DeWitt C. Baldwin

Assistance from Family Members, Friends, Paid Care Givers, and Volunteers in the Care of Terminally Ill Patients

BACKGROUND In addition to medical care, dying patients often need many types of assistance, including help with transportation, nursing care, homemaking services, and personal care. We interviewed terminally ill adults and their care givers in six randomly selected areas of the United States (five metropolitan areas and one rural county) to determine how their needs for assistance were met and the frequency with which they received such assistance from family members and paid and volunteer care givers. METHODS The patients, whose physicians estimated them to have less than six months to live and who had clinically significant illness other than human immunodeficiency virus infection or the acquired immunodeficiency syndrome, were referred to the study by their physicians. Of the 1131 eligible patients, 988 (87.4 percent) consented to a detailed in-person interview conducted in English, as did 893 of the 915 eligible primary care givers (97.6 percent). RESULTS Of the 988 terminally ill patients, 59.4 percent were over the age of 65 years, and 51.5 percent were women. The most frequent terminal illness was cancer (in 51.8 percent of the patients), followed by heart disease (18.0 percent) and chronic obstructive pulmonary disease (10.9 percent). Four percent of the patients were in an institution, such as a nursing home, residential hospice, or hospital; the rest were living in a private residence. A need for assistance was reported by 86.8 percent of the patients; they required help with transportation (reported by 62.0 percent), homemaking services (55.2 percent), nursing care (28.7 percent), and personal care (26.0 percent). Of the care givers, 72.1 percent were women. Primary care givers were family members in 96.0 percent of cases; only 4.0 percent were unrelated. Most patients relied completely on family members and friends for assistance. A total of 15.5 percent of patients relied only on paid assistance for more than half of the types of care that they needed. Volunteers (that is, unpaid helpers who were not family members or friends) provided less than 3 percent of all care. CONCLUSIONS In our survey of terminally ill patients, family members, usually women, provided the majority of assistance with nonmedical care. Although many people received assistance from paid care givers, very few had assistance from volunteers.

The moral development of medical students: a pilot study of the possible influence of medical education

Summary. Medicine endorses a code of ethics and encourages a high moral character among doctors. This study examines the influence of medical education on the moral reasoning and development of medical students. Kohlbergs Moral Judgment Interview was given to a sample of 20 medical students (41.7% of students in that class). The students were tested at the beginning and at the end of their medical course to determine whether their moral reasoning scores had increased to the same extent as other people who extend their formal education. It was found that normally expected increases in moral reasoning scores did not occur over the 4 years of medical education for these students, suggesting that their educational experience somehow inhibited their moral reasoning ability rather than facilitating it. With a range of moral reasoning scores between 315 and 482, the finding of a mean increase from first year to fourth year of 18.5 points was not statistically significant at the P≤ 0.05 level. Statistical analysis revealed no significant correlations at the P≤ 0.05 level between the moral reasoning scores and age, gender, Medical College Admission Test scores, or grade point average scores. Along with a brief description of Kohlbergs cognitive moral development theory, some interpretations and explanations are given for the findings of the study.

A national survey of residents' self-reported work hours: thinking beyond specialty.

Purpose. To secure data from residents regarding residency work hours and correlates. Method. A national, random sample of postgraduate year 1 (PGY1) and year 2 (PGY2) residents in the 1998-1999 training year was identified using the American Medical Association’s Graduate Medical Education database. Residents completed a five-page survey with 44 questions and 144 separate data elements relating to their residency experience. Results. Completed surveys were received from 3,604 of 5,616 (64.2%) residents contacted. PGY1 residents reported working an average of 83 hours a week versus 76.2 hours for PGY2 residents (p < .0001). Total work hours were significantly correlated with reported stress and hours of sleep per week. Residents averaging more than 80 work hours per week were more likely to be involved in a personal accident or injury, a serious conflict with other staff members, and making a significant medical error. Cluster analysis revealed four different types of residency experience: high intensity, moderate intensity, low intensity, and moonlighters, suggesting that residents may have some choice in selecting a residency experience suited to their particular personal and professional needs. Conclusion. Nearly half of PGY1 and one third of PGY2 residents reported working more than 80 hours per week. These extended hours are significantly correlated with a number of patient care and personal health variables. Given the variety of program and specialty requirements and demands, it seems unlikely that an arbitrary limit or a simple decrease in work hours will provide a satisfactory solution to many resident and patient care concerns.

Evaluation of teaching medical ethics by an assessment of moral reasoning

Summary. This study assessed the hypothesis that the formal teaching of medical ethics promotes a significant increase in the growth and development of moral reasoning in medical students. Results indicated a statistically significant increase (P ≤ 0.0005) in the level of moral reasoning of students exposed to a medical ethics course compared to the control group that was not exposed to the medical ethics course. When the posttest scores were adjusted by subtracting the pretest scores, the differences were even more significant (P ≤ 0.0002). This study confirmed similar findings of another study using a different instrument of assessment. Brief discussion is given of the fundamental premise that the appropriate function of teaching medical ethics in our modern pluralistic society is to improve students’ moral reasoning about value issues regardless of what their particular set of moral values happens to be.

The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students.

PURPOSE: To examine how much exposure to small-group case-study discussion is necessary to significantly increase moral reasoning skills. METHOD: For the classes of 1991-1998 at Texas A&M, using Rests Defining Issues Test, the authors tested groups of students for moral reasoning skills both before and after the students participated in small-group case-study discussions of medical ethics. RESULTS: From 960 students asked to participate, the authors collected complete data for 729 students (75.9% response rate). Small-group case-study exposures ranged from 0 to 44 hours. Groups of students exposed to 20 hours or more demonstrated a significant increase in their moral reasoning scores. Groups with less than 20 hours of exposure demonstrated no significant increase in their scores. CONCLUSION: This study indicates that moral reasoning skills are teachable and measurable, and that small-group discussion significantly increases moral reasoning skills. Further studies are needed to increase the generalizability of these findings.

Substance Use by Fourth-Year Students at 13 U.S. Medical Schools.

Fourth-year medical students at 13 medical schools in different regions of the United States received an anonymous questionnaire designed to examine their current and prior use of 11 substances and their attitudes toward substance use among physicians. Of 1,427 questionnaires distributed, 41 percent were returned. The questionnaire and distribution method were derived from an ongoing survey on drug use in order to permit comparison of the medical students with a national sample of age- and sex-matched cohorts. The rates of substance use during the 30 days preceding receipt of the questionnaire were: alcohol, 87.8 percent; marijuana, 17.3 percent; cigarettes, 9.0 percent; cocaine, 5.6 percent; heroin, 0.0 percent; other opiates, 0.9 percent; LSD, 0.2 percent; other psychedelics, 0.5 percent; barbiturates, 0.5 percent; tranquilizers, 2.2 percent; and amphetamines, 1.2 percent. Compared with their age and sex cohorts nationally, the medical students reported less use of marijuana, cocaine, cigarettes, LSD, barbiturates, and amphetamines. However, their use of other opiates was approximately the same and their use of tranquilizers and alcohol was slightly higher than that of the other cohorts. Data on their sources of knowledge about drug abuse indicate the need for greater attention to this issue in the medical curriculum.

Presenteeism Among Resident Physicians

individuals for leading healthy lifestyles is currently the subject of policy experiments in Europe. The Dutch Council for Public Health, like the British National Health Service and the GermanStatutoryHealth Insurance, is experimentingwith incentives to encourage healthy lifestyles in health insurance. What can be learned from these European policy experiments? First, it is questionable whether prevention programs and incentives work at the individual level. There is a great deal of evidence that these policies fail to change people’s lifestyles in the long run because unhealthy living habits are strongly predicted by a person’s socioeconomic position and social circumstances. Certain social contexts make it harder for people to make the “right” individual choices with regard to exercise, diet, and other health habits. In some cases, what seems like a personal choice to adopt an unhealthy lifestyle might not be; the choice may be driven by the fact that realistic options do not exist. Second, there is a danger that focusing on individual responsibility reinforces existing socioeconomic health inequalities. By rewarding healthy lifestyles and punishing unhealthy behaviors, the initial advantage of the well educated and well paid may tend to beget further advantage, and disadvantage those most in need of health improvements, creating widening gaps between haves and have-nots. Strikingafairbalanceinhealthcareismorecomplicatedthan moralizingriskybehavior.For individuals tobeable to take individual responsibility for their health, they first and foremost need adequate opportunities to achieve good health, such as affordableandaccessiblehealthcare—nottheotherwayround.

BEHAVIORAL CONSEQUENCES OF JOB-RELATED STRESS AMONG RESIDENT PHYSICIANS: THE MEDIATING ROLE OF PSYCHOLOGICAL STRAIN '

This study examined the correlations among stressors, psychological strain, and behavioral reactions in a national sample of 1785 resident physicians, 27 to 33 years old. Consistent with previous studies of resident physicians, analysis showed that those experiencing high job-related stressors experienced high psychological strain in both their personal and professional lives. Stressors were also correlated with behavioral reactions. Hierarchical regression suggested that psychological strain mediated the relations between two of the stressors and behavioral reactions to some extent. This was consistent with recent research suggesting that psychological reactions may mediate the relations between stressors and outcomes. Further research on both medical residency and the stressing process was suggested.

Moral reasoning, professionalism, and the teaching of ethics to orthopaedic surgeons.

Moral reasoning is not the only component of moral behavior, but it is an important and measurable constituent. Eighty orthopaedists, who took a standardized test of moral reasoning, showed marked heterogeneity in scores, ranging from the level of junior high students to the level of moral philosophers. This variability poses difficulty for those who plan educational courses in ethics, but is not an insurmountable difficulty.

Professionalism and professional values in orthopaedics.

During a consensus conference in Fall, 1998, the Academic Orthopaedic Society identified the values and qualities of professionalism as defined by its members. One hundred eighty-six respondents rated 20 characteristics and values describing professionalism, based on the extent to which they believed each item was appropriate. The five items receiving highest average ratings were: integrity, trustworthiness, responsibility, reliability, and accountability. Principal components analysis yielded five factors that captured 62% of the total variability. These factors were labeled respect and relationships, altruism, accountability and reliability, integrity, and excellence. The authors anticipate that the Academic Orthopaedic Society will find these data useful, and incorporate this information into their decisions concerning evaluation of current residents and applicants to their programs. An additional challenge will be to develop a values curriculum (formal curriculum) and a learning environment (informal curriculum) that will encourage residents and faculty to aspire to the highest in professional values and professional conduct.