Guidelines for medical practice

Conclusion In his accompanying article, Dr. Alper points out that the intellectual and economic foundations of the practice of internal medicine are under attack. The intellectual foundations of many routine practices certainly are under attack. The attack comes from within the profession, although its historical antecedents come from society as a whole. The “attack” is simply the scientific method being applied to practices that have not yet been studied carefully. The present generation of practice guidelines are an important beginning, but they are often based on limited data that have been obtained in referral centers. The long-range solution should be based upon data obtained from community physicians’ practices. There is every reason to predict success when academic physicians join forces with community physicians to answer these fascinating questions about the practice of medicine.     

北京市基层医生医学知识获取途径及临床问题解决方式的现状研究

目的 :了解北京市基层一、二级医院医生获取新的医学知识的主要途径 ,及其在临床实践中解决问题的主要方式。分析影响基层医生将知识转化为临床能力的因素。方法 :北京市海淀区和朝阳区 4 2家基层医院 (包括二级医院 9家 ,一级医院 17家 ,乡卫生院 16家 )共计 6 32名内科系列的医生 ,采用问卷调查方式 ,进行继续医学教育和临床能力调查。结果 :1 基层医生获取医学知识的主要途径中“参加院外市级或区级继续教育培训”排在第一位 (4 4 % ) ,其次是阅读专业期刊书籍 (2 2 % )和上级医生指导 (15 % )。 2 .高级职称医生中通过阅读获取知识的比例明显高于初中级职称的医生。 3.当在临床实践中遇到问题时 ,高级职称医生最常用的解决途径为“查看有关疾病的诊疗指南”、“查看相关书籍、期刊” ,而中低职称医生解决的主要途径为“请教上级医生”、“查看有关疾病的诊疗指南”。 4 .基层医生认为影响诊疗水平提高的原因为“缺乏学习时间”(34% )和“缺乏专家的实际指导”(33% )。 5 .基层医生认为目前继续教育系统存在的问题包括 :与临床实际联系不足 ,且内容重复、陈旧 ,授课时间和地点不合理 ,授课形式枯燥。结论 :1.继续医学教育课程是基层医生获取临床知识的主要途径。 2 .该系统课程设置、教学方式、教学?     

When patients choose faith over medicine: physician perspectives on religiously related conflict in the medical encounter

BACKGROUND: Patients at times disagree with medical recommendations for religious reasons. Despite a lively debate about how physicians should respond to patients' religious concerns, little is known about how physicians actually respond. We explored the ways in which physicians interpret and respond to conflict between medical recommendations and patients' religious commitments. METHODS: One-to-one, in-depth, semistructured interviews with 21 physicians from a range of religious affiliations, specialties, and practice settings. Interviews were transcribed, coded, and analyzed for emergent themes through an iterative process of textual analysis informed by the principle of constant comparison. RESULTS: Conflict introduced by religion is common and occurs in 3 types of settings: (1) those in which religious doctrines directly conflict with medical recommendations, (2) those that involve an area in which there is extensive controversy within the broader society, and (3) settings of relative medical uncertainty in which patients "choose faith over medicine." In response to such conflict, physicians first seek to accommodate patients' ideas by remaining open-minded and flexible in their approach. However, if they believe patients' religiously informed decisions will cause them to suffer harm, physicians make efforts to persuade patients to follow medical recommendations. CONCLUSIONS: When religiously related conflict arises, physicians appear to intuitively navigate a tension between respecting patients' autonomy by remaining open-minded and flexible and seeking patients' good by persuading them to follow medical recommendations. In such contexts, religion and medicine are intertwined, and moral counsel inheres in physicians' medical recommendations.     

