Ethics and communication: does students' comfort addressing: ethical issues vary by specialty team?

Ethics education aims to train physicians to identify and resolve ethical issues. To address ethical concerns, physicians may need to confront each other. We surveyed medical students to determine if their comfort challenging members of their ward teams about ethical issues varies by specialty and what attributes of students and their teams contributed to that comfort. Compared to other specialties, students felt significantly less comfortable challenging team members about ethical issues on surgery and obstetrics/gynecology. We suggest that ethics education must address the atmosphere on ward teams and give students skills to help them speak out despite their discomfort.

A follow-up study of the characteristics of dean's letters

PURPOSE

To assess the content and quality of dean's letters since the publication of guidelines recommended by the Association of American Medical Colleges (AAMC) in 1989.

METHOD

In 1998, the dean's letter writers at all 124 U.S. medical schools were surveyed. The questionnaire incorporated items from two previous surveys (1981 and 1992). In addition, samples of dean's letters (n = 451) from all U.S. medical schools for the graduating class of 1998 were rated based on the AAMC's guidelines.

RESULTS

The response rate of the 1998 survey (66%) was lower than those of the two previous surveys (87% for 1992 and 85% for 1981). Schools that prepared letters that followed the AAMC's guidelines were somewhat more likely to have responded. According to the letter writers in 1998, close to 300,000 letters (approximately 1,050,000 pages total) were sent to residency directors, at an estimated cost of $26,000 per school. A total of 65% of schools produced adequate dean's letters based on the 1989 AAMC's guidelines, compared with 55% in 1992. Many schools were organizing the dean's letter in more readable formats, and more schools provided information that allowed for a comparison of students within the same school.

CONCLUSION

The improvements in dean's letters are encouraging, but ten years after the AAMC's guidelines, 35% of U.S. schools still produce unacceptable letters. With the addition of the electronic submission of information, it is time to review further improvements to the dean's letter.

Did I answer your question? Attending physicians' recognition of residents' perceived learning needs in ambulatory settings

Accurately recognizing the learning goals of trainees should enhance teachers' effectiveness. We sought to determine how commonly such recognition occurs and whether it improves residents' satisfaction with the teaching interaction. In a cross-sectional survey of 97 internal medicine residents and 42 ambulatory clinic preceptors in five ambulatory care clinics in Washington and Oregon, we systematically sampled 236 dyadic teaching interactions. Each dyad participant independently indicated the residents' perceived learning needs from a standardized list. Overall, the preceptors' recognition of the residents' learning needs, as measured by percentage of agreement between preceptors and residents on the learning topics, was modest (kappa 0.21, p =.02). The percentage of agreement for all topics was 43%, ranging from 8% to 66%. Greater time pressures were associated with lower agreement (38% vs 56% for the highest and lowest strata of resident-reported time pressure; 15% vs 43% for highest and lowest strata of preceptor-reported time pressure). Agreement increased as the number of sessions the pair had worked together increased (62% for pairs with > 20 vs 17% for pairs with 0 previous sessions). Satisfaction with teaching encounters was high (4.5 on a 5-point scale) and unrelated to the degree of agreement ( p =.92). These findings suggest that faculty development programs should emphasize precepting skills in recognizing residents' perceived learning needs and that resident clinics should be redesigned to maximize preceptor-resident continuity and minimize time pressure.

Informed decision making in outpatient practice: time to get back to basics

CONTEXT

Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice.

OBJECTIVE

To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons.

DESIGN

Cross-sectional descriptive evaluation of audiotaped office visits during 1993.

SETTING AND PARTICIPANTS

A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office.

MAIN OUTCOME MEASURES

Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure). Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent.

RESULTS

The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making. Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71 %) and assessment of patient understanding least frequently (1.5%).

CONCLUSIONS

Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.

How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting

OBJECTIVE

To characterize the informed consent process in routine, primary care office practice.

DESIGN

Cross-sectional, descriptive evaluation of audiotaped encounters.

SETTING

Offices of primary care physicians in Portland, Oregon.

PARTICIPANTS

Internists (54%) and family physicians (46%), and their patients.

MEASUREMENTS AND MAIN RESULTS

Audiotapes of primary care office visits from a previous study of doctor-patient communication were coded for the number and type of clinical decisions made. The discussion between doctor and patient was scored according to six criteria for informed decision making: description of the nature of the decision, discussion of alternatives, discussion of risks and benefits, discussion of related uncertainties, assessment of the patient's understanding and elicitation of the patient's preference. Discussions leading to decisions included fewer than two of the six described elements of informed decision making (mean 1.23, median 1.0), most frequent of these was description of the nature of the decision (83% of discussion). Discussion of risks and benefits was less frequent (9%), and assessment of understanding was rare (2%). Discussions of management decisions were generally more substantive than discussions of diagnostic decisions (p = .05).

CONCLUSIONS

Discussions leading to clinical decisions in these primary care settings did not fulfill the criteria considered integral to informed decision making. Physicians frequently described the nature of the decision, less frequently discussed risks and benefits, and rarely assessed the patient's understanding of the decision.