Hepatitis B prevention: practices and attitudes of physicians and dentists.

A survey of community-based physicians and dentists from the Washington, D.C., metropolitan area was conducted to assess the practices and attitudes of these health professionals relative to hepatitis B prevention. Mail questionnaires were sent to 200 physicians and 200 dentists. An overall response rate of 50 percent was obtained with one follow-up to all nonrespondents. The preventive practices adopted by the physicians were found to differ significantly from those of the dentists, including risk factors, history taking, using gloves and/or masks, and routinely screening for serologic markers. The physicians were significantly more likely than the dentists to be unwilling to take a safe, effective, hepatitis vaccine (p less than .01). Concerns about long-term safety and side effects were the most frequently mentioned reasons for this attitude. Though most survey respondents believed that if they were to become a hepatitis B chronic carrier, it would be better to know about it. Twenty six percent of the physicians and 14 percent of the dentists believed that not knowing about being a chronic carrier would be protective in a legal action against them. A majority of all of the health professionals surveyed felt that knowing their carrier status could jeopardize their career.

Primary care: questions raised by a definition.

In Defining Primary Care: An Interim Report, the Institute of Medicine offers a set of attributes for primary care that raise many unresolved empirical and philosophical questions. For instance, the "integrated nature" of primary care immediately challenges the validity of the content of research in primary care using data such as ICD-9 codes, which, by nature, reduce patients to disaggregated sets of problems rather than coherent wholes. Likewise, considering accessibility as a hallmark of primary care focuses attention on how health care is organized, and whether depending on primary care-trained professionals as the necessary or ideal first point of access might be a deterrent to the delivery of optimal care among some populations. Primary care clinicians should and will be held accountable for achieving the attributes of practice that make primary care unique. This paper provides a detailed examination of the Institute's definition, and identifies many aspects that require additional thought and research before these attributes can be applied as criteria for the evaluation of primary care practice.

Ethics committees: is there a role for them in the laboratory?

Ethics committees are commonly found in United States health-care institutions. As multidisciplinary committees within the medical staff structure, they are active in education, policy development, and case consultation. Clinical pathology laboratories face a number of ethically sensitive issues, including the confidentiality of sensitive data, problems of patient-caregiver or caregiver-patient transfer of the human immunodeficiency virus (HIV), and conflicts about allocating scarce resources such as blood. Ethics committees can be an important resource to clinical laboratorians seeking to develop ethically defensible policies and procedures.

Hippocrates and the health maintenance organization. A discussion of ethical issues.

Health maintenance organizations (HMOs) are providing an increasing proportion of medical care in the United States. Characteristics of these organizations such as cost containment, incentives to reduce spending by practitioners, and barriers to access for clients raise significant ethical concerns. This paper considers how these features of the HMO withstand ethical scrutiny and what may be done to prevent abuse. Generally, the challenges to the moral integrity of physicians practicing in HMOs are neither intractable nor in all cases unique, although special arrangements may have to be made to ensure that ethical standards are upheld. Independent practice associations pose particular problems. Finally, whether or not an HMO is a for-profit enterprise is a significant consideration.

The teaching of liberal arts in internal medicine residency training.

Forty-four members of the Association of Program Directors in Internal Medicine and 58 members of the Society for Research and Education in Primary Care Internal Medicine completed questionnaires on the teaching of liberal arts in internal medicine residency programs and the importance of liberal arts to the practice of medicine. They rated economics of medical care and bioethics as essential to residency training. Law and organization of the health care system as well as economics and bioethics were rated as essential to medical practice. Although there was great variability in the curricula represented, over 40 percent of the respondents reported having formal lecture and/or seminar exposure to these topics in their programs. Problems encountered in implementing liberal arts programs included lack of curriculum time, limited-faculty members, and a lack of interest on the part of residents. There is a need both to arrive at a consensus among residency directors and to explore means of developing interdisciplinary faculties if the liberal arts are to form an established part of internal medicine residency training.

Decision making with pregnant patients: a policy born of experience.

One hospital has developed an institutional policy to guide decision making between physicians and pregnant patients. Read the policy and a description of how it was developed by the ethics committee at the George Washington University Hospital.

