William L. Toffler

Impact of the presence of a third-year medical student on gross charges and patient volumes in 22 rural community practices.

No abstract available.

Vaginal Po2 in healthy women and in women infected withTrichomonas vaginalis: Potential implications for metronidazole therapy

We measured the PO2, pH, and temperature in the vaginal canals of nine patients with symptomatic Trichomonas vaginitis and those of 10 healthy women. The patients included eight women with primary infections caused by metronidazole-susceptible strains and one refractory case that resulted from infection with a metronidazole-resistant Trichomonas vaginalis. The median vaginal PO2, pH, and temperature in the patient group were 1 mm Hg, 6, and 37.3 degrees C respectively; these medians were 1 mm Hg, less than or equal to 4.5, and 37.2 degrees C in the healthy group. These data show that vaginal environment is anaerobic or microaerophilic (it has reduced oxygen tension). Because the activity of metronidazole is reduced under aerobiosis, the vaginal environment should enhance the biologic activity of the drug.

Principles of clinical medicine: Oregon Health Sciences University School of Medicine

In 1992, the School of Medicine at Oregon Health Sciences University inaugurated a Principles of Clinical Medicine (PCM) course as part of an overall curricular revision. The PCM course, which covers the first and second years of medical school, integrates material from ten separate courses in the previous curriculum. Students learn longitudinally over the two years, rather than “cramming” discrete areas of knowledge and then moving on. Course sessions are related to concurrently taken basic science classes. Meeting two afternoons per week, the PCM course offers preceptorships, health care issues sessions, and patient examination sessions. The PCM course aims to encompass the body of knowledge, skills, and attitudes necessary to become a competent physician. First- and second-year students have more opportunities than previously to interact with patients and practicing physicians in the community. Competition between learning areas, student perceptions of “soft” and “hard” courses, teacher recruitment, and administrative burnout are ongoing difficulties, while faculty recognition and development, administrative commitment and flexibility, and student and faculty feedback all contribute to the success of the course. The PCM course is now the backbone of the first two years of medical school and creates a solid foundation for the third and fourth years.

The POLST paradigm and form:Facts and analysis

This white paper, prepared by a working group of the Catholic Medical Association, provides a commentary on a new type of end-of-life document called a POLST form (Physician Orders for Life-Sustaining Treatment) as well as on its model (or “paradigm”) for implementation across the United States. After an introductory section reviewing the origin, goals, and standard defenses of the POLST paradigm and form, the paper offers a critical analysis of POLST, including an analysis of the risks that POLST poses to sound clinical and ethical decision-making. The paper ends with several recommendations to help Catholic healthcare professionals and institutions better address the challenges of end-of-life care with alternatives to POLST.

Principles of clinical medicine: an interdisciplinary integrated 2-year longitudinal course.

In keeping with the Report of the Panel on the General Professional Education of the Physician ( Association of American Medical Colleges 1984 ), Oregon Health Sciences University (OHSU) School of Medicine is in the midst of revising its curriculum. After a 4‐year process, the Curriculum Committee mandated development of the Principles of Clinical Medicine course, a 2‐year longitudinal course integrating input from both basic and clinical science departments. We describe the steps leading to the courses implementation, its administrative and organizational structure, the evaluation of student performance, teacher training, course curriculum, and the use of interdisciplinary teaching. This course embodies many of the changes called for in the AAMC Report and serves as a model for interdisciplinary education.

Dorsal penile nerve block during newborn circumcision: underutilization of a proven technique?

Newborn circumcision is the most common surgical procedure in the United States. The technique for local anesthesia, dorsal penile nerve block (DPNB), was first described in 1978. Although multiple subsequent studies have reported that DPNB can relieve pain and stress during a newborn’s circumcision without any additional morbidity, many practitioners do not employ this technique. A survey of randomly selected active members of the Oregon Academy of Family Physicians evaluated their perception and use of DPNB. One hundred members were contacted, and 96 responded. Only 36 percent of those physicians performing circumcision used DPNB in circumcisions. The most common reasons given for not employing DPNB were a lack of awareness of the technique (31 percent), believing that pain response in circumcision was not significant (29 percent), and concern about risks (27 percent). The median effectiveness rate reported by those using the block was 70 percent. The majority of respondents were interested in the results of the survey as well as in more information regarding the technique. We believe further educational efforts are indicated to increase awareness and use of DPNB in performing circumcisions in the newborn. Because there is significant variation in the effect achieved, some instruction in appropriate technique also is needed as part of this educational effort.