Common issues in medical professionalism: room to grow

PURPOSE: Much of the respect and trust that society grants to physicians is based on the expectation of upholding professional values. We performed this study to assess responses to common challenges to medical professionalism and to ascertain physician satisfaction with training in professionalism. METHODS: A self-administered questionnaire containing six challenges to professionalism (acceptance of gifts, conflict of interest, confidentiality, physician impairment, sexual harassment, and honesty) with multiple-choice responses was mailed to 528 medical students and 779 house officers at the University of Colorado Health Sciences Center and to 900 randomly selected Colorado physicians. Information about previous exposure to the issue depicted in the scenarios and satisfaction with, and site of, previous education in medical professionalism was obtained. An independent panel selected the best or acceptable answers to the challenges. RESULTS: In all, 961 evaluable responses were received. More than 40% of physicians reported experience with four of the six challenges. The frequency of the best or acceptable answers to the six scenarios ranged from 12% to 86%. Best or acceptable responses were more common in physicians than in house officers, and in house officers than in medical students (P < 0.001). Practice setting and specialty type had only modest effects. The physician impairment scenario was the most challenging: Only 12% of physicians provided the best answer. Most (73%) respondents reported having 10 or fewer hours of formal course work in professionalism, and many (40%) were dissatisfied with their training in professionalism. CONCLUSIONS: While everyday challenges to professionalism are commonly encountered by trainees and practicing physicians, many practitioners are dissatisfied with their training in this area and were unable to provide an acceptable answer to these challenges.     

Changing face of medical curricula

The changing role of medicine in society and the growing expectations patients have of their doctors means that the content and delivery of medical curricula also have to change. The focus of health care has shifted from episodic care of individuals in hospitals to promotion of health in the community, and from paternalism and anecdotal care to negotiated management based on evidence of effectiveness and safety. Medical training is becoming more student centred, with an emphasis on active learning rather than on the passive acquisition of knowledge, and on the assessment of clinical competence rather than on the ability to retain and recall unrelated facts. Rigid educational programmes are giving way to more adaptable and flexible ones, in which student feedback and patient participation have increasingly important roles. The implementation of sustained innovation in medical education continues to present challenges, especially in terms of providing institutional and individual incentives. However, a continuously evolving, high quality medical education system is needed to assure the continued delivery of high quality medicine.     

Artificial intelligence in medical imaging of the liver

Artificial intelligence(AI), particularly deep learning algorithms, is gaining extensive attention for its excellent performance in image-recognition tasks. They can automatically make a quantitative assessment of complex medical image characteristics and achieve an increased accuracy for diagnosis with higher efficiency. AI is widely used and getting increasingly popular in the medical imaging of the liver, including radiology, ultrasound, and nuclear medicine. AI can assist physicians to make more accurate and reproductive imaging diagnosis and also reduce the physicians' workload. This article illustrates basic technical knowledge about AI, including traditional machine learning and deep learning algorithms, especially convolutional neural networks, and their clinical application in the medical imaging of liver diseases, such as detecting and evaluating focal liver lesions, facilitating treatment, and predicting liver treatment response. We conclude that machine-assisted medical services will be a promising solution for future liver medical care. Lastly, we discuss the challenges and future directions of clinical application of deep learning techniques.     

Emergency physicians and disclosure of medical errors

Error in medicine is a subject of continuing interest among physicians, patients, policymakers, and the general public. This article examines the issue of disclosure of medical errors in the context of emergency medicine. It reviews the concept of medical error; proposes the professional duty of truthfulness as a justification for error disclosure; examines barriers to error disclosure posed by health care systems, patients, physicians, and the law; suggests system changes to address the issue of medical error; offers practical guidelines to promote the practice of error disclosure; and discusses the issue of disclosure of errors made by another physician.     

Training and learning professionalism in the medical school curriculum: Current considerations

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned. This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.     

A comparison of humanistic qualities among medical students, residents, and faculty physicians in internal medicine

Humanistic qualities of integrity, respect and compassion are important components of medical education. Studies, however, suggest that students may not perceive their faculty physicians as humanistic. Knowing how the perception of humanistic qualities varies by training level may offer insight on how we teach humanism. In this study, the authors compared humanistic quality scores of fourth-year medical students, internal medicine residents, and attending physicians on a general medicine ward of a teaching hospital. A validated nursing survey to assess humanistic qualities among physicians was distributed to randomly selected nurses on the medicine wards. The survey measured physician relationships with other medical staff, the patient, and family members. Each item was scored on a 5-point Likert scale. Composite scores for physician to staff relationships and physician to patient/family relationships, as well as an overall evaluation score, were compared across levels of physician training. A t test was done to determine statistical significance across training levels. No statistically significant differences were found between internal medicine residents and attending physicians. Subinterns appear to have better perceived qualities of humanism compared with resident and attending physicians. Because resident and attending physicians play an important role in medical education, efforts should be made to improve the perceived humanistic qualities of both resident and attending physicians.     

Attaining academic department status for emergency medicine within medical schools

The specialty of emergency medicine has emerged as a separate academic department within medical schools. These academic departments were contacted and asked to submit information on the process they undertook to attain department status. The path taken by each department was unique and dependent on many factors. Information about these departments is summarized, and ten broad recommendations for academic emergency physicians to consider when seeking department status are given.     

Extended care in nursing homes: a program for a county teaching medical center

A continuity care program for patients in nursing homes using internal medicine residents in training has been developed in a county teaching hospital. Resident physicians on a paid basis assume primary care responsibility for 1000 patients in 29 private community nursing homes. A faculty internist coordinates the activities of the residents and monitors patient care through an extended care office in the county hospital. The program has produced a significant upgrading of the continuity and quality of care of patients in these nursing homes as well as providing medical residents with geriatric and nursing home experience. The increased sensitivity and concern for the needs of nursing home patients developed by the medical residents seems to continue after they complete their training.     

52 precepts that medical trainees and physicians should consider regularly

Being a physician is rewarding but also challenging in the complex health care system. As physicians, we are continually trying to deliver more effective and higher quality care to our patients. With improvement in mind, a list of precepts has been generated as a tool to remind all of us in clinical medicine about the exemplary characteristics, behaviors, and attitudes that are expected as the norm in this profession. The list is organized into four categories: promotion of relationships with patients, principles of the effective clinician, growth and improvement, and values to guide one's career in medicine. The list is envisioned as an instrument that may be helpful to medical learners and physicians by promoting reflection about ways to consistently perform at a high level while more fully appreciating the joy of practicing medicine. The list of precepts may also be useful to medical educators who wish to successfully mold the physicians of tomorrow.     

From Laennec to lobotomy: teaching medical history at academic medical centers

Although clinicians without a sense of history may not be condemned to repeat the past, the historical record offers many informative lessons. For one thing, history demonstrates the changing nature of scientific knowledge; current understandings of health and disease may prove as ephemeral as earlier discarded theories. In addition, history reminds us that social and cultural factors influence how physicians diagnose and treat various medical conditions. When attempting to teach the history of medicine at academic medical centers, instructors should be innovative as opposed to comprehensive. Students and residents are likely to find recent historical issues to be more relevant, particularly when such material can be integrated into the existing curriculum. Provocative topics include depictions of medicine in old Hollywood films, the contributions made by famous physicians at one's own institution, and historical debates over controversial events, such as the Tuskegee syphilis study and the use of lobotomy in mental institutions in the 1950s.     

Role of certified geriatric medical doctors in university hospitals in Japan

The role of certified specialists in geriatric medicine in Japanese University Hospitals is discussed in this section. First, they should act as geriatric general physicians to provide a comprehensive medical care for elderly patients against a background complicatedly divided medical departments in university hospitals. Second, they should create attractive undergraduate programs for geriatric education in medical schools and training programs in geriatric medicine for doctors to develop certified specialists in geriatric medicine in the future. Finally, they should perform clinical research to provide an evidence to construct better social policies to keep older people healthy.     

Sources of ethical conflict in medical housestaff training: a qualitative study

PURPOSE: Despite increased emphasis on medical ethics and professionalism in medical education, concern about unethical and unprofessional behavior by physicians is widespread. This study sought to identify and classify the range of work-related ethical conflicts experienced by medical house officers. METHODS: We performed a qualitative study using data from in-depth interviews conducted in 2001 with 31 internal medicine residents in one traditional and one primary care residency. Using the constant comparative method, we explored work-related experiences during housestaff training that involved ethical conflict with patients or colleagues. RESULTS: The interviews revealed five categories of ethical conflict: concern over telling the truth, respecting patients' wishes, preventing harm, managing the limits of one's competence, and addressing performance of others that is perceived to be inappropriate. Conflicts occurred between residents and attending physicians, patients or families, and other residents. Many of the conflicts were exacerbated by the function of the hierarchical structure in residency training. CONCLUSIONS: This study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development. By attending to the challenges that residents face, particularly previously underemphasized conflicts concerning competence and performance, this framework can be used to enhance education in ethics and professionalism.     

Physician surveys to assess customary care in medical malpractice cases

OBJECTIVE: Physician experts hired and prepared by the litigants provide most information on standard of care for medical malpractice cases. Since this information may not be objective or accurate, we examined the feasibility and potential value of surveying community physicians to assess standard of care. DESIGN: Seven physician surveys of mutually exclusive groups of randomly selected physicians. SETTING: Iowa. PARTICIPANTS: Community and academic primary care physicians and relevant specialists. INTERVENTIONS: Included in each survey was a case vignette of a primary care malpractice case and key quotes from medical experts on each side of the case. Surveyed physicians were asked whether the patient should have been referred to a specialist for additional evaluation. The 7 case vignettes included 3 closed medical malpractice cases, 3 modifications of these cases, and 1 active case. MEASUREMENTS AND MAIN RESULTS: Sixty-three percent of 350 community primary care physicians and 51% of 216 community specialists completed the questionnaire. For 3 closed cases, 47%, 78%, and 88% of primary care physician respondents reported that they would have made a different referral decision than the defendant. Referral percentages were minimally affected by modifying patient outcome but substantially changed by modifying patient presentation. Most physicians, even those whose referral decisions were unusual, assumed that other physicians would make similar referral decisions. For each case, at least 65% of the primary care physicians disagreed with the testimony of one of the expert witnesses. In the active case, the response rate was high (71%), and the respondents did not withhold criticism of the defendant doctor. CONCLUSIONS: Randomly selected peer physicians are willing to participate in surveys of medical malpractice cases. The surveys can be used to construct the distribution of physician self-reported practice relevant to a particular malpractice case. This distribution may provide more information about customary practice or standard of care than the opinion of a single physician expert.     

Emergency Medicine in Population-Based Systems of Care

EDs and emergency physicians play a critical role in health care delivery—providing care to those with life-threatening conditions, as well as serving as provider of last resort to those without options for primary care. This diversity of functions provides unique opportunities for identifying important unmet community needs and developing solutions to address these needs. Future challenges for emergency medicine include assessing and improving the quality of care provided within the ED and identifying the role of the ED in systems of care. Health services research can help define the optimal functions of emergency medicine in enhancing population health. [Clancy CM, Eisenberg JM: Emergency medicine in population-based systems of care. Ann Emerg Med December 1997;30:800-803.]     

Ambulatory medical education

This paper deals with the varied sites and teachers that can and should be used in educating residents and medical students in ambulatory care. A basic premise is that sites other than academic medical centers and teachers other than physician faculty members should be among those used. The paper describes how institutions have used nontraditional sites and teachers. Then, after emphasizing the need to choose settings according to curricular objectives, it discusses teaching sites, both hospital-based (general medical, specialty, and multidisciplinary clinics) and community-based (home care settings, rural clinics, nursing homes, and community clinics). Next it describes the array of current and potential teachers, which includes generalist and specialist physician faculty members, community physicians, residents, and allied personnel such as pharmacists and nurses. The paper also discusses forces resisting and supporting the use of new sites and teachers. It ends with general recommendations.     

Narrative ethics: a means to enrich medical education

The study of literature and medicine enriches the humanistic skills of medical students and physicians. In particular, the study of medical ethics through the lens of narrative enlightens the moral imagination, and provokes moral reflection. In this article, examples will be discussed with the analysis of two books used in a medical-ethics curriculum.     

Expansion of emergency medicine's responsibilities for preclinical education of medical students

Many medical schools have required emergency medicine courses for freshmen medical students, usually through participation in BLS (basic life support) or EMT activities. For several years students at our institution have participated in a required emergency medical technician-ambulance grade (EMT-A) course. While retaining much of the material presented in that original EMT-A course, the course has now been expanded to serve as the medical students' introduction to clinical medicine. This expansion resulted from the belief that emergency medicine provides initial patient contact in the presence of a faculty uniquely suited to introduce the broad domain of clinical medicine to the medical student. Emergency physicians, more than any other specialists, must possess the ability to obtain an incisive history promptly, perform an accurate physical examination, and arrive at an assessment with limited laboratory and radiologic data. Initial access to the clinical education of medical students provides the opportunity to direct their efforts in a prioritized fashion, and thus helps to organize their thought processes for further development as clinicians. Departments of emergency medicine should be willing to accept this incremental responsibility for the introduction of the medical student to the clinical and laboratory assessment of patients.