Medical students' skills, attitudes, and behavior needed for literature reading.

Skills, attitudes, confidence, and behavior needed for literature reading were studied in first- versus fourth-year medical students at George Washington University in Washington, D.C. Questions on diagnostic test skills were used for comparison. Anonymous questionnaires were completed by 114 first-year and 84 fourth-year students. Fourth-year students read considerably more literature than first-year students, valued reviews over original research, and placed more value on the journal's reputation. They had greater confidence and objective knowledge than first-year students on diagnostic test skills but not greater confidence or objective knowledge on literature reading skills. Most dramatic was their "lower" willingness to admit uncertainty, even when taking into account their level of knowledge. Less willingness to admit uncertainty on the part of fourth-year medical students than first-year students may reflect medical education's emphasis on specific answers and its failure to teach students how to analyze data and draw conclusions. A need exists for specific training in literature reading skills with preevaluations and postevaluations of skills, attitudes, and behavior.

The humanities, humanistic behavior, and the humane physician: a cautionary note.

Efforts to teach and evaluate humanistic qualities in physicians in residency training are marred by ambiguous goals. The humane physician can be characterized by four distinct qualities: technical competence, humanistic attitude, knowledge of humanistic concepts, and humanistic behavior. Education in the humanities can foster humanistic attitudes, but it cannot promise to lead to changes in behavior. Likewise, although formal training in communication teaches the skills necessary for humanistic behavior, without an understanding of humanistic concepts these skills may not serve medical or moral ends. Evaluation of the humane physician must also include modalities that test attitude, knowledge, and behavior. Testing one characteristic does not ensure competence in other areas; knowledge of the requirements for informed consent, for example, does not guarantee one's ability to discuss this concept effectively with patients. In this article, we suggest ways to combine the humanities and communication skills in the clinical setting and we emphasize both the training and the evaluation of humane physicians.

Patients' therapeutic preferences in an ambulatory care setting.

One thousand two hundred-fifteen adult outpatients of an urban health maintenance organization completed questionnaires containing four hypothetical clinical situations. Of these patients, 72 per cent preferred a non-drug "home remedy" when given a choice among that and two different drug options. Risk aversion and willingness to accept current discomfort were stronger than demographic variables in predicting this preference. We conclude that patients informed about the risks and benefits of drug and non-drug therapies will prefer the latter if that option is offered.

Angiotensin converting enzyme inhibitors and progressive renal insufficiency. Current experience and future directions.

STUDY OBJECTIVE: To review the rationale for using angiotensin converting enzyme (ACE) inhibitors in progressive renal disease, and to evaluate the experience with these agents in patients with hypertension and renal insufficiency. DATA IDENTIFICATION: Experimental and clinical studies published from January 1977 to November 1988 were identified by searching the literature and by extensive hand searching of bibliographies of identified articles. STUDY SELECTION: Experimental studies of glomerular function during therapy with ACE inhibitors or other antihypertensive regimens were reviewed. Series using ACE inhibitors for treating hypertensive patients with renal disease were evaluated and reports of adverse events were studied. RESULTS OF DATA SYNTHESIS: Experimentally, ACE inhibitors seem to decrease glomerular injury by reducing both systemic and glomerular hypertension. Clinically, ACE inhibitors reduce systemic blood pressure in hypertensive patients with diabetic and nondiabetic renal disease without causing dramatic changes in glomerular filtration rate or renal blood flow. Most studies of nondiabetic renal insufficiency suggest that proteinuria is reduced in most patients. However, no long-term controlled study on the effect of ACE inhibitors on the progression rate of nondiabetic renal disease has been completed. ACE inhibitors have not yet been approved by the Food and Drug Administration (FDA) for treating or preventing progressive renal disease. Such use would therefore be considered "innovative" therapy. CONCLUSIONS: ACE inhibitors are tolerated by azotemic patients, although transient reductions in renal function can occur. Patients with bilateral renal insufficiency or low cardiac output are at increased risk for developing reversible acute renal insufficiency. Hyperkalemia may occur, particularly in patients with diabetes or severe renal insufficiency. In many patients with renal disease, ACE inhibitors dramatically reduce proteinuria, but whether they also reduce the rate of progression of renal disease remains unproved.