Daniel D. Federman

The Physician's Responsibility toward Hopelessly Ill Patients

Abstract Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care — one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive ...

The physician's responsibility toward hopelessly ill patients. A second look.

Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care--one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive care unit, and the nursing home. Finally, we consider the physicians response to the dying patient who is rational and desires suicide or euthanasia.

A survey of medical ethics education at U.S. and Canadian medical schools

Purpose. To assess the format, content, method, and placement of medical ethics education in medical schools; the faculty and curricular resources and institutional structure and support of medical ethics; and the perceptions of ethics education among deans of medical education and medical ethics course directors at U.S. and Canadian medical schools. Method. Two questionnaires were mailed to 125 U.S. medical schools and 16 Canadian schools: one to be completed by the deans of medical education and one to be completed by the medical ethics course director. Descriptive statistics were used to compare responses. Results. In all, 123 (87%) deans and 91 (64%) course directors responded, providing information about 91 schools (six Canadian). All responding institutions offered some formal instruction in medical ethics, and among these, 71 (78%) incorporated ethics into required preclinical courses. The primary pedagogic course structure was small-group discussion and the primary pedagogic method was case discussions. One-fifth of schools provided no funding for ethics teaching, and 47 (52%) did not fund curricular development in ethics. Institutions with a dedicated ethics faculty member were twice as likely to have a mandatory introductory ethics course (64% versus 32%, p < .05). The primary obstacles to ethics education were thought to be a lack of time in the curriculum, a lack of qualified teachers, and a lack of time in faculty schedules. Conclusions. Within a few decades the number of U.S. and Canadian medical schools requiring medical ethics has increased. Nevertheless, significant variation in the content, method, and timing of ethics education suggests consensus about curricular content and pedagogic methods remains lacking. Further progress in ethics education may depend on institutions’ willingness to devote more curricular time and funding to medical ethics.

Effects of Methyl Testosterone on Thyroid Function, Thyroxine Metabolism, and Thyroxine-Binding Protein

Studies on the effect of androgenic steroids on thyroid function are difficult to evaluate because of a number of apparent discrepancies. Money, Kirschner, Kraintz, Merrill, and Rawson (1), using castrate rats on a low iodine diet, found that testosterone propionate had no influence on thyroid weight or on thyroid weight: body weight ratio, but did increase the radioiodine uptake. Kochakian and Evans (2) recently reported that this form of testosterone failed to influence the uptake or release of radioiodine by the thyroid of the castrate rat. Burris, Bogart, and Krueger (3), using heifers and young steers, found that testosterone propionate produced an increased gain in weight; furthermore, the thyroids of the treated animals weighed more, contained less colloid, and exhibited an increase in thyroid cell height. Voitkevich (4) is cited as stating that the goiters produced by propylthiouracil in guinea pigs and cocks are very considerably decreased by simultaneously administered methyl testosterone, and that propylthiouracil goiters are larger in castrate than -in normal cocks.

A Multi-institutional Randomized Controlled Trial of Adjuvant Web-based Teaching to Medical Students

Purpose To investigate the impact of an adjuvant Web-based teaching program on medical students’ learning during clinical rotations. Method From April 2003 to May 2004, 351 students completing clinical rotations in surgery–urology at four U.S. medical schools were invited to volunteer for the study. Web-based teaching cases were developed covering four core urologic topics. Students were block randomized to receive Web-based teaching on two of the four topics. Before and after a designated duration at each institution (ranging one to three weeks), students completed a validated 28-item Web-based test (Cronbach’s alpha = .76) covering all four topics. The test was also administered to a subset of students at one school at the conclusion of their third-year to measure long-term learning. Results Eighty-one percent of all eligible students (286/351) volunteered to participate in the study, 73% of whom (210/286) completed the Web-based program. Compared to controls, Web-based teaching significantly increased test scores in the four topics at each medical school (p < .001, mixed analysis of variance), corresponding to a Cohen’s d effect size of 1.52 (95% confidence interval [CI], 1.23–1.80). Learning efficiency was increased three-fold by Web-based teaching (Cohen’s d effect size 1.16; 95% CI 1.13–1.19). Students who were tested a median of 4.8 months later demonstrated significantly higher scores for Web-based teaching compared to non-Web-based teaching (p = .007, paired t-test). Limited learning was noted in the absence of Web-based teaching. Conclusions This randomized controlled trial provides Class I evidence that Web-based teaching as an adjunct to clinical experiences can significantly and durably improve medical students’ learning.

Psychosexual Adjustment in Congenital Adrenal Hyperplasia

The hormones of the adrenal cortex play a critical part in both daily life and the reaction to stress. Aldosterone is crucial in the regulation of sodium balance and blood volume, and cortisol is n...

