Teresita McCarty

What and How Psychiatry Residents at Ten Training Programs Wish to Learn About Ethics

The study’s objective was to survey what and how psychiatry residents want to learn about ethics during residency. A 4-page questionnaire developed for this study was sent to 305 residents at 10 adult psychiatry programs in the United States. One-hundred and eighty-one (59%) of those surveyed responded. Seventy-six percent reported facing an ethical dilemma in residency for which they felt unprepared. Forty-six percent reported having received no ethics training during residency. More than 50% of the respondents requested that “more” curricular attention be paid to 19 specific ethics topics and more than 40% for 25 topics. Preferences with respect to learning methods are presented. This survey may provide guidance in structuring the content and process of ethics education for psychiatry residents. These findings should stimulate the efforts of faculty to commit time and attention to this important curricular area.

Tracking development of clinical reasoning ability across five medical schools using a progress test.

Purpose Little is known about the acquisition of clinical reasoning skills in medical school, the development of clinical reasoning over the medical curriculum as a whole, and the impact of various curricular methodologies on these skills. This study investigated (1) whether there are differences in clinical reasoning skills between learners at different years of medical school, and (2) whether there are differences in performance between students at schools with various curricular methodologies. Method Students (n = 2,394) who had completed zero to three years of medical school at five U.S. medical schools participated in a cross-sectional study in 2008. Students took the same diagnostic pattern recognition (DPR) and clinical data interpretation (CDI) tests. Percent correct scores were used to determine performance differences. Data from all schools and students at all levels were aggregated for further analysis. Results Student performance increased substantially as a result of each year of training. Gains in DPR and CDI performance during the third year of medical school were not as great as in previous years across the five schools. CDI performance and performance gains were lower than DPR performance and gains. Performance gains attributable to training at each of the participating medical schools were more similar than different. Conclusions Years of training accounted for most of the variation in DPR and CDI performance. As a rule, students at higher training levels performed better on both tests, though the expected larger gains during the third year of medical school did not materialize.

The revised Anxious Thoughts and Tendencies (AT&T) scale: a general measure of anxiety-prone cognitive style

BACKGROUND The AT&T was developed from a perspective which proposes that panic disorder with agoraphobia arises from interaction between a specific biological predisposition, expressed in spontaneous panic attacks, and a general anxiety-prone cognitive style. Many items of the original AT&T, a putative measure of the cognitive component, were complex and ambiguous; and normative data were not available. METHOD In this research, the items were simplified and clarified. A community sample of northern New Mexico Hispanics and geographically matched non-Hispanic whites was identified from an earlier epidemiological study. The sample included 151 Anglos and 168 Hispanics; 98 respondents aged 18-34, 75 aged 35-49, 69 aged 50-64, and 77 aged 65 or more; and 111 men and 208 women. RESULTS Factor analysis produced one major factor with high loadings from the 15 negatively worded items, that accounted for about 41% of the total variation in the 15 items. The mean major factor score for Anglos was 1.65 with a standard deviation of 0.48, and for Hispanics was 1.76+/-0.52. F = 4.17, df = 1/311, P < 0.05, and effect size d = 0.22. There were no significant age or gender effects. Item analysis of the major factor produced item/total correlations from 0.49 to 0.68 and a Cronbachs alpha of 0.91. In a separate clinical sample of 30 patients with panic disorder, the test-retest correlation of the major factor at baseline and after 8 weeks of treatment was 0.75. In the community sample, the correlations of the major factor with anxiety-related clusters of the SCL-90 were: Somatization, 0.36; Anxiety, 0.53: and Phobia, 0.44. CONCLUSIONS AND RECOMMENDATIONS We recommend that the AT&T be reduced to the 15 items of its major factor, and we supply quantiles and moments based on the full community sample of 319 as a standard of comparison. Further research with the AT&T in clinical samples of patients with anxiety disorders is ongoing.

