How do you decide what it is and what to do?

The setting out of management problems in the sequence of question--evidence--action follows practice realities in many situations more closely than the inductive sytle of evidence--diagnosis--action. Explicit setting out of the decision-making process provides a framework for clearer role-identification for different practice specialities, with the opportunity for closer cooperation and joint investigation. Sequential investigation and decision-making separate categories of patients. This streaming can maximize efficiency of investigation and minimize wasteful over-investigation. Teaching a sequential approach to diagnosis and management provides the student with a practical method for solving problems in the real world. If every investigation sought must be justified in terms of the specific question it is to answer, the student will be trained to avoid unnecessary investigation, and the young graduate will find it more difficult to "procrastinate by investigation" because of inability to face up to decision-making.     

Informed consent in Ghana: what do participants really understand?

OBJECTIVES: To explore how subjects in a placebo-controlled vitamin A supplementation trial among Ghanaian women aged 15-45 years perceive the trial and whether they know that not all trial capsules are the same, and to identify factors associated with this knowledge. METHODS: 60 semistructured interviews and 12 focus groups were conducted to explore subjects' perceptions of the trial. Steps were taken to address areas of low comprehension, including retraining fieldworkers. 1971 trial subjects were randomly selected for a survey measuring their knowledge that not all trial capsules are the same. The subjects' fieldworkers were also interviewed about their characteristics and trial knowledge. Factors associated with knowledge were explored using multi-level modeling. RESULTS: Although subjects knew they were taking part in research, most thought they were receiving an active and beneficial medication. Variables associated with knowledge were education and district of residence. Radio broadcasts benefited those with some schooling. Fieldworkers' characteristics were not associated with subjects' knowledge. CONCLUSIONS: Research and debate on new or improved consent procedures are urgently required, particularly for subjects with little education.     

Dissatisfaction in general practice: what do patients really want?

In 31 general practices in Adelaide, approximately 100 consecutive adult patients aged 15-64 years completed a 21-item questionnaire that related to their dissatisfaction with aspects of the care that was provided in the practice. Fourteen of the practices were "solo" practices, five practices were two-person partnerships and 12 practices involved three or more partners. The 21 items divided naturally into five groups: "architecture", "receptionists", "accessibility", "quality" and "communication". Factor analysis of the responses provided support for the idea that "receptionists", "accessibility" and "communication" were independent issues for the respondents and that "quality" was less discrete and was embedded in a factor which we have labelled "mechanics". For nearly all items, the mean dissatisfaction values for the practices were greatest in the larger practices and least in the two-person practices, with solo practices occupying an intermediate position. The main dissatisfaction related to accessibility and communication. These issues are explored in the light of current trends in the organization of primary medical care.     

To what do we have moral obligations and why? I

In one of a series of articles on philosophical medical ethics, Gillon examines the nature of moral obligations entailed in the claim that all innocent human beings have a fundamental right to life. He considers four moral positions offered as justifications for distinguishing morally among different sorts of beings. The first position is the Benthamite claim that humans and other sentient creatures are morally equivalent, with moral importance attaching only to the need to avoid suffering and promote pleasure; the second is that membership in the species homo sapiens confers a unique moral importance; the third is that all "viable" innocent human beings--including viable fetuses--have a right to life; and the fourth holds that, within the class of sentient beings, there is a morally more important subclass that possesses special attributes--namely, persons.     

To what do we have moral obligations and why? II

Following up on his 1 June 1985 article on moral obligations to living human beings versus other sentient beings, Gillon focuses on arguments for and against prohuman "speciesism," the claim that "viability" is a justifiable criterion for differentiating between humans that may be killed and those that may not, and claims that "personhood" is a morally relevant differentiating concept. He discusses the positions taken by Peter Singer and Dame Mary Warnock on "speciesism," and the theories of such philosphers as John Locke, Immanuel Kant, and Michael Tooley regarding the essence of personhood. He sees no solid basis for grounding the scope of moral obligations on simple sentience, membership in the human species, or technical differentia such as viability, and concludes that medical ethics still suffers from the lack of an adequate theory on which to base a right to life.     

