratings. Two-way analyses of variances and t-tests were used to determine the effects of gender of applicants and interviewers. Cronbach's alpha coefficients were used as measures of interviewers' reliability. RESULTS: GPA was the best predictor for both years but accounted for double the amount of variance in interview ratings in 1992 (15.7%) compared with 1993 (7.4%). The reliability coefficients for the interviewers were .496 for 1992 and .473 for 1993. CONCLUSION: If the goal of the medical school admission interview is to assess noncognitive traits independently from academic skills, the authors recommend that MCAT and GPA data not be available to interviewers during interviews. The authors also found that gender and race influenced interview ratings in accordance with affirmative-action goals. Finally, the authors found that interview scores were only moderately reliable across different interviewers. They discuss ways to increase their reliability.

Survey of family medicine residents evaluation methods.

BACKGROUND: Family medicine residents are evaluated to ensure mastery of required practice skills by a variety of methods. The objective of this paper is to report the results of a sample of the 394 accredited family practice residencies to determine the evaluation methods used and their corresponding value to the program. METHODS: Questionnaires were sent to program directors and chief residents of all accredited family practice residency programs. RESULTS: Responses were received from the director or chief resident of 354 (90%) programs. For 195 programs, both the chief resident and program director responded. The five most common evaluation methods were the American Board of Family Practice In-Training Examination, formative review sessions, resident chart review, list of procedures performed, and family medicine conference attendance. Of 195 programs for which directors and chief residents both responded, directors and chief residents differed significantly in the reported number of evaluation methods but not in perceived value of those evaluation methods. Neither geographic region, community or university affiliation, class size, nor age of program was associated with differences in numbers of evaluation methods or perceived value of those methods. CONCLUSION: Many highly rated resident evaluation methods are being utilized by less than one-third of the programs. The most prevalent forms of evaluation appear to be auditing medical practices and behaviors.

Using self-evaluation to maintain competence.

This limited study examined differences in pharmacists' competencies through self-assessment. By using self-assessment with specified objectives, pharmacists can target areas for CE programs. Pharmacists can then improve and maintain their competencies in these specific areas. A future study could focus on discovering the reasons some pharmacists do not feel comfortable in giving advice/information to other healthcare professionals.

Association between third-year medical students' abilities to organize hypotheses about patients' problems and to order appropriate diagnostic tests.

The authors studied the abilities of three groups of third-year medical students (a total of 310) at two schools to order appropriate diagnostic tests and procedures for four cases studies. Each student was classified as "organized," "mixed," or "non-organized" based on the degree of organization of the approach the student used to list hypotheses for the two cases he or she was assigned. Analysis of variance revealed that the students in the organized and mixed groups spent significantly fewer dollars for inappropriate diagnostic evaluations than did the students in the non-organized group for three of the four cases (p less than .05). Analyses of the mean expenditures for all cases revealed that the students in the organized and mixed groups spent significantly fewer dollars for inappropriate evaluations than did the students in the non-organized group (p less than .05). The medical school that was teaching its students to organize hypotheses had more students in the organized group than expected for every case. The authors conclude that the ability of students to organize hypotheses is directly related to their ability to avoid increased expenditures for inappropriate diagnostic tests and procedures, and that organized thinking about patients' problems is a skill that can be taught.

The relationship between medical students' locus of control and promotion of breast self-examination.

There is general agreement that medical school curricula should involve the teaching of preventive health behaviours. Locus of control is a personality variable that has been associated with health practices and may be associated with tendencies to promote health practices. Few significant relationships have been found correlating health locus of control beliefs with preventive health behaviours. This study investigated the health locus of control of medical students and their tendencies to talk about and teach breast self-examination to women patients. Women students' health locus of control and breast self-examination practices were also investigated. The authors conclude that health locus of control has little influence on the tendency of medical students to promote breast self-examination. Other factors apparently have more effect on the student doctor's tendencies to promote health practices.

Family physicians' attitudes toward death and the terminally-ill patient.

Family physicians often experience a continuing relationship with the terminally-ill patient. Like other physicians, they may experience difficulty in these relationships. We surveyed 441 family physicians practicing in South Carolina to determine their personal attitudes toward death, and their feelings and reactions toward terminally-ill patients and their families. Physicians aged 50 years and older had a significantly more positive attitude toward death than did physicians aged 25-34 years (p less than .05). In addition, more positive attitudes were present in physicians who had a strong religious orientation (p less than .002) or had received some death education instruction in medical school (p less than .002). The study suggests that the basic concepts of death and dying should be included in medical school curricula. In addition, a medical education series offering practitioners an opportunity to express their feelings about this topic might also be beneficial.

The educational value of community preceptorships in surgery.

Increasing class size provided the impetus to send students on the core surgery course at the Medical University of South Carolina College of Medicine into the community hospitals with members of the clinical faculty. Each student was assigned to a surgeon and accompanied this preceptor on rounds, in the operating room, and in the office. To determine whether the students' learning was affected by being outside the university, the authors looked at the experience from 1977 to 1986 with 683 surgery students who took community preceptorships and 696 surgery students who took only university-based rotations. The two groups were compared in regard to age, sex, basic science grade-point average, class rank at the end of the first two years in medical school, ward evaluations, grades on departmental final examinations, and National Board of Medical Examiners "mini-examination" scores and Part II surgery scores. No differences were found. Choices of specialty for the first postgraduate year and evaluations of program directors were reviewed for 1982, 1985, and 1986, and were similar for all three years. The preceptorship program has been popular with students, who stated that they valued the one-to-one relationship with surgeons who liked to teach. The program has relieved pressure on the university hospital system and provided a good learning experience for students.

Impact of undergraduate courses on medical student performance in basic sciences.

Many students planning to apply to medical school take undergraduate courses (for example, biochemistry, embryology, histology, and vertebrate anatomy) covering concepts that are taught within the medical school curriculum. Do these students perform better in similar courses in medical school than students without prior exposure? In the study reported here of 310 medical students, approximately 50 percent had taken biochemistry, 50 percent had taken a course dealing with vertebrate anatomy, 25 percent had taken embryology, and 25 percent had taken histology as undergraduates. In comparisons of the students with prior exposure to these courses and those without prior exposure, no statistical difference was noted in cumulative grade-point averages for the first year in medical school or in the students' scores in three of the four individual medical courses examined. In addition, there was no significant difference in the academic performances in the four courses between the students in the upper and the lower quartiles of the class. Implications regarding undergraduate preparation of medical school applicants are discussed.