Personal characteristics, career plans, and specialty choices of medical students elected to Alpha Omega Alpha.

Among US medical graduates in 1983, personal characteristics, career plans, and specialty choices of men and women elected to Alpha Omega Alpha (AOA), the honor medical society, differed in a number of ways from those of their non-AOA classmates. Students in AOA scored significantly higher on each subtest of the Medical College Admission Test, were disproportionately white, and had a higher proportion of parents achieving a post-high school education. Members of AOA participated in undergraduate medical research and authored papers during medical school significantly more frequently than those who were not members of AOA, planned a major career commitment to research, and planned careers in academic medicine significantly more frequently than those who did not belong to AOA. In contrast, neither religious preference, among students from Catholic, Jewish, or Protestant backgrounds, nor gender differentiated members of AOA from non-AOA members. Among the 15 specialties studied, internal medicine subspecialties and internal medicine attracted the highest proportion of students elected to AOA.

Resident physician substance use, by specialty.

OBJECTIVE: This study compares substance use by medical specialty among resident physicians. METHOD: The authors estimated the prevalence of substance use of 11 medical specialties from a national sample of 1,754 U.S. resident physicians. RESULTS: Emergency medicine and psychiatry residents showed higher rates of substance use than residents in other specialties. Emergency medicine residents reported more current use of cocaine and marijuana, and psychiatry residents reported more current use of benzodiazepines and marijuana. Contrary to recent concerns, anesthesiology residents did not have high rates of substance use. Family/general practice, internal medicine, and obstetrics/gynecology were not among the higher or lower use groups for most substances. Surgeons had lower rates of substance use except for alcohol. Pediatric and pathology residents were least likely to be substance users. CONCLUSIONS: The authors' previous research indicates that residents overall have lower rates of substance use than their age peers in society. Yet resident substance use patterns do differ by specialty. Residents in some specialties are more likely to use specific classes of drugs, to use a greater number of drug classes, and to be daily users of alcohol or cigarettes.

Cocaine use by senior medical students.

The authors studied 589 senior medical students' attitudes about and use of cocaine. Reported use was 36% in the students' lifetimes, 17% in the past year, and 6% in the past month. Overall, these rates were lower than those of an age-matched cohort.

Isolation and identification of a diuretic hormone from Zootermopsis nevadensis.

A diuretic hormone (DH) was isolated from extracts of heads of Zootermopsis nevadensis, a dampwood termite. The peptide has 46 residues, M(r) = 5,328.2 Da, with the sequence TGAVPSLSIVNPLDVLRQRLLLEIARRRMRQSQDQIQANREMLQTI-NH(2,) showing it to be a CRF-related DH. This peptide increases cyclic AMP production in Malpighian tubules of Manduca sexta. We detected another factor in the head extracts which behaved as a more basic peptide on ion exchange chromatography. The latter factor also stimulated cyclic AMP production in the bioassay, but two large scale attempts to isolate this peptide were unsuccessful. We believe the second peptide is acid labile.

Teaching medical ethics to first-year students by using film discussion to develop their moral reasoning.

PURPOSE: To evaluate a project on teaching medical ethics to first-year students by using film discussion to develop the students' moral reasoning. METHOD: The participants were 114 first-year students at Texas A&M University Health Science Center College of Medicine in 1989-90, 1990-91, and 1991-92: (1) 48 (20 women and 28 men) who participated during the fall quarter in an elective course on social issues in medicine, which consisted of weekly one-hour discussions of short films; (2) 37 (18 women and 19 men) who participated in the course during both the fall and winter quarters; and (3) a control group of 29 (8 women and 21 men) who did not take the course and so had no exposure to the film discussions. The influence of the discussions on the students' moral reasoning was measured by using Rest's Defining Issues Test for pretests and posttests. The scores of the three groups were compared by using multivariate analysis of variance. RESULTS: There were statistically significant increases in the moral reasoning scores of both the course registrants with one-quarter exposure to the film discussions (p < .002) and those with two-quarter exposure (p < .008) compared with the scores of the students who did not take the course and had no exposure (p < .109). CONCLUSION: No doubt there was a self-selecting bias on the part of the course registrants; however, since both groups of registrants showed significant increases on their posttest scores, clearly the course did have a positive influence on these students' moral reasoning. Thus, it is possible to develop young people's moral reasoning in medical school as well as in earlier educational environments.

