The Freiburg approach to ethics consultation: process, outcome and competencies.
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The paper describes how ethics consultation can be valuable to health professionals, patients and their families in understanding and evaluating ethical values and their consequences in a particular situation. Ethics consultation as it is practised at the university hospital of Freiburg is a special professional service offered by members of an academic institution. The practical approach and the goals are illustrated by a case study showing the difficulties of deciding about the limitation of intensive care medicine after heart surgery in the setting of maximum treatment. Here, the ethics consultation was initiated by the relatives of the patient who wanted a decision to withhold further life-sustaining treatment. Following the experiences in Freiburg, it is concluded that clinical ethicists have to cover a variety of relevant fields of knowledge, need special analytical skills, and should have professional competence in counselling, including conflict mediation or crisis intervention. (+info)
Morbidity of first trimester aspiration termination and the seniority of the surgeon.
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Vacuum aspiration is a safe, acceptable, and efficacious method of first trimester pregnancy termination. The success and complication rates are thought to be partially dependent on operator experience and gestation. We examined this further by studying the outcome of 828 consecutive surgical abortions up to 13 weeks gestation in our hospital. The following outcomes were measured: surgical curettage for presumed retained products of conception; continuing pregnancy; uterine perforation; pelvic sepsis requiring intravenous antibiotics; and blood transfusion required. The complete abortion rate was 94.6% and the rate of continuing pregnancy 0.24%. There was a significant relationship between efficacy and seniority of the surgeon; consultants, senior registrars, registrars, and senior house officers had complete abortion rates of 97.8, 92.8, 94.7, and 88.4% respectively (P = 0.039). Parity did not affect efficacy. Terminations at 12-13 weeks gestation were associated with a significantly lower complete abortion rate. The rates of uterine perforation, blood transfusion, pelvic sepsis requiring intravenous antibiotics, and overnight hospital admission were 0.24, 0, 0.97, and 1.69% respectively. Thus, the only significant factors affecting outcome of surgical abortion are grade of operating surgeon or terminations performed at later gestations of 12-13 weeks. It is vital that physicians performing surgical terminations are adequately trained. (+info)
Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications.
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OBJECTIVE: Oral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process. DESIGN: Descriptive study. SETTING: Inpatient general medicine service in a university-affiliated public hospital. PARTICIPANTS: Twelve third-year medical students during their internal medicine clerkship and 14 teachers. MEASUREMENTS: One-hundred sixty hours of ethnographic observation. including 73 oral presentations on rounds. Discoursed-based interviews of 8 students and 10 teachers. Data were qualitatively analyzed to uncover recurrent patterns of communication. MAIN RESULTS: Students and teachers had different perceptions of the purpose of oral presentation, and this was reflected in performance. Students described and conducted the presentation as a rule-based, data-storage activity governed by "order" and "structure." Teachers approached the presentation as a flexible means of "communication" and a method for "constructing" the details of a case into a diagnostic or therapeutic plan. Although most teachers viewed oral presentations rhetorically (sensitive to context), most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (e.g., comment "be brief" resulted in reading faster rather than editing) and unintended value acquisition (e.g., request for less social history interpreted as social history never relevant). CONCLUSIONS: Students learn oral presentation by trial and error rather than through teaching of an explicit rhetorical model. This may delay development of effective communication skills and result in acquisition of unintended professional values. Teaching and learning of oral presentation skills may be improved by emphasizing that context determines content and by making explicit the tacit rules of presentation. (+info)
The factor structure of the working alliance inventory in cognitive-behavioral therapy.
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Studies of the therapeutic alliance in cognitive-behavioral therapy (CBT) have varied in their results, necessitating a deeper understanding of this construct. Through an exploratory factor analysis of the alliance in CBT, as measured by the Working Alliance Inventory (shortened, observer-rated version), the authors found a two-factor structure of alliance that challenges the commonly accepted one general factor of alliance. The results suggest that the relationship between therapist and client (Relationship) may be largely independent of the client's agreement with and confidence in the therapist and CBT (Agreement/ Confidence), necessitating independent measures of these two factors, not one measure of a general alliance factor. (+info)
Risk communication, the West Nile virus epidemic, and bioterrorism: responding to the communication challenges posed by the intentional or unintentional release of a pathogen in an urban setting.
