Senior medical students' perceptions of the adequacy of education on end-of-life issues.

CONTEXT: It is unclear how well prepared U.S. senior medical students are to handle end-of-life issues as they reach the end of medical school. Additionally, the most optimal way of providing medical student end-of-life education has not been adequately defined. OBJECTIVE: This study aims to determine the preparedness of senior medical students at U.S. medical schools regarding end-of-life issues. DESIGN: A self-administered survey. SETTING: Six medical schools throughout the United States, two of which have a formal curriculum on end-of-life issues, and four of which do not. PARTICIPANTS: Fourth-year medical students during November through February of their senior year. MAIN OUTCOME MEASURE: Self-reported preparation on a number of end-of-life competencies. RESULTS: Of the 757 surveys sent out, 262 responses were received (34.6%). Only 22% to 53% of students (varying by topic) felt prepared by their education in the selected end-of-life competencies. Students attending medical schools with a formal end-of-life curriculum were more likely to feel prepared than students with no formal curriculum to address psychosocial issues (21% higher, p = 0.008), cultural/spiritual issues (21% higher, p = 0.005), technical aspects of end-of-life care (18% higher, p = 0.001), and treatment of common symptoms (34% higher, p = 0.001). Students who had more clinical experiences in palliative care were more likely to feel prepared to discuss end-of-life issues with patients (p = 0.013) and to treat common symptoms (p = 0.011). CONCLUSIONS: This study demonstrates support for development of formal curriculum on end-of-life issues, and emphasizes the importance of clinical exposure to terminally ill patients to prepare medical students to provide quality end-of-life care.

Multivariate analysis of factors associated with postoperative pulmonary complications following general elective surgery.

OBJECTIVE: To develop a predictive model identifying perioperative conditions associated with postoperative pulmonary complications (PPCs). DESIGN: A prospective survey of patients whose preoperative history and physical examination, spirometric, PaO2 and PaCO2 analysis, and operative results were recorded. These patients underwent postoperative cardiopulmonary examinations until they were discharged from the hospital; their medical records were also reviewed until they were discharged from the hospital. SETTING: The Louisville Veterans Administration Medical Center, Louisville, Ky. PATIENTS: A randomly chosen sample of patients aged 40 years or older who required elective, nonthoracic surgery under general or spinal anesthesia and who were hospitalized at least 24 hours postoperatively. MAIN OUTCOME MEASURE: An analysis of risk factors associated with the development of 1 or more of the following conditions: acute bronchitis, bronchospasm, atelectasis, pneumonia, adult respiratory distress syndrome, pleural effusion, pneumothorax, prolonged mechanical ventilation, or death secondary to acute respiratory failure. RESULTS: Postoperative pulmonary complications developed in 16 (11%) of 148 patients. The risk factors found to be higher among those with PPCs compared with those without PPCs were postoperative nasogastric intubation (81% vs 16%, P<.001), preoperative sputum production (56% vs 21%, P=.005), and longer anesthesia duration (480 vs 309 minutes, P<.001). Upper abdominal surgery was performed in 11 (69%) of the 16 patients with PPCs and in 20 (15%) of the 132 patients without PPCs (P<.001); this difference lost significance in multivariate analysis. The final linear logistic model included postoperative nasogastric intubation (odds ratio [OR], 21.8), preoperative sputum production (OR, 4.6), and longer anesthesia duration (OR exp[0.01x] for an increase in x minutes) (1 minute of additional anesthesia time increases the OR to 1.01), resulting in 92% accuracy in predicting PPCs. CONCLUSIONS: We identified 3 potentially modifiable risk factors for PPCs. If validated, our results may lead to modifications of perioperative care that will further reduce PPCs.

Patient and physician roles in end-of-life decision making. End-of-Life Study Group.

This study is a cross-sectional descriptive survey of randomly selected primary care patients and physicians regarding patient, physician, and family roles in end-of-life decision making. The subjects included 329 adult outpatients and 272 practicing physicians. Physicians were more likely than patients to believe the patient alone was responsible for making end-of-life decisions. Patients were more likely than physicians to believe the physician should provide a recommendation in addition to facts to help the patient make end-of-life decisions. We conclude that patients prefer a more active role for physicians in both decision making and discussion of end-of-life care than do physicians themselves.

Patient and physician roles in end-of-life decision making.

