Katherine A. Green Hammond

When Residents Need Health Care: Stigma of the Patient Role

ObjectiveWhether and under what circumstances medical residents seek personal health care is a growing concern that has important implications for medical education and patient welfare, but has not been thoroughly investigated. Barriers to obtaining care have been previously documented, but very little empirical work has focused on trainees who seek health care at their home institution.MethodsA self-report survey on special issues in personal health care of residents was created and distributed at the University of New Mexico School of Medicine in 2001. The authors report findings regarding stigma, fear of jeopardy to training status, and attitudes toward seeking self-care for residents in dual roles as patients and trainees.ResultsResidents (N = 155) rated their concerns regarding stigma and jeopardy to training status and the likelihood of seeking care at their training institution for six vignettes. The vignettes were paired to make comparisons between attending or supervisor as treating physician and between clinical scenarios. Alcohol abuse, nausea and diarrhea, panic attacks, and pregnancy were the most highly stigmatizing to residents; diabetes and hypertension were the least. Differences were also found for gender and specialty.ConclusionResidents’ perceived stigma for clinical situations was an influential factor, strongly affecting concern about jeopardizing training status and likelihood of avoiding care at their home institution.

Teaching medical students to discern ethical problems in human clinical research studies.

Purpose Investigators and institutional review boards are entrusted with ensuring the conduct of ethically sound human studies. Assessing ethical aspects of research protocols is a key skill in fulfilling this duty, yet no empirically validated method exists for preparing professionals to attain this skill. Method The authors performed a randomized controlled educational intervention, comparing a criteria-based learning method, a clinical-research- and experience-based learning method, and a control group. All 300 medical students enrolled at the University of New Mexico School of Medicine in 2001 were invited to participate. After a single half-hour educational session, a written posttest of ability to detect ethical problems in hypothetical protocol vignettes was administered. The authors analyzed responses to ten protocol vignettes that had been evaluated independently by experts. For each vignette, a global assessment of the perceived significance of ethical problems and the identification of specific ethical problems were evaluated. Results Eighty-three medical students (27%) volunteered: 50 (60%) were women and 55 (66%) were first- and second-year students. On global assessments, the criteria-focused group perceived ethical problems as more significant than did the other two groups (p < .02). Students in the criteria-focused group were better able than students in the control group (p < .03) to discern specific ethical problems, more closely resembling expert assessments. Unexpectedly, the group focused on clinical research participants identified fewer problems than did the control group (p < .05). Conclusions The criteria-focused intervention produced enhanced ethical evaluation skills. This work supports the potential value of empirically derived methods for preparing professionals to discern ethical aspects of human studies.

Psychiatrists' attitudes regarding genetic testing and patient safeguards: a preliminary study.

AIMS A probability sample of U.S. psychiatrists (n = 93) was invited to complete a mail survey regarding the likely impact of genetic testing on psychiatry; the clinical utility of pharmacogenetic, diagnostic, and susceptibility genetic testing; and 14 proposed ethical and legal safeguards for clinical genetic testing. RESULTS Forty-five psychiatrists participated in the survey (response rate = 48%). The majority (80% and 60%, respectively) believed that genetic testing would benefit many psychiatric patients and would dramatically change the way psychiatry is practiced. Many psychiatrists (73-85%) also stated that pharmacogenetic, diagnostic, and susceptibility tests for common psychiatric disorders would be somewhat useful or extremely useful in the clinical setting. Nearly all (98-100%) believed that psychiatrists should obtain informed consent before genetic testing, should keep test results confidential, should provide pre- and posttest counseling, and should demonstrate competence in interpreting test results. Nearly all (96-100%) supported laws and regulations to prevent discrimination based on genetic test results and to protect consumers from misleading advertisements for testing. Ninety-one percent endorsed restrictions on the sale of genetic tests directly to consumers. CONCLUSIONS This probability sample of U.S. psychiatrists expressed a strongly positive view of genetic testing in psychiatry, while voicing nearly unanimous support for seven ethical and legal safeguards.