Clarifying the relationship of medical education and moral development.

PURPOSE: To assess the development of the moral reasoning skills of medical students through the course of their education, and to determine whether their scores would reflect the increases usually found at this age range and education level. METHOD: Using Rest's Defining Issues Test (DIT), the authors assessed the moral reasoning of a total of 95 Texas A&M medical students from the classes of 1991-94 at the beginning of their first semester, at the end of a required first-semester medical ethics course, and at the end of the students' fourth year. RESULTS: The mean score on the first test was 47.7; on the second, 53.7; and on the third, 56.5. The +6.0 change in mean scores from the first to second test was statistically significant (p < .0001), as was the +8.8 change from the first to final test (p < .0001). The +2.8 change from the second to final test was also significant, although at a lower level (p < .0302). Analysis revealed no significant correlation between moral reasoning scores and age; however, there was a significant correlation between moral reasoning scores and sex, with women scoring higher than men on all three tests. CONCLUSIONS: While data from the current study seem to contradict earlier findings that medical education inhibits an increase in moral reasoning skills, the current findings may alternatively be interpreted as resulting mainly from the required first-semester medical ethics course, which involved small-group discussion of moral dilemmas, an educational method shown elsewhere to be effective in enhancing moral reasoning skills.

The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students.

PURPOSE: To examine how much exposure to small-group case-study discussion is necessary to significantly increase moral reasoning skills. METHOD: For the classes of 1991-1998 at Texas A&M, using Rest's Defining Issues Test, the authors tested groups of students for moral reasoning skills both before and after the students participated in small-group case-study discussions of medical ethics. RESULTS: From 960 students asked to participate, the authors collected complete data for 729 students (75.9% response rate). Small-group case-study exposures ranged from 0 to 44 hours. Groups of students exposed to 20 hours or more demonstrated a significant increase in their moral reasoning scores. Groups with less than 20 hours of exposure demonstrated no significant increase in their scores. CONCLUSION: This study indicates that moral reasoning skills are teachable and measurable, and that small-group discussion significantly increases moral reasoning skills. Further studies are needed to increase the generalizability of these findings.

The effect of teaching medical ethics on medical students' moral reasoning.

A study assessed the effect of incorporating medical ethics into the medical curriculum and the relative effects of two methods of implementing that curriculum, namely, lecture and case-study discussions. Results indicate a statistically significant increase (p less than or equal to .0001) in the level of moral reasoning of students exposed to the medical ethics course, regardless of format. Moreover, the unadjusted posttest scores indicated that the case-study method was significantly (p less than or equal to .03) more effective than the lecture method in increasing students' level of moral reasoning. When adjustment were made for the pretest scores, however, this difference was not statistically significant (p less than or equal to .18). Regression analysis by linear panel techniques revealed that age, gender, undergraduate grade-point average, and scores on the Medical College Admission Test were not related to the changes in moral-reasoning scores. All of the variance that could be explained was due to the students' being in one of the two experimental groups. In comparison with the control group, the change associated with each experimental format was statistically significant (lecture, p less than or equal to .004; case study, p less than or equal to .0001). Various explanations for these findings and their implications are given.

Unethical and unprofessional conduct observed by residents during their first year of training.

PURPOSE: To present residents' personal observations of unethical and unprofessional conduct in medicine during their first year of training. METHOD: Eight hundred and fifty-seven second-year residents who had previously participated in a study of perceived mistreatment as senior medical students were resurveyed by a three-tiered mail process concerning their experiences during their first postgraduate year, including their personal observations of four types of unethical and unprofessional conduct. RESULTS: Surveys were returned by 571 residents, for a response rate of 67%. Personal observations of falsification of patient records by others on at least one occasion were reported by 44.5% of the responding residents, while 73.8% reported direct observations of mistreatment of patients. Nearly half of the residents (46.7%) reported that others had taken credit for their work, and 72.8% said they had observed colleagues working in an impaired condition at least once during their first year of training. Over one fourth of the residents (28.6%) stated that they had been required to do something during the year that they believed was immoral, unethical, or personally unacceptable. There was an inverse relationship between the residents' observations of unethical and unprofessional conduct and their overall satisfaction with their first year of training (p < .001). CONCLUSIONS: The residents reported observing several types of unethical and unprofessional conduct among their colleagues and superiors. These findings confirm similar reports among medical students and residents and raise questions about the possible effect of such observations on the ethical principles and behavior of physicians-in-training.