Evaluating Medical Students' Skills in Obtaining Informed Consent for HIV Testing

OBJECTIVE: To evaluate fourth-year medical students’ abilities to obtain informed consent or refusal for HIV testing through a performance-based evaluation method.DESIGN: Student competence was assessed in a standardized patient interaction in which the student obtained informed consent or refusal for HIV testing. A previously validated 16-item checklist was completed by the standardized patient. A subset was independently reviewed and scored by a faculty member to calculate interrater reliability for this report. Student feedback on the assessment was elicited.SETTING: School of Medicine at the University of New Mexico.PATIENTS/PARTICIPANTS: All senior medical students in the class of 2000 were included.INTERVENTIONS: A 10-minute standardized patient interaction was administered within the context of a formal comprehensive performance assessment.MEASUREMENTS and MAIN RESULTS: Seventy-nine students participated, and most (96%) demonstrated competence on the station. For the 15 specific items, the mean score was 25.5 out of 30 possible points (range, 13 to 30; SD, 3.5) on the checklist. A strong positive correlation (rs=.79) was found between the total score on the 15 Likert-scaled items and the score in response to the global item, “I would return to this clinician’ (mean, 3.5; SD, 1.0). Scores given by the standardized patients and the faculty rater were well correlated. The station was generally well received by students, many of whom were stimulated to pursue further learning.CONCLUSIONS: This method of assessing medical students’ abilities to obtain informed consent or refusal for HIV testing can be translated to a variety of clinical settings. Such efforts may help in demonstrating competence in performing key ethics skills and may help ensure ethically sound clinical care for people at risk for HIV infection.

Alcohol prescription by surgeons in the prevention and treatment of delirium tremens: historic and current practice.

Beer, other alcohol beverages, and IV alcohol are still used to prevent or treat alcohol withdrawal delirium on surgical services. The history of the use of alcohol by surgeons may play a role in its continued use for withdrawal. In this policy survey 32 inpatient hospital pharmacies were called and asked if alcohol was available, if it was used to treat alcohol withdrawal, and the medical specialties that requested it. Recommendations about the use of alcohol were examined in recent textbooks and from those published early in the twentieth century. One half of the 32 hospitals surveyed had alcoholic beverages available for patient use and eleven hospitals used either package alcohol or IV alcohol in the treatment of alcohol withdrawal. Surgeons used alcohol before anesthesia to help patients tolerate procedures, and the use of alcohol for treatment of alcohol withdrawal still appears in the surgical literature. This preliminary survey indicates that some hospitals still provide beverage alcohol for the treatment of alcohol withdrawal and that surgeons are the specialty ordering alcohol for their patients.

Perceptions of the Ethical Acceptability of Using Medical Examiner Autopsies for Research and Education A Survey of Forensic Pathologists

BACKGROUND Forensic pathologists face difficult moral questions in their practices each day. Consistent ethical and legal guidelines for autopsy tissue use extending beyond usual clinical and legal imperatives have not been developed in this country. OBJECTIVE To obtain the perceptions of medical examiners regarding the ethical acceptability of autopsy tissue use for research and education. METHOD A written, self-report questionnaire was developed and piloted by a multidisciplinary team at the University of New Mexico, Albuquerque. All individuals who attended a platform presentation at the National Association of Medical Examiners Annual Meeting in September 1997 were invited to participate. RESULTS Ninety-one individuals completed the survey (40% of all conference registrants and approximately 75% of presentation attendees). Sixty-three percent of respondents had encountered an ethical dilemma surrounding autopsy tissue use, and one third reported some professional ethics experience. Perspectives varied greatly concerning the ethical acceptability of using autopsy tissues to demonstrate or practice techniques (eg, intubation, brachial plexus dissection) and of fulfilling requests to supply varying kinds and quantities of tissues for research and education. Most respondents indicated that consent by family members was important in tissue use decisions. Respondents agreed on the importance of basic values in education and research, such as integrity, scientific or educational merit, and formal institutional approval of a project. Characteristics of the decedent did not influence decisions to release tissues, except when the individual had died from a mysterious or very rare illness. Attributes of medical examiners, with the exception of sex, also did not consistently predict responses. CONCLUSION Significant diversity exists in beliefs among medical examiners regarding perceptions of the appropriate use of autopsy tissues for education and research. There is need for further inquiry and dialogue so that enduring policy solutions regarding human tissue use for education and research may be developed.

Clinical Ethics Teaching in Psychiatric Supervision

Supervision of psychiatric residents provides a natural context for clinical ethics teaching. In this article, the authors discuss the need for ethics education in psychiatry residencies and describe how the special attributes of supervision allow for optimal ethics training for psychiatry residents in their everyday encounters with ethical problems. Ethical decision making in clinical settings is briefly reviewed, and a 6-step strategy for clinical ethics training in psychiatric supervision is outlined. The value of the clinical ethics supervisory strategy for teaching and patient care is illustrated through four case examples.