Principles of clinical medicine: A multidisciplinary, integrated, two-year longitudinal curriculum

No abstract available.

Surgery clerkship evaluations drive improved professionalism

PURPOSE To determine whether a brief student survey can differentiate among third-year clerkship students professionalism experiences and whether sharing specific feedback with surgery faculty and residents can lead to improvements. METHODS Medical students completed a survey on professionalism at the conclusion of each third-year clerkship specialty rotation during academic years 2007-2010. RESULTS Comparisons of survey items in 2007-2008 revealed significantly lower ratings for the surgery clerkship on both Excellence (F = 10.75, p < 0.001) and Altruism/Respect (F = 15.59, p < 0.001) subscales. These data were shared with clerkship directors, prompting the surgery department to discuss student perceptions of professionalism with faculty and residents. Postmeeting ratings of surgery professionalism significantly improved on both Excellence and Altruism/Respect dimensions (p < 0.005 for each). CONCLUSIONS A brief survey can be used to measure student perceptions of professionalism and an intervention as simple as a surgery department openly sharing results and communicating expectations appears to drive positive change in student experiences.

Euthanasia and Physician-Assisted Suicide

ducted and elsewhere, as well as the comprehensive care that Remy and colleagues provide to families grieving after the death of their children. The study was not designed to test the effectiveness of intensive and comprehensive palliative care consultation for families of ICU patients. Instead, the goal was to learn whether family and patient outcomes might be improved by having structured, supportive conversations that focused on explaining the nature and prognosis of chronic critical illness compared with usual communication provided by intensivists. Palliative care clinicians are trained and frequently consulted to lead discussions of prognosis and goals of care. We asked palliative care clinicians rather than intensivists to conduct the conversations in the study to eliminate the confounder of baseline clinician communication skills. What does this study add to the science of communication interventions? The findings show that, beyond what is already provided by skilled ICU clinicians, supportive and informative discussions led by other skilled communicators do not by themselves improve the outcomes that were evaluated. As Martin points out, we cannot know from the findings whether this intervention would have any benefit in ICUs where the staff is less skilled or less available to meet with families. With regard to other factors that may have been associated with outcomes such as family anxiety or stress, we adjusted for the occurrence of patient death by time of family interview and for full formal palliative consultation; neither of these factors explained the lack of differences in the primary outcomes. We do not have data on palliative care or other interactions after hospital discharge or follow-up measurements beyond the 3-month interviews. The study was not intended to examine the effectiveness of comprehensive palliative care consultation for patients who are critically ill and their families. Its findings should not be interpreted to undermine the evidence showing the benefits of specialty palliative care and comprehensive communication interventions for this population.

Regarding Kathryn Tucker's “Ensuring Informed End-of-Life Decisions”

Dear Editor: In her letter to the editor, Kathryn Tucker, attorney for Compassion and Choices of Oregon, encourages the spread of California’s ‘‘Right to Know End of Life Options Act’’ legislation to other states. We strongly disagree. This legislation negatively impacts patients with its legal mandates on patient–doctor communication specifically requiring discussion of comprehensive end-of-life information at the time of diagnosis of terminal illness. Such legislation forces doctors and other health care providers to treat anyone at the time of terminal illness diagnosis as if they are imminently facing death. This is counter to the freedom for a skilled physician to judge the right moment to discuss such information based on individual patient circumstances and state of mind. This legal mandate could trigger a deluge of information about end of life, at the very moment the patient is—and should be—most focused on treatment options and most needing of encouragement. Diagnosis of terminal illness is too early a point for many options, discussing them would wrongly assume that ‘‘one size fits all.’’ While we are fully supportive of openness and informed choices as a principle, this legislation fails to appreciate the appropriate nuance and discretion essential to medical practice. We agree that we want improved end-of-life care. Yet, the devil is in the details. The effort to legislate the substance of the highly personal and private patient-physician relationship is misguided at best. Such attempts depersonalize this relationship—effectively reducing it to ‘‘vending-machine medicine.’’ Furthermore, there is highly problematic language; specifically, ‘‘terminal illness’’ is undefined in the act. Many of our patients are considered to have terminal diseases, yet thankfully, many will live many years. In fact, many die of causes other than their ‘‘terminal’’ diagnosis. The peril of this act and the vulnerability of patients with serious illness to the whims and errors of their caregivers has been well described. Tucker specifically advocates for legislative coercion, rather than education, and ignores the significant positive improvement in palliative care as reported nationally in 2008: