Doctor in the house: the medical student as academic,attendant and apprentice?

It is contended that change in the health services should be accompanied by a re-examination of medical education. Changes in professional roles and practices, specialist training and the location of patient care should be more central to informing change in undergraduate medical education. Although innovation in undergraduate curricula is taking place, much of this is in relation to improvement in educational methods. We would argue that these initiatives need to be more firmly linked to the realities of delivering healthcare today.     

Specified principlism: what is it, and does it really resolve cases better than casuistry?

Principlism has been advocated as an approach to resolving concrete cases and issues in bioethics, but critics have pointed out that a main problem for principlism is its lack of a method for assigning priorities to conflicting ethical principles. A version of principlism referred to as 'specified principlism' has been put forward in an attempt to overcome this problem. However, none of the advocates of specified principlism have attempted to demonstrate that the method actually works in resolving detailed clinical cases. This paper shows that when one tries to use it, specified principlism fails to provide practical assistance in deciding how to resolve concrete cases. Proponents of specified principlism have attempted to defend it by arguing that it is superior to casuistry, but it can be shown that their arguments are faulty. Because of these reasons, specified principlism should not be considered a leading contender in the search for methods of making justifiable decisions in clinical cases.     

NIH approves the consent for Baby Fae, or does it?

Levine summarizes portions of the report submitted by a National Institutes of Health (NIH) committee after its visit to Loma Linda University Medical Center, site of the Baby Fae baboon heart transplant. The particulars of the parents' consent to the procedure were of special interest to the site visit team, which concluded that the informed consent document had shortcomings but that the consent process was satisfactory. Both the NIH and Loma Linda officials agreed that, before a second transplant is performed, all information on the Baby Fae xenograft should be carefully documented and the informed consent document should be revised to correct inadequacies.     

Medically Assisted Dying and Suicide: How Are They Different,and How Are They Similar?

The practice of medically assisted dying has long been contentious, and the question of what to call it has become increasingly contentious as well. Particularly among U.S. proponents of legalizing the practice, there has been a growing push away from calling it “physician-assisted suicide,” with assertions that medically assisted dying is fundamentally different from suicide. Digging deeper into this claim about difference leads to an examination of the difference between two kinds of suffering—suffering from physical conditions and suffering from psychological conditions—and therefore leads also toward an examination of whether requests for medical assistance in dying by those suffering from psychological conditions and those suffering from physical conditions should be painted with the same brush. In this article, I aim both to illuminate some of the considerations that ought to be included in discussions related to medically assisted dying and to shed light on what the indirect effects of such discussions can be. I consider some of the reasons commonly given for holding that suicide and medically assisted dying differ fundamentally and then whether the conclusion that medically assisted dying should not be called “suicide” follows from the premises. I ask what else might justify the conclusion that the two acts ought to be called by different names, and I examine possible justifications for accepting this premise, as well as what justifications might exist for emphasizing how the acts are alike. Finally, I argue that we should be cautious before concluding that medically assisted dying should not be called “suicide.” We need more evidence either that the two acts are fundamentally different or that emphasizing differences between them is not likely to do more harm than good.     

Organ transplantation and personal identity: how does loss and change of organs affect the self?

In this paper, changes in identity and selfhood experienced through organ transplantation are analyzed from a phenomenological point of view. The chief examples are heart and face transplants. Similarities and differences between the examples are fleshed out by way of identifying three layers of selfhood in which the procedures have effects: embodied selfhood, self-reflection, and social-narrative identity. Organ transplantation is tied to processes of alienation in the three layers of selfhood, first and foremost a bodily alienation experienced through illness or injury and in going through and recovering from the operation. However, in cases in which the organ in question is taken to harbor the identity of another person, because of its symbolic qualities (the heart) or its expressive qualities (the face), the alienation process may also involve the otherness of another person making itself, at least imaginatively, known.     

Competencies,milestones, and EPAs – Are those who ignore the past condemned to repeat it?

Background: The idea of competency-based education sounds great on paper. Who wouldn’t argue for a standardized set of performance-based assessments to assure competency in graduating students and residents? Even so, conceptual concerns have already been raised about this new system and there is yet no evidence to refute their veracity.

Aims: We argue that practical concerns deserve equal consideration, and present evidence strongly suggesting these concerns should be taken seriously.

Method: Specifically, we share two historical examples that illustrate what happened in two disparate contexts (K-12 education and the Department of Defense [DOD]) when competency (or outcomes-based) assessment frameworks were implemented. We then examine how observation and assessment of clinical performance stands currently in medical schools and residencies, since these methodologies will be challenged to a greater degree by expansive lists of competencies and milestones.

Results/Conclusions: We conclude with suggestions as to a way forward, because clearly the assessment of competency and the ability to guarantee that graduates are ready for medical careers is of utmost importance. Hopefully the headlong rush to competencies, milestones, and core entrustable professional activities can be tempered before even more time, effort, frustration and resources are invested in an endeavor which history suggests will collapse under its own weight.     

The Principles of the Belmont Report Revisited: How Have Respect for Persons,Beneficence, and Justice Been Applied to Clinical Medicine?

Although written primarily for medical research, the Belmont principles have permeated clinical medicine as well. In fact, they are part of a broad cultural shift that has dramatically reworked the relationship between doctor and patient. In the early 1950s, medicine was about making the patient better and maintaining optimism when the patient could not get better. By the 1990s, medicine was about the treatment of specific physiological systems, as directed by the patient, but as limited by the society's concern for justice.     

As depressing as it was predictable? Lung cancer, clinical trials, and the Medical Research Council in postwar Britain

In recent years lung cancer specialists have complained that due to stigma resulting from the association of the disease with smoking, theirs is a neglected field. This paper demonstrates that in the 1950s and 1960s, when the British Medical Research Council (MRC) started to organize clinical trials for various forms of cancer, this was not the case. Rather, the organizers of these trials saw lung cancer as a particularly promising object of research, for much was known about the disease. The cancer trials were part of a strategy to use the Randomized Controlled Trial (RCT) technology to cement the role of the MRC as the dominant body overseeing medical research in