Racial-ethnic background and specialty choice: a study of U.S. medical school graduates in 1987.

This study used two Association of American Medical Colleges' questionnaires to determine whether there was a relationship between the racial-ethnic backgrounds and the specialty choices of a 1987 cohort of 11,136 U.S. medical school seniors, both prior to entering medical school and as they prepared for residency training. Their specialty preferences as premedical students were shown by their responses to the Premedical Student Questionnaire, administered when they registered for the Medical College Admission Test; their specialty choices at the end of their medical school training were shown by their responses to the Medical Student Graduation Questionnaire, which they completed shortly before graduation. Racial-ethnic backgrounds, self-recorded, were classified into black, other underrepresented minorities, Asian, other non-underrepresented minorities, and white. Specialties were clustered into primary care, medical specialties, surgical specialties, and supporting services. Before entering medical school, the students had similar specialty preferences regardless of background. As seniors in medical school, there was even greater convergence of specialty choices among the students of all backgrounds. Racial-ethnic background in itself appears not to have been a major factor influencing the senior medical students' specialty choices.

Cheating in medical school: a survey of second-year students at 31 schools.

BACKGROUND: Although there have been a number of studies of cheating in universities, surprisingly little has appeared recently in the literature regarding academic dishonesty among medical students. METHOD: To assess the prevalence of cheating in medical schools across the country, class officers at 31 of 40 schools contacted distributed a survey in the spring of 1991 to their second-year classmates. The survey consisted of questions about the students' attitudes toward cheating, their observations of cheating among their classmates, and whether they had themselves cheated. The results were analyzed using contingency tables, t-tests, Pearson correlations, and one-way analysis of variance. RESULTS: Of the 3,975 students attending the 31 schools, 2,459 (62%) responded. Thirty-nine percent of the respondents reported witnessing some type of cheating among classmates during the first two years of medical education, while 66.5% reported having heard about such cheating. When reporting about themselves, 31.4% admitted cheating in junior high school, 40.5% in high school, 16.5% in college, and only 4.7% in medical school. Reports of cheating varied across medical schools, but no relationship was found between rates of cheating and medical school characteristics. Men were more likely to report having cheated than were women. The best predictor of whether someone was likely to cheat in medical school was whether they had cheated before, although the data strongly support the role of environmental factors. Medical school honor codes exercised some effect on cheating behavior, but the effect was not large. CONCLUSION: About 5% of the medical students surveyed reported cheating during the first two years of medical school. The students appeared resigned to the fact that cheating is impossible to eliminate, but they lacked any clear consensus about how to proceed when they became aware of cheating by others. The guidance students appear to need concerns not so much their own ethical behaviors as how and when to intervene to address the ethical conduct of their peers.

Withdrawal and extended leave during residency training: results of a national survey.

BACKGROUND: Although national figures for medical student withdrawal and extended leave have long been reported, similar data have not been available for residents in training. METHOD: Data for this study came from the American Medical Association survey of the 1991-92 residency year, in which program directors were asked for information about residents who had taken extended leave or had withdrawn or been dismissed from their programs prior to completion. Data are reported for 89,368 residents enrolled in 6,302 programs (89.2% of all surveyed programs). RESULTS: During the 1991-92 year, 2,449 residents (2.7%) withdrew or were dismissed from their programs and 887 (1.0%) took extended leave. Specialty and program changes accounted for 56% of the withdrawals, while performance difficulties were implicated in 12.9%. Maternity or paternity leave was involved in 32.2% of extended leaves, followed by research sabbaticals (11.4%) and physical problems (10.5%). Women had higher rates of both withdrawal and extended leave than men. Withdrawal for performance difficulties was lowest among graduates of U.S. and Canadian allopathic schools as compared with graduates of osteopathic or foreign medical schools, and lowest among Caucasians as compared with those of other racial-ethnic identities. CONCLUSION: Although overall figures and percentages are low, there are small but persistent losses of residents annually that vary by specialty, gender, race-ethnicity, and education.

Assessing rural community resources for health care: the use of health services catchment area economic marketing studies.

A relatively simple method for estimating the ability of rural communities to support health provider personnel services, the utilization of this tool is described and illustrated. Special aspects of the approach include: (1) its application on a systematic basis to an entire state, utilizing identified economic marketing areas and local determination of data; (2) the use of the finished product, or study, as a focus for community discussion and decision making; (3) its use as a recruitment device for physicians as well as communities; and (4) its use for long term state health and educational planning. Within this broad approach, the specific figures and conclusions are less important than the interpretation, application and use of the method.

