Placebo medication use in patient care: a survey of medical interns.
The use of placebo medication, long recognized by clinicians, often has serious practical implications, such as patient deception. Past evidence has suggested that resident physicians tend to misuse placebo medication. Interns from two consecutive years of a residency program were surveyed anonymously to assess their knowledge and use of placebos. Of the 74 interns surveyed, 44 (59%) were familiar with placebo use in patient care. Fifty percent of these interns familiar with placebo use had learned about placebos from another physician. All interns who had learned about placebos during their internships had learned from another physician, whereas interns who had gained their knowledge of placebos as medical students were as likely to have learned from the medical literature as they were to have learned from a physician (P = 0.027). Interns aware of placebo use were more likely to consider placebo administration for suspected, factitious pain (P = 0.022). The present study uncovered no relationship between interns' estimations of placebo efficacy and the utility they attributed to placebos in assessing a complaint of pain. This suggests that conceptual inconsistencies underlie their use of placebos. Interns often learn of placebos as medical students and are influenced by physician-mentors. Placebo use in patient care is an area of attention for medical educators. (+info)
Residents' exposure to aboriginal health issues. Survey of family medicine programs in Canada.
OBJECTIVE: To determine whether Canadian family medicine residency programs currently have objectives, staff, and clinical experiences for adequately exposing residents to aboriginal health issues. DESIGN: A one-page questionnaire was developed to survey the details of teaching about and exposure to aboriginal health issues. SETTING: Family medicine programs in Canada. PARTICIPANTS: All Canadian family medicine program directors in the 18 programs (16 at universities and two satellite programs) were surveyed between October 1997 and March 1998. MAIN OUTCOME MEASURES: Whether programs had teaching objectives for exposing residents to aboriginal health issues, whether they had resource people available, what elective and core experiences in aboriginal health were offered, and what types of experiences were available. RESULTS: Response rate was 100%. No programs had formal, written curriculum objectives for residency training in aboriginal health issues, although some were considering them. Some programs, however, had objectives for specific weekend or day sessions. No programs had a strategy for encouraging enrollment of residents of aboriginal origin. Eleven programs had at least one resource person with experience in aboriginal health issues, and 12 had access to community-based aboriginal groups. Core experiences were all weekend seminars or retreats. Elective experiences in aboriginal health were available in 16 programs, and 11 programs were active on reserves. CONCLUSIONS: Many Canadian family medicine programs give residents some exposure to aboriginal health issues, but most need more expertise and direction on these issues. Some programs have unique approaches to teaching aboriginal health care that could be shared. Formalized objectives derived in collaboration with other family medicine programs and aboriginal groups could substantially improve the quality of education in aboriginal health care in Canada. (+info)
Consent obtained by the junior house officer--is it informed?
Of 30 junior house officers questioned, 21 had obtained patients' consent for colonoscopy. Of these 21, about one-third did not routinely discuss with patients the risks of perforation and haemorrhage. Ideally, consent should be obtained by a person capable of performing the procedure. If it is to be obtained by junior house officers, they need to know exactly what must be disclosed about each procedure. This could easily be done as part of the induction package. (+info)
Views of managed care--a survey of students, residents, faculty, and deans at medical schools in the United States.
BACKGROUND AND METHODS: Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. RESULTS: Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. CONCLUSIONS: Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans. (+info)
Obstetrics anyone? How family medicine residents' interests changed.
OBJECTIVE: To determine family medicine residents' attitudes and plans about practising obstetrics when they enter and when they graduate from their residency programs. DESIGN: Residents in each of 4 consecutive years, starting July 1991, were surveyed by questionnaire when they entered the program and again when they graduated (ending in June 1996). Only paired questionnaires were used for analysis. SETTING: Family medicine residency programs at the University of Toronto in Ontario. PARTICIPANTS: Of 358 family medicine residents who completed the University of Toronto program, 215 (60%) completed questionnaires at entry and exit. MAIN OUTCOME MEASURES: Changes in attitudes and plans during the residency program as ascertained from responses to entry and exit questionnaires. RESULTS: Analysis was based on 215 paired questionnaires. Women residents had more interest in obstetric practice at entry: 58% of women, but only 31% of men were interested. At graduation, fewer women (49%) and men (22%) were interested in practising obstetrics. The intent to undertake rural practice was strongly associated with the intent to practise obstetrics. By graduation, residents perceived lifestyle factors and compensation as very important negative factors in relation to obstetric practice. Initial interest and the eventual decision to practise obstetrics were strongly associated. CONCLUSIONS: Intent to practise obstetrics after graduation was most closely linked to being a woman, intending to practise in a rural area, and having an interest in obstetrics prior to residency. Building on the interest in obstetrics that residents already have could be a better strategy for producing more physicians willing to practise obstetrics than trying to change the minds of those uninterested in such practice. (+info)
Referrals by general internists and internal medicine trainees in an academic medicine practice.
Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed. (+info)
Experiences and attitudes of residents and students influence voluntary service with homeless populations.
OBJECTIVE: To assess the impact of two programs at the University of Pittsburgh, one that requires and one that encourages volunteer activity. In the program that requires primary care interns to spend 15 hours in a homeless clinic, we measured volunteer service after the requirement was fulfilled. In the program that encourages and provides the structure for first- and second-year medical students to volunteer, we assessed correlates of volunteering. MEASUREMENTS AND MAIN RESULTS: When primary care interns were required to spend time at homeless clinics, all (13/13) volunteered to work at the same clinic in subsequent years. Categorical interns without this requirement were less likely to volunteer (24/51; chi2 = 12.7, p >. 001). Medical students who volunteered were more likely to be first-year students, have previously volunteered in a similar setting, have positive attitudes toward caring for indigent patients, and have fewer factors that discouraged them from volunteering (p <. 01 for all) than students who did not volunteer. CONCLUSIONS: Volunteering with underserved communities during medical school and residency is influenced by previous experiences and, among medical students, year in school. Medical schools and residency programs have the opportunity to promote volunteerism and social responsibility through mentoring and curricular initiatives. (+info)
Turfing: patients in the balance.
OBJECTIVE: To examine the language of "turfing," a ubiquitous term applied to some transfers of patients between physicians, in order to reveal aspects of the ideology of internal medicine residency. SETTING: Academic internal medicine training program. MEASUREMENTS: Using direct observation and a focus group, we collected audiotapes of medical residents' discussions of turfing. These data were analyzed using interpretive and conversation analytic methods. The focus group was used both to validate and to further elaborate a schematic conceptual framework for turfing. MAIN RESULTS: The decision to call a patient "turfed" depends on the balance of the values of effectiveness of therapy, continuity of care, and power. For example, if the receiving physician cannot provide a more effective therapy than can the transferring physician, medical residents consider the transfer inappropriate, and call the patient a turf. With appropriate transfers, these residents see their service as honorable, but with turfs, residents talk about the irresponsibility of transferring physicians, burdens of service, abuse, and powerlessness. CONCLUSIONS: Internal medicine residents can feel angry and frustrated about receiving patients perceived to be rejected by other doctors, and powerless to prevent the transfer of those patients for whom they may have no effective treatment or continuous relationship. This study has implications for further exploration of how the relationships between physicians may uphold or conflict with the underlying moral tenets of the medical profession. (+info)