Professionalism and Ethics Education on Relationships and Boundaries: Psychiatric Residents’ Training Preferences

ObjectiveAwareness of the privileges and limits of one’s role as physician, as well as recognition and respect for the patient as a human being, are central to ethical medical practice. The authors were particularly interested in examining the attitudes and perceived needs of psychiatric residents toward education on professional boundaries and relationships given the heightened current focus on professionalism and ethics.MethodsResidents from six psychiatric residencies provided views on professionalism and ethics education on a survey encompassing 10 domains of professionalism. The authors focus on residents’ perceived need for education on boundaries in the psychiatrist-patient relationship and in peer-peer and supervisor-trainee interactions.ResultsRespondents (N = 134) felt that nine relationship and boundary issues arising during training should receive more education: being asked to work with inadequate supervision, resolving conflicts between attendings and trainees, resident health care, adequately caring for patients while adhering to work-hour guidelines, performing work beyond one’s competence, mistreatment of residents, sexual/romantic relationships between faculty and trainees, mistreatment of medical students, and sexual/romantic relationships between residents and medical students (p>0.05 in all cases). In addition, 15 relationship and boundary issues arising during clinical practice were felt to warrant more education: responding to impaired colleagues, coping with mistakes in clinical care, reporting mistakes, balancing personal and professional life, resolving conflicts, writing prescriptions for friends or family, allocation of health care resources, providing medical advice to friends and family, physicians’ social responsibilities, interacting with families, medicine as a profession, gender bias, being asked to falsify clinical information, accepting gifts from patients, and personal relationships with patients (p>0.05 in all cases).ConclusionThe authors found a perceived need for more education for psychiatric residents for the majority of topics pertaining to boundaries and relationships. Residents who reported encountering ethical dilemmas more frequently wanted more education on these topics.

Psychiatrists' attitudes, knowledge, and experience regarding genetics: a preliminary study.

Purpose: This study is the first survey of a random national sample of US psychiatrists to assess attitudes, knowledge, and clinical experience regarding genetics. We hypothesized that clinicians with more recent genetics training would demonstrate more positive attitudes and greater genetics knowledge and experience than those with less recent training.Methods: A probability sample of US psychiatrists (n = 93) was invited to participate in a mail survey regarding genetic medicine.Results: Forty-five psychiatrists completed the survey (response rate = 48%). All believed that genetics strongly or moderately influenced a persons mental health. Respondents expressed positive attitudes toward incorporating genetics into psychiatric practice, but most did not have recent genetics training or experience in referring patients to genetic counselors or ordering genetic tests. Psychiatrists who had genetics training within the previous 5 years had more experience in providing genetic services.Conclusions: This survey identified areas of strength (positive attitudes about providing genetic services, belief in the heritability of mental illness) and future targets for educational intervention (general genetics, information about testing and counseling resources). The association between recent training and a greater level of clinical genetics experience suggests that educational efforts may be successful in preparing psychiatrists to provide genetic services in the future.

Medical Students’ Affirmation of Ethics Education

ObjectiveDespite the acknowledged importance of ethics education in medical school, little empirical work has been done to assess the needs and preferences of medical students regarding ethics curricula.MethodsEighty-three medical students at the University of New Mexico participated in a self-administered written survey including 41 scaled questions regarding attitudes, needs, and preferences toward medical ethics and ethics education.ResultsStudents reported strong personal interest in learning more about ethics in clinical medicine and research. They most strongly endorsed as valid objectives of ethics education the goals of helping professionals “better recognize ethical issues and clarify values-laden choices,” “improve patient care and clinical decision-making,” and “improve ethical practices in clinical research.” Participants strongly agreed that “professional attitudes and values are an appropriate focus for medical education” and also expressed strong interest in learning more about specific ethical topics and learning methods. Women more strongly endorsed interest in additional ethics education and a preference for increased ethics education than men. Preclinical participants expressed a greater desire for additional training on all ethics topics than clinical students.ConclusionThe medical students surveyed strongly affirmed ethics education in medical school and expressed clear preferences for curricular topics and teaching methods.

Personal Health Care of Residents: Preferences for Care Outside of the Training Institution

ObjectiveThe personal health care issues of residents are important but have received minimal study. Available evidence suggests that residents experience difficulties obtaining care, partly related to both the demands of medical training and concerns about confidentiality and privacy.MethodsA self-report survey was distributed in 2000–2001 to advanced residents at the University of New Mexico Health Sciences Center. Questions related to personal health and health care attitudes, behaviors, preferences, and experiences, and vignettes related to personal illness and treatment. Here the authors report findings regarding preferences for obtaining health care “at” versus “outside” of one’s training institution.ResultsData from 141 residents are presented. A substantial minority of residents had obtained care outside of their institution in the preceding year. Residents expressed concerns about their medical privacy and confidentiality related to obtaining care within their own institution, including concerns about being seen by other residents or by past or future attendings. Women expressed more concern than did men on numerous issues, as did residents in primary care versus specialty training. Residents expressed a preference for care outside the training institution when taking into account confidentiality and prevention of embarrassment; care at their own institution was preferred when considering expense and scheduling. Outside care was more strongly preferred for more stigmatizing illnesses (e.g., mental health-related). Most residents felt poorly informed regarding their personal health care confidentiality rights and did not know whether their institution had confidentiality policies regarding residents who develop physical or mental health problems.ConclusionResidents worry about confidentiality and privacy when deciding where to obtain personal medical care. Trainees’ concerns are relevant to crafting policies on resident health care. Programs should strive to inform residents thoroughly about policies and rights pertaining to personal health care.

Coexisting Commitments to Ethics and Human Research: A Preliminary Study of the Perspectives of 83 Medical Students

Human research is accepted in our society because it is seen as generating valuable new knowledge that may alleviate suffering and bring benefit to ill persons now and in the future (Brody 1998; Faden 1996; National Commission for the Protection of Human Subjects 1979). Performing research that involves human participants is ethically complex, however, and ethical and scientific considerations in human research historically have been viewed as being in tension (Freedman 1987; Michels 1999). Some have asserted that ethical restrictions, while necessary, directly impede scientific progress (Woodward 1999). Controversies in human research ethics have centered on ethical safeguards as burdensome, disproportionate, and distorting of scientific findings (Brody 1998; Edlund et al. 1985; Faden 1996; Gray 1975; Katz 1972). The past half-century, furthermore, provides many tragic examples of disregard for ethical principles and practices in the search for scientific progress (Beecher 1966; Katz 1996). Ethics and human research thus have been seen as uncompanionable and opposing forces (Faden 1996). A new view appears to be emerging in which ethics and human research are understood as significant coexisting commitments (Roberts 2002). Engaging in human research is itself seen as an ethical duty in this paradigm, and optimal scientific approaches may be reliant on the adoption of optimal ethical practices (Fried 2001). This new model of the relationship between science and ethics reinvigorates interest in recurring questions related to the ethical role of scientific design, the value of human research safeguards, whether ethical considerations are seen as detracting from scientific endeavors, under what circumstances ethically problematic research would be tolerated if the results were scientifically valuable, and the fundamental legitimacy of ethical controversies in human research (Brody 1998). These issues have been articulated over several decades in the published literature, but few data exist regarding the attitudes of stakeholders in the research process toward the relationship between science and ethics (Sung et al. 2003). Attitudes regarding the importance of ethics in the professions also have evolved in recent years and it is unknown how physicians-in-training perceive scientific and ethical considerations in human research (Wenger et al. 1997). The perspectives of these early career health professionals are important, however, as they will serve as investigators who conduct human studies, will facilitate protocols in diverse roles as clinicians, academic physicians, and reviewers of human research projects, or will provide care that is informed by evidence derived from human research (Braxton et al. 2001). Empirical ethics studies involving medical students have revealed their sensitivity to nuanced ethical issues in clinical training and practice and suggest strong levels of interest in ethics, especially among women physicians-intraining (Green et al. 1995; Hayward et al. 1985; Roberts et al. 1996). A survey of 2,010 clinical and basic science trainers in 1990 found that 11% had had formal preparation on research ethics (Kalichman and Friedman 1992). To our knowledge, however, no published studies have specifically examined attitudes of early career health professionals toward the relationship of scientific and ethical considerations in human research. For this reason, we performed a preliminary study of medical students’ perspectives on this topic area as part of a sequence of studies that examined ethically important issues in human research from the perspectives of key stakeholders, including clinical research participants, clinical investigators, clinicians, and physicians-in-training.