What terminally ill patients care about: toward a validated construct of patients' perspectives.

BACKGROUND: Citizens have conveyed to professionals that care at the end of life is less than optimal. Efforts to improve matters have tended to work in piecemeal fashion, on tangible more than personal aspects of care, and without the benefit of documented perspectives of those who face dying. Policy initiatives and clinical interventions need guidance from a broad framework that is validated by patients' perspectives. PURPOSE: Our goals were to: (1) assess the construct validity and stability over time of the portions of a conceptual framework that concern patients' subjective experiences; (2) develop a foundation for measurement of these personally meaningful factors; and (3) examine these factors' associations for potential clinical or policy significance. POPULATION: Patients were from six diverse geographical areas whose physicians judged their survival prognosis to be 6 months or less. Physicians who referred the patients were randomly selected from state and specialty association lists. METHODS: We used in-person survey methodology and multivariate analysis of patient responses. The analysis fell into two parts. Using exploratory factor analysis, we looked for evidence of discrete dimensions of experiences. Using regression analysis, we examined associations among them. RESULTS: Of 1,131 eligible patients, 988 were interviewed (87.4% response rate). Of 682 patients who survived to follow-up interview 4-6 months later, 650 were interviewed (95.3% response rate). Exploratory factor analysis identified 12 discrete factors (accounting for 55% of variance; maximum Spearman's p = 0.24), 8 of which met criteria for representing measurable dimensions (accounting for 46% of variance). These 8 were: patient-clinician relationship; social connectedness; caregiving needs; psychological distress; spirituality/religiousness; personal acceptance; sense of purpose; and clinician communication. Eigenvalues ranged from 1.45 to 6.30 and Cronbach's alpha from 0.63 to 0.85. The concordance between these dimensions and those in the proposed framework indicated that two dimensions required minor modifications and six were confirmed, providing evidence of good construct validity for this portion of the framework. The same dimensions were also evident at follow-up except that the first two above-listed loaded on one combined factor, clinician interaction (eigenvalues 1.83-7.92; Cronbach's alpha from 0.64 to 0.86). This provides evidence of the construct's stability over time. Clinical communication and patient-clinician relationship were associated (odds ratio [OR] 2.79, 2.31-3.36). Better clinician communication correlated with somewhat better personal acceptance (OR 1.10,1.02-1.19), and a better patient-clinician relationship correlated with less psychological distress (OR 0.84, 0.75-0.95). CONCLUSIONS: We conclude that: (1) Personally meaningful aspects of patients' experience of terminal illness can be represented in valid, multidimensional constructs that are stable over time; (2) They are measurable; and (3) Aspects of the therapeutic relationship appear to correlate with patients' experience of the dying process.

Alternative models for the delivery of rural health care: a case study of a western frontier state.

This is a case study illustrating the wide variety of models for rural health care delivery found in a western "frontier" state. In response to a legislative mandate, the University of Nevada School of Medicine created the Office of Rural Health in 1977. Utilizing a cooperative, community development approach, this office served as a resource, as well as a catalyst, in the development and expansion of a variety of alternative practice models for health care delivery to small, underserved rural communities. These models included small, single, and multispecialty group practices; self-supporting and subsidized solo practices; contract physicians; midlevel practitioners; and National Health Service Corps personnel. The rural health care system that was created featured regional and consortial arrangements, urban and medical school outreach programs, and a "flying doctor" service.

Physician substance use by medical specialty.

Self-reported past year use of alcohol, tobacco, marijuana, cocaine, and two controlled prescription substances (opiates, benzodiazepines); and self-reported lifetime substance abuse or dependence was estimated and compared for 12 specialties among 5,426 physicians participating in an anonymous mailed survey. Logistic regression models controlled for demographic and other characteristics that might explain observed specialty differences. Emergency medicine physicians used more illicit drugs. Psychiatrists used more benzodiazepines. Comparatively, pediatricians had overall low rates of use, as did surgeons, except for tobacco smoking. Anesthesiologists had higher use only for major opiates. Self-reported substance abuse and dependence were at highest levels among psychiatrists and emergency physicians, and lowest among surgeons. With evidence from studies such as this one, a specialty can organize prevention programs to address patterns of substance use specific to that specialty, the specialty characteristics of its members, and their unique practice environments that may contribute risk of substance abuse and dependence.

Primary care by desire or default? Specialty choices of minority graduates of US medical schools in 1983.

This study was undertaken to determine if US medical school students of different racial/ethnic backgrounds demonstrate similar patterns of evolution of specialty choice between their senior year of medical school and their third postgraduate year. The study identified the specialty choices of US medical school seniors in 1983 through their responses to the Association of American Medical Colleges Graduating Medical Student Questionnaire (GQ). The cohort was classified into three groups: underrepresented minorities, non-underrepresented minorities, and whites. Using these AAMC data as baseline, each racial/ethnic background group was tracked through their third residency year. Comparisons were made between anticipated specialty choices as senior medical students and actual specialties as revealed through residency tracking. The study found that more than 95% of the cohort began residencies in specialties compatible with their GQ choices. Unexpectedly, almost 20% of blacks, Commonwealth Puerto Ricans, and other Hispanics were not in graduate medical education in their third postgraduate year. This group needs to be studied further in order to learn the proportion of these physicians who subsequently completed residency training and the reason(s) for attrition in physicians who did not fulfill minimum training requirements for board certification.

Clarifying the relationship of veterinary medical education and moral development.

OBJECTIVE: To clarify the relationship between veterinary medical education and moral development in response to 2 previous studies that presented conflicting evidence that the experience of veterinary medical education may inhibit moral development. DESIGN: The Defining Issues Test (DIT) was used to survey the moral reasoning of veterinary medical students at the beginning and end of their education. SAMPLE POPULATION: First and fourth-year veterinary medical students. PROCEDURE: The moral reasoning of 98 veterinary medical students was assessed at the beginning of their first semester of veterinary medical education and again, 4 years later, at the end of their last semester to determine whether their moral reasoning scores would reflect the expected maturity-related increases usually found at this age range and education level. RESULTS: The DIT scores ranged from 8.3 to 70.0 for first-year students and from 16.7 to 76.7 for fourth-year students. The first-year mean was 44.0 and the fourth-year mean was 45.4. The mean change of +1.45 points was not significant. Statistical analysis did not reveal any significant correlation between the moral reasoning scores and age; however, there was a significant correlation between the moral reasoning scores and gender, with females scoring higher on the first and second test. The difference in the rate of change between tests by gender was not significant. CONCLUSION: This study appears to confirm the findings of an earlier study suggesting veterinary medical education inhibits an increase of moral reasoning in veterinary medical students.

Study of the influence of veterinary medical education on the moral development of veterinary students.

Although veterinary medicine endorses high moral character and adherence to a code of ethics, to our knowledge, virtually no studies have examined the influence of veterinary medical education on the moral development of its students. Using the Kohlberg standard moral judgment interview, this study examined that relationship in a sample of 20 veterinary medical students (16.0% of the veterinary college's student body). The students were tested at the beginning and at the end of their veterinary medical education to determine whether their moral reasoning scores had increased to the same extent as those of other postgraduate students. It was found that normally expected increases in moral reasoning did not occur over the four years of veterinary medical education for these students, suggesting that their veterinary medical educational experience somehow inhibited their moral reasoning ability rather than facilitated it. With a range of moral reasoning scores between 313 and 436, the mean increase from first year to fourth year of 12.5 points was not statistically significant. Statistical analysis revealed no significant correlations between the moral reasoning scores on age or gender, although there were significant correlations with Medical College Admissions Test scores and grade point average scores.

Moral reasoning and malpractice. A pilot study of orthopedic surgeons.

The relationship between moral reasoning and malpractice claims was studied in 53 orthopedic surgeons. Levels of moral reasoning were defined by the percentage of principled responses (P-score) on Rest's Defining Issues Test, while annualized rates of malpractice claims were computed on the basis of data from a regional, physician-owned, interindemnity/liability protection trust. Orthopedic surgeons with fewer than 0.20 claims per year demonstrated significantly (P = 0.04) higher levels of moral reasoning (mean P-score of 43.8) than did those with claims rates higher than 0.40 claims per year (mean P-score of 38.0). Only 1 of 13 orthopedists with P-scores over 50 was found in the higher claims group, suggesting that high levels of moral reasoning may provide a protective element against malpractice claims.