Appropriate Expertise and Training for Standardized Patient Assessment Examiners

ConclusionExpertise varies by domain and does not readily transfer from one domain to another. In performance assessment, the application of expertise begins with the selection of the objectives to be assessed. Clarity about the assessment of objectives directs the designers to the most relevant domains of needed expertise. For assessment outcomes to be valid, the context, design, scoring guides, examiners, training, and implementation—all of which imply different areas of expertise—must be considered. Sometimes these areas of expertise may reside in one expert, and sometimes they may be constellated across different experts. The realistic infusion of expertise throughout the assessment is what supports validity.

Standardized patient interviewing with remote interactive technologies

Standardized patients (SPs), people who have been trained to simulate or represent a medical condition in a standardized way, are commonly used in medical education. However, considerable effort is required to maintain a panel of SPs and trained evaluators. We conducted a study using the Access Grid advanced videoconferencing system and the Internet2 high performance research and education network at a hospital in Hawaii with medical residents and a medical school in New Mexico with an SP programme. After receiving one didactic presentation and written material about smoking cessation, three residents in Hawaii each counselled an SP in New Mexico via the Access Grid. One evaluator was located in New Mexico at an Access Grid node. Two evaluators were located in Hawaii, one in the same room as the residents, and one connected via the Access Grid. Evaluators scored the learners using 11 criteria. Student and SP feedback and inter-rater reliability among evaluators were good. Teaching and evaluating interviewing skills appear to be feasible using the Access Grid. Wider implementation of the technique will require considerable technical, logistical and curriculum coordination among participating sites.

Comparing medical students' performances and their achievements as residents: similar findings.

We wish to report similar findings to those described by Paolo and Bonaminio of the University of Kansas School of Medicine (UKSM) and also to support the generalizability to other medical school graduate populations of their work correlating undergraduate medical education (UME) performance with achievement in residency. Paolo and Bonaminio surveyed residency directors of programs where their school’s 1998, 1999, and 2000 graduates from the UKSM were training nine months into their first year of residency. The 25-item surveys asked directors to rate graduates’ knowledge, skills, and attitudes on a five-point Likert scale. We sent a similar survey to the directors of the residency programs training our school’s 210 graduates from the classes of 1999, 2000, and 2001 after they had been in training approximately 11 months. Ninety-six percent of the directors returned usable surveys after two reminders had been sent to nonrespondents. Graduates evaluated in the UKSM study were 60% men and approximately 10%–12% from underrepresented minorities. Graduates evaluated in our study were 44% men and 32% from underrepresented minorities. We asked directors to rate our graduates on items grouped into the five following competence areas using a five-point Likert scale ranging from 1 “unsatisfactory” to 5 “superior”: medical knowledge, clinical skills, effective interpersonal skills, clinical communication of medical information, and professionalism. The internal consistency of our 15-item survey was 0.96 compared with 0.98 for the UKSM survey. An average of the 15-item ratings was compared with the following four indicators of UME performance: gradepoint averages (GPAs) in basic science courses, GPAs in required clerkships, and scores on the first taking of the United States Medical Licensing Examination (USMLE) Steps 1 and 2. These four performance indicators accounted for 24% of the variance in average directors’ ratings, just as did the combination of medical board scores and GPAs used by Paolo and Bonaminio. Pearson product-moment correlations between UME performance and overall residency director ratings ranged from 0.40–0.49 in the UKSM study and from 0.33–0.46 in our study. In both studies, the highest correlation was between the clinical GPAs and residency director ratings. Ratings by residency directors at the medical school from which students had graduated were compared with the ratings by directors at other medical schools in both studies. No statistically significant differences were found between same-school directors’ and other directors’ ratings of graduates. Our findings complement the findings of Paolo and Bonaminio. Because UME performance indicators such as GPAs and board scores are not strong predictors of how well graduates will perform as interns, additional investigation into the correlates of residency performance is needed. Future research, including new data sources—such as the future USMLE Clinical Skills Performance Examination and in-house OSCEs and performance examinations—may explain additional variance in residency directors’ ratings. Our results emphasize the importance of asking residency program directors for feedback on graduates as part of the ongoing evaluation of an undergraduate medical school curriculum.