This study is a cross-sectional descriptive survey of randomly selected primary care patients and physicians regarding patient, physician, and family roles in end-of-life decision making. The subjects included 329 adult outpatients and 272 practicing physicians. Physicians were more likely than patients to believe the patient alone was responsible for making end-of-life decisions. Patients were more likely than physicians to believe the physician should provide a recommendation in addition to facts to help the patient make end-of-life decisions. We conclude that patients prefer a more active role for physicians in both decision making and discussion of end-of-life care than do physicians themselves.

The discussion about advance directives. Patient and physician opinions regarding when and how it should be conducted. End of Life Study Group.

BACKGROUND: Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions. METHODS: This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives. RESULTS: The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion. CONCLUSION: We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives.

Comparison of three methods of gut decontamination in tricyclic antidepressant overdose.

The purpose of this study was to prospectively compare the effectiveness of three different gut decontamination methods in 51 patients presenting to an emergency department with tricyclic antidepressant overdose. Patients were randomized to three treatments; Group 1 received activated charcoal, Group 2 received saline lavage followed by activated charcoal, and Group 3 received activated charcoal followed by saline lavage followed by activated charcoal. Baseline characteristics of the three groups did not differ, including Glasgow Coma Scores, age, and mean tricyclic antidepressant levels. Average length of stay in admitted patients was 93.3 hours in Group 1, 107.2 hours in Group 2, and 66.7 hours in Group 3. Of those admitted to an ICU, average ICU time was 66.9 hours in Group 1, 54.1 hours in Group 2, and 34.4 hours in Group 3. Average duration of sinus tachycardia was 20.8 hours in Group 1, 30.8 hours in Group 2, and 32.2 hours in Group 3. Of those requiring mechanical ventilation, average ventilator time was 43.4 hours in Group 1, 24.1 hours in Group 2, and 17.8 hours in Group 3. No statistically significant difference could be shown with respect to the clinical endpoints noted. There were no deaths in any of the groups. All three methods of gut decontamination had similar clinical outcomes.

The discussion of end-of-life medical care by primary care patients and physicians: a multicenter study using structured qualitative interviews. The EOL Study Group.

OBJECTIVES: To identify primary care patients' and physicians' beliefs, attitudes, preferences, and expectations regarding discussions of end-of-life medical care, and to identify factors limiting the quality and frequency of these discussions. DESIGN: Descriptive study using audiotaped, structured, qualitative interviews. SETTING: Ambulatory care clinics and offices at eight medical centers in six states. PARTICIPANTS: Forty-three primary care physicians and 47 ambulatory outpatients. RESULTS: The patients expressed strong feelings about having end-of-life discussions early in their medical courses while they were competent. They desired straightforward and honest discussions and were less concerned than the physicians about damaging hope. The patients wanted their physicians to play central roles in discussions and both the patients and the physicians noted the impact of the patient-physician relationship on these discussions. The patients desired information focusing more on expected outcomes than on medical processes. The physicians expressed feelings of ambiguity when their desire to save lives clashed with their belief that aggressive life-sustaining treatments were futile. The physicians described their roles in end-of-life discussions in five major categories; lifesaver, neutral scientist, guide, counselor, and intimate confidant. The physicians considered living wills excellent "icebreakers" for starting discussions but of limited utility otherwise. CONCLUSIONS: Patients prefer end-of-life discussions earlier and with greater honesty than physicians may perceive. These discussions are inseparably linked with the patient-physician relationship. Physicians can better address patients' desires in end-of-life discussions by altering their timing, content, and delivery.

The characteristics of medical retraction notices.

During the past twenty years, more than ninety retraction notices have been published in biomedical journals. These retractions constitute a unique body of literature that biomedical researchers, bibliographers, and librarians must monitor to reduce scientific use of retracted, invalid papers. An analysis of medical retraction notices shows that very few are prominent in style, format, or placement, in spite of authoritative publication standards formulated by the International Council of Medical Journal Editors. Although researchers are ultimately responsible for the validity of the information they cite in their own publications, biomedical librarians are in a unique position to educate their patrons regarding retracted papers.

Medical school libraries' handling of articles that report invalid science.

In 1989-90 the authors conducted a nationwide study to examine how academic medical libraries handled articles that report invalid science and to determine the effectiveness of any policies implemented to limit the use of such articles. Ninety-five of the 127 medical school libraries the authors surveyed completed questionnaires analyzing policy and attitude issues. Eighty-four of these libraries manually reviewed the available copies they held of ten retracted articles. Of the 811 copies of the retracted, invalid articles reviewed, 742 (91.5%) were not tagged as being invalid. Seventy-nine percent of the libraries had tagged none of the retracted studies and only 16% had policies for managing articles that report invalid science. Academic librarians reflected a common attitude against perceived library censorship and emphasized the user's role in assuring validity. The nation's medical libraries, at least in part by intent, do not commonly identify or have policies to handle the invalid articles they hold. The authors conclude that biomedical researchers, clinicians, and teachers should not assume published studies held in libraries are inherently valid. The lack of stated policy and the disparate assumptions about the role libraries play in this area may perpetuate the use of invalid articles.

The influence of student interest on teaching evaluation.

OBJECTIVES: To analyze the influence of student subject bias on the evaluation of didactic teaching. DESIGN: Prospective study evaluating the relationship between the interest of junior students in 30 clinical topics and the students' subsequent evaluations of lecturers for these topics. SETTING: University internal medicine junior core curriculum. PARTICIPANTS: 56 junior students. Lecturers were senior internal medicine residents. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: There was no correlation between mean student interest scores for the topics and either immediate or end-of-rotation lecturer evaluation scores (R = -0.14 and 0.09 and p = 0.47 and 0.61, respectively). For 20 of 30 topics (66%) more than 50% of the students assigned the same level of high, intermediate, or low interest. There was no significant difference (p = 0.84) in the mean lecturer evaluation scores for these three divergent groups. Analysis of individual lecturers' evaluation scores revealed stratification to a given range independent of student interest in the topic. CONCLUSIONS: Students do not appear to be biased by their degree of interest in a subject when evaluating teaching skills. It appears unlikely that specific teaching assignments need to be considered when evaluating competence in didactic teaching.

The continued use of retracted, invalid scientific literature.

Little is known about the ultimate scientific fate of retracted, invalid literature. We identified 82 completely retracted articles by electronic and manual methods and measured their subsequent use in the scientific literature by performing citation analysis. After retraction, these studies were cited, for support of scientific concepts, 733 times. Comparison with a control group revealed that retraction reduces subsequent citation by approximately 35%. There was no evidence that small, obscure journals, non-US journals, or non-US authors were disproportionately responsible for these citations. Although, after retraction, US authors accounted for a smaller percentage of citations, they continued to be the single greatest source. Several possible reasons why invalid information continues to be used were identified. These included a dearth of available information on retracted works; inconsistency in retraction format, terminology, and indexing; and an apparent lack of sufficient attention to manuscripts by some authors and editors.

KIE: The authors performed a citation analysis on 82 articles retracted because of fraud or error to measure their subsequent use in the scientific literature. The 82 articles were cited 733 times after retraction, with a small percentage of the subsequent citations referring to the retraction as well as to the original article. Pfeifer and Snodgrass conclude that articles citing invalid, retracted work are "abundant and ubiquitous." They identify several possible reasons why invalid scientific information is not being effectively purged from the literature.

Teaching residents to read the medical literature: a controlled trial of a curriculum in critical appraisal/clinical epidemiology.

OBJECTIVE: To teach internal medicine residents key principles of clinical epidemiology that are necessary to read critically the medical literature. DESIGN: Two-phase, non-randomized, controlled educational trial. SETTING: University-based training program for residents (PGY-l-PGY-3) in internal medicine. PARTICIPANTS: All 83 residents participated in the trial. Seventy residents completed a test in clinical epidemiology at the end of Phases I and II. INTERVENTIONS: Residents were assigned to one of eight ambulatory care clinics for half a day each week. A literature-based curriculum in critical appraisal was the subject of a weekly pre-clinic conference for four clinics (Group A). The other four clinics (Group B) had a weekly conference on topics in ambulatory care medicine. At the end of Phase I, both groups were given a test of basic knowledge of clinical epidemiology. The curriculum was then modified with the addition of written questions to emphasize important educational points and to stimulate resident participation. The modified curriculum became the subject of the pre-clinic conference for Group B, while Group A changed to topics in ambulatory medicine. At the end of Phase II both groups were again tested on basic knowledge of clinical epidemiology. RESULTS: Group B performed significantly better on the second test than on the first, 68.5% vs. 63.3% (p = 0.034), while Group A did not improve (64.5% vs. 65.9%). The differences in test scores for Test II minus Test I were +5.17% in Group B and -1.44% in Group A (p = 0.019). Twenty-one percent of Group B residents vs. 5% of Group A residents improved their scores by 18% or more. CONCLUSIONS: The residency period is a difficult but important time to teach critical appraisal skills. Educational gains may be small and need to be critically evaluated to stimulate the development of more effective educational programs.