Standardised monitoring of patients on long-term medication in primary care.

A three-year pilot study was initiated in collaboration with three general practices to develop a standardised monitoting (SM) system to ensure that chronically sick patients on long-term medication, such as thyroxine, diuretics angiotensin convening enzyme (ACE) inhibitors statins and antirheumatics were reliabily monitored following fixed protocols. A high standard of care was achieved, which included identifying and following up patients with borderline or unacceptable results and persistent non-attendees. In addition, the scheme guaranteed that a current set of results was provided in time for clinical review.

MedEthEx Online: a computer-based learning program in medical ethics and communication skills.

BACKGROUND: Bioethics education often focuses on lectures and discussions to set a foundation for ethical decision making. Our goal was to bridge the gap between classroom learning and bedside competence through computer-assisted instruction. This article assesses the efficacy of MedEthEx Online, a computer-based learning program as part of a required Bioethics course. DESCRIPTION: Of 173 American medical students, 89 in Section 1 attended 8 bioethics lectures and 8 small-group discussions. Eighty-four in Section 2 had a similar course, although two group discussions were replaced with computerized learning. We compared (a) final exam scores, (b) topic-specific question scores, (c) performance with standardized patients, (d) self-assessments, and (e) course evaluations. EVALUATION: Exam scores were comparable, although computerized-learning students scored higher in specific exam areas, felt somewhat more clinically prepared, and rated the course slightly better. Standardized patient interactions differed, although they were comparable overall. CONCLUSION: MedEthEx Online is a viable option for fostering effective communication and problem resolution skills.

Goals and strategies for teaching death and dying in medical schools.

Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.

Improving physician recruitment for rural hospitals.

Faced with a shortage of primary care and specialty physicians at its 23 facilities, Lifepoint Hospitals developed an aggressive recruiting and screening program to bring the right physicians to small towns--and help them stay.

Preserving the best of the art of teaching.

Teachers often develop unique methods to help students learn, but these techniques may be lost when they retire from the profession. In the 15 years that they have conducted the Effective Teaching Workshop: Improving Your Skills, the authors of this paper have observed presentations of many innovative teaching methods. The article describes five methods recently presented at the annual workshop: the use of a flipchart with slides; the use of Polarmotion overhead transparencies; an asthma simulation; a breast-mass simulation; and teamwork and game-playing. The authors present these techniques in the hope of reaching a broader audience, and to stimulate other teachers to submit descriptions of innovative teaching methods for possible publication in the Ideas for Medical Education column.

Institutional ethics committees and the shield of immunity.

Institutional ethics committees have been hailed as a good resource for physicians confronting complex ethical issues in patient care. Physicians may seek ethics committee consultations to receive impartial assistance in decision making, to resolve conflicts, and to avoid cumbersome court procedures and unwieldy litigation. The endorsement of ethics committees by the President's Commission, the American Hospital Association, the American Medical Association, and the Department of Health and Human Services, along with recent state legislation governing committees in Maryland, New Jersey, and Hawaii, raises questions about the proper scope and authority of ethics committees. We examined the accountability of institutional ethics committees and argue against immunity-conferring statutes that shield physicians who follow a committee's advice from civil and criminal liability.

Nutritional support of the patient with cancer.

The role of nutritional support in the management of the critically ill patient has been a topic of much concern and research. Malnutrition experienced by patients with cancer can be related to the nutritional status of the patient before the development of cancer, to the tumor itself, and to cancer therapy. Aggressive treatment may increase the degree of malnutrition, and the combination of the effects of therapy and progressive malnutrition may be a frequent cause of death. The use of intensive nutritional support for some patients may promote weight gain and positive nitrogen balance, increase tolerance of cancer therapy, and improve immune response. The benefits of nutritional support in the patient with cancer may outweigh concerns of nutrition effects on tumor growth. The choice of nutritional support is dependent on the availability of and access to a functioning gastrointestinal tract, comfort and compliance of the patient, the toxicity of drugs, and site of radiation therapy. Extended length of treatment, availability of care givers, and costs are also factors considered in delivering nutrients. Nutrition requirements, nutritional tolerance, and immune status should be monitored by the nurse. The nurse can function as coordinator for treatments and care as well as act as interpreter, teacher, and counselor to coordinate medical and nutritional management of the patient's illness into overall high-quality nursing care.

Determinants of health-promoting behaviors in adults.

Risk reduction for coronary artery disease (CAD) is a goal of health providers. The purposes of this study were to determine: 1) adults' knowledge about CAD; 2) if adults who have risk for CAD also practice health-promoting behaviors; and, 3) if there is a correlation among adults' practice of health-promoting behaviors, health locus of control, value of health, and knowledge of CAD risk factors. Findings indicate that subjects were knowledgeable about personal CAD risk, and those with higher CAD risk knowledge also practiced more health-promoting behaviors. Subjects had less knowledge about elevated cholesterol levels, diabetes, and use of oral contraceptives. Additional findings suggest that individuals' beliefs about control over their health, health value, and knowledge about CAD risk factors are related to their participation in health-promoting behaviors.

The Philadelphia story.

KIE: A coordinator of the Delaware Valley Ethics Committee Network (DVECN) reports on DVECN's project to develop Sample Policy Packets. These packets, researched and put together by DVECN's Policies and Research Subcommittee, are designed to provide an educational resource for members whose hospital ethics committees have been charged with writing or revising institutional policies on specific topics. Each packet contains several sample policies, a cover sheet that highlights important issues, and a list of references. Packets have been issued on withholding/withdrawing treatment, do-not-resuscitate orders, organ donation, and HIV infection.^ieng

Abnormalities of carbohydrate metabolism and of OCT gene function in the Rett syndrome.

The pathogenetic basis of the Rett syndrome (RS) is unknown: an X-linked dominant, male-lethal gene defect is thought likely. We present a girl with RS who has defects both of the urea cycle and of carbohydrate metabolism resulting in fasting hypoglycaemia, post-prandial hyperlactataemia and excess urinary orotic acid excretion after alanine load. Her sister has a similar clinical picture, but less marked metabolic anomalies. The mother of these sisters has abnormal urinary orotic acid excretion; she transmitted opposite ornithine carbomoyltransferase (OCT) alleles to the two girls. Another girl with RS has similar metabolic responses to fasting and to carbohydrate load. We conclude that RS may be an aetiologically homogeneous condition, but that it includes a variable pattern of metabolic anomalies, and that the gene defect is distinct from the OCT locus.

Giving answers or raising questions?: the problematic role of institutional ethics committees.

Institutional ethics committees (IECs) are part of a growing phenomenon in the American health care system. Although a major force driving hospitals to establish IECs is the desire to resolve difficult clinical dilemmas in a quick and systematic way, in this paper we argue that such a goal is naive and, to some extent, misguided. We assess the growing trend of these committees, analyse the theoretical assumptions underlying their establishment, and evaluate their strengths and shortcomings. We show how the 'medical consultation' model is often inappropriately applied to IECs and suggest that IECs must operate under a different framework. Finally, we argue that IECs should be valued for the process they facilitate, and not for the product that they are, often unreasonably, expected to deliver.