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The intentional or unintentional introduction of a pathogen in an urban setting presents severe communication challenges. Risk communication--a science-based approach for communicating effectively in high-concern situations--provides a set of principles and tools for meeting those challenges. A brief overview of the risk communication theoretical perspective and basic risk communication models is presented here, and the risk communication perspective is applied to the West Nile virus epidemic in New York City in 1999 and 2000 and to a possible bioterrorist event. The purpose is to provide practical information on how perceptions of the risks associated with a disease outbreak might be perceived and how communications would be best managed. (+info)
Does a third year of emergency medicine training make a difference? Historical cohort study of Queen's University graduates.
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OBJECTIVE: To describe outcomes of a third-year residency (PGY-3) program in family medicine/emergency medicine in terms of its graduates' practice characteristics and their self-assessed preparedness for practising emergency medicine. DESIGN: A questionnaire was sent to graduates of Queen's University's family medicine residency programs. SETTING: Recent graduates' practices. PARTICIPANTS: All 30 graduates of Queen's University's Family Medicine/Emergency Medicine Program (PGY-3s) from 1988 to 1997 and 90 matched controls chosen randomly from among the 250 graduates of the 2-year family medicine residency program (PGY-2s) during the same period. Six of the 120 were excluded. Response rate was 89%. MAIN OUTCOME MEASURES: Current practice of family and emergency medicine, leadership activities in emergency medicine, self-assessment of preparedness to practise and to lead others at the end of training, self-report of frequency of emergency care situations in subsequent practice for which physicians felt unprepared by their training, and catchment population and "rurality" of location of current practice. RESULTS: Compared with controls, more PGY-3s practiced and took leadership roles in emergency medicine in their hospitals and communities. At the end of their training, PGY-3s reported higher levels of preparedness for practicing and providing leadership in emergency medicine. Both groups reported the same frequency of encountering emergency situations in subsequent practice for which they felt inadequately prepared. Both groups practised in communities of similar size and location. CONCLUSION: Graduates of Queen's University's third-year emergency medicine program appear to practise in accordance with their extra training. (+info)
Taking the first steps. Research career program in family medicine.
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PROBLEM BEING ADDRESSED: Research is not new to family medicine, yet it is pursued less than in other clinical disciplines. We need to establish a critical mass of family medicine researchers. OBJECTIVE OF PROGRAM: To establish a departmental research organization using a strategy implemented in 1995 by the Department of Family and Community Medicine at the University of Toronto. MAIN COMPONENTS OF PROGRAM: We set out to establish a critical mass of researchers. Applicants were required to complete credible and feasible 3- to 5-year research plans and to have formal support from their clinical chiefs. Once selected, researchers were supported for 40% of their time. Support was provided for 3 years and was renewable according to progress on their research plans. Researchers were expected to publish on average two papers yearly and be involved as principal investigator or co-principal investigator on at least one successful grant after the first 3 years. Since implementation in 1996, funded researchers have become principal investigators in 80% of the grants in which they are involved compared with 20% before the support program. Nine of 15 Medical Research Council grants held by family physicians in Canada have department members as principal investigators. Faculty-supported researchers contributed more than 200 peer-reviewed publications to the literature between 1996 and 2000. CONCLUSION: Four years of experience allows for early assessment of the first step taken to build a thriving family medicine research organization using limited departmental resources. (+info)
The human genome, implications for oral health and diseases, and dental education.
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We are living in an extraordinary time in human history punctuated by the convergence of major scientific and technological progress in the physical, chemical, and biological ways of knowing. Equally extraordinary are the sparkling intellectual developments at the interface between fields of study. One major example of an emerging influence on the future of oral health education is at the interface between the human genome, information technology, and biotechnology with miniaturizations (nanotechnology), suggesting new oral health professional competencies for a new century. A great deal has recently been learned from human and non-human genomics. Genome databases are being "mined" to prompt hypothesis-driven "postgenomic" or functional genomic science in microbial models such as Candida albicans related to oral candidiasis and in human genomics related to biological processes found in craniofacial, oral, and dental diseases and disorders. This growing body of knowledge is already providing the gene content of many oral microbial and human genomes and the knowledge of genetic variants or polymorphisms related to disease, disease progression, and disease response to therapeutics (pharmacogenomics). The knowledge base from human and non-human genomics, functional genomics, biotechnology, and associated information technologies is serving to revolutionize oral health promotion, risk assessment using biomarkers and disease prevention, diagnostics, treatments, and the full range of therapeutics for craniofacial, oral, and dental diseases and disorders. Education, training, and research opportunities are already transforming the curriculum and pedagogy for undergraduate science majors, predoctoral health professional programs, residency and specialty programs, and graduate programs within the health professions. In the words of Bob Dylan, "the times they are a-changing." (+info)