Life without Estrogen

Most biologic arrangements seem so obvious, and so well adapted to their uses, that we tend to forget that things might have been worked out quite differently. Impious as it may be, it is worth thi...

FACTITIOUS DISEASES: CLINICAL STAFF CONFERENCE AT THE NATIONAL INSTITUTES OF HEALTH

Excerpt DR. JOSEPH J. BUNIM: Since the Clinical Center opened in July 1953 we have protested that this is not a diagnostic center, nor is it an institution devoted primarily to the care of patients...

Women and Health Research: A Report from the Institute of Medicine

In recent years, claims have been made by segments of the research community and by womens health advocacy groups that clinical research practices and policies have not benefitted womens health to the same extent as mens health. Central to these claims has been an assertion that women have been inadequately represented as subjects of clinical studies and that as a result neither health conditions unique to women — e.g., menopause — nor womens manifestations of health problems affecting both sexes — e.g., heart disease — have been investigated sufficiently.The scientific community, including federal agencies that sponsor and regulate clinical studies, is increasingly responsive to these claims and is taking steps to raise the level of womens participation in clinical studies. Controversy and concern have surrounded these actions, however. Two of the claims that have been made are: (1) that women are more difficult to study than men because of their cyclical hormonal changes; and (2) that conducting gender-specific subgroup analyses would increase the size of study populations, raise the cost of studies, and thereby reduce the number of studies that could be performed with the limited resources available. In addition, controversy over the inclusion of women of childbearing potential and pregnant women has been particularly salient. Concerns have been expressed about avoiding potential harm to existing or potential fetuses and about the possible legal and financial ramifications of such harm. A further concern involves the perceived difficulties in enrolling women in studies and retaining them for the duration of the studies.Against this backdrop, the Office of Research on Womens Health at the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) in October 1992 to establish the Committee on the Ethical and Legal Issues Relating to the Inclusion of Women in Clinical Studies. The Committees charge was to: (1) consider the ethical and legal implications of including women, particularly pregnant women and women of childbearing potential, in clinical studies; (2) examine known instances of litigation regarding injuries to research subjects and describe existing legal liabilities and protections; and (3) provide practical advice on these issues for consideration by NIH, institutional review boards (IRBs), and clinical investigators.The 16 Committee members came from diverse backgrounds: bioethics, law, epidemiology and biostatistics, public health policy, obstetrics and gynecology, clinical research, pharmaceutical development, social and behavioral sciences, and clinical evaluative sciences. Chaired by two of the authors of this article, Ruth Faden and Daniel Federman, and coordinated by the third, IOM Study Director Anna Mastroianni, the Committee met five times over a fourteen-month period, convened a one-and-one-half day invitational workshop, and commissioned several background papers. The Committees deliberations were complicated by the announcement of new federal policies late in its term. Specifically, the Food and Drug Administration (FDA) issued guidelines (FDA 1993) to replace its 1977 guidelines, which prohibited the inclusion of women of childbearing potential in early phases of most clinical drug trials. In addition, Congress passed the NIH Revitalization Act of 1993 (P.L. 103-43), which contains provisions mandating the inclusion of women and racial and ethnic minorities in NIH-sponsored clinical research. In February 1994, the IOM Committee publicly issued its final report and recommendations, Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies, publishing the workshop presentations and commissioned papers in a separate volume.

Estrogen Use and Postmenopausal Women: A National Institutes of Health Consensus Development Conference

The concensus conclusions reached at a concensus development conference on Estrogen Use and Postmenopausal Women in September 1979 are based on 3 position papers prepared for the conference, the response of the panel, and the general discussion by the audience, followed by the panel and other conference participants. The evidence for the efficacy of estrogens in treating specific conditions associated with menopause was reviewed 1st. It was accepted that estrogens are more effective than placebo in decreasing the frequency and severity of vasomotor symptoms. Estrogens are effective in overcoming the atrophy of the vaginal epithelium and the associated symptoms. Present evidence does not justify the use of estrogens to treat primary psychological problems. The validity of 3 randomized trials indicating that exogenous estrogens can retard bone loss if given around the time of menopause was acknowledged. There is no convincing evidence that estrogens in customary doses increase the risk of thromboembolic phenomena, stroke, or heart disease in women who have undergone natural menopause. Evidence was also reviewed concerning adverse effects associated with post-menopausal estrogen use. In the absence of exogenous estrogens, the incidence of endometrial cancer is about 1/1000 postmenopausal women per year. This rate increases severalfold beginning after about 2-4 years of use of 0.625 or 1.25 mg of conjugated estrogens daily. Cystic hyperplasia of the endometrium, regarded as a premalignant condition, has been associated with unopposed estrogen, whether endogenous or exogenous.