What is a doctor, and what does a doctor do?

The Productivity Commission's recent proposal to modify the roles of health professionals raises these important questions.     

Misinformation in the medical literature: what role do error and fraud play?

Media attention to retracted research suggests that a substantial number of papers are corrupted by misinformation. In reality, every paper contains misinformation; at issue is whether the balance of correct versus incorrect information is acceptable. This paper postulates that analysis of retracted research papers can provide insight into medical misinformation, although retracted papers are not a random sample of incorrect papers. Error is the most common reason for retraction and error may be the principal cause of misinformation as well. Still, one-quarter of retracted papers are fraudulent, and misinformation may also arise through fraud. This paper hypothesises that error and fraud are the main sources of misinformation and that error is more common than fraud. Retraction removes misinformation from the literature; bias is non-retracted misinformation. Bias arises when scientific impropriety results in false research findings. Impropriety can involve experimental design, data collection, data analysis, or data presentation. Yet impropriety also arises through earnest error or statistical naiveté; not all bias is fraud. Several measures are proposed to minimise misinformation in the medical literature, including: greater detail in the clinical trial registry, with rigorous definition of inclusion and exclusion criteria and primary endpoints; clear statistical criteria for every aspect of clinical trials, especially sample size; responsibility for data integrity that accrues to all named authors; increased transparency as to how the costs of research were paid; and greater clarity as to the reasons for retraction. Misinformation can arise without malicious intent; authors of incorrect papers are owed a presumption of incompetence, not malice.     

Poor-quality medical research: what can journals do?

Douglas G. Altman, DSc

JAMA. 2002;287:2765-2767.

The aim of medical research is to advance scientific knowledge and hence—directly or indirectly—lead to improvements in the treatment and prevention of disease. Each research project should continue systematically from previous research and feed into future research. Each project should contribute beneficially to a slowly evolving body of research. A study should not mislead; otherwise it could adversely affect clinical practice and future research. In 1994 I observed that research papers commonly contain methodological errors, report results selectively, and draw unjustified conclusions. Here I revisit the topic and suggest how journal editors can help.

     

Teaching Medical Students,what do Consultants think?

Background:

The approach to and delivery of medical student education has undergone significant change within the last decade. There has been a shift away from didactic lectures to small group tutorials, facilitated by clinicians. Anecdotally there is an impression that enthusiasm for teaching is waning. The aim of this qualitative study is to assess the current attitudes of consultants, across all specialities, to teaching medical students in small group settings.

Methods:

A Likert scale questionnaire, relating to teaching medical students in small group tutorials, was distributed via email to all consultants working in one region. Questions considered the categories: attitudes to teaching, financial considerations, time constraints and attitudes to students.

Results:

367 responses were received. 72% of responders were actively involved in teaching. 72% of respondents indicated that medical students should be taught by consultants and 80% felt that teaching medical students was enjoyable. 60% felt they were not financially remunerated for teaching and 50% indicated teaching was not included in job plans; despite this a significant proportion of these respondents remain involved in teaching (68%). Non-teachers were more likely to indicate that teaching was not paid for (p=0.003). 78% indicated consultants do not have adequate time to teach medical students. 82% felt that medical students appreciate consultant led teaching but only 55% felt students had an appropriate level of enthusiasm for learning.

Conclusion:

Consultants in this Deanery are actively involved in medical student teaching and enjoy it. Consultants perceive that they are not adequately financially rewarded but for the most part this is not a deterrent. Time constraints are an issue and there is a desire to have teaching included in job plans to counteract this. Most consultants are complimentary about student attitudes but there is a perception that medical students need to contribute more to their own learning.     

Medical information and the Internet: do you know what you are getting?

Due to the Internet technology, hundreds of Web sites are accessible for medical information, and the retrieval of such information is quite rapid. Once you as a consumer obtain all of this information, how do you determine whether the information you are looking at is valid and current and even relevant to your needs? This article presents various criteria necessary to evaluate the information on a medical Web site; no standards currently are in place to mandate the validity of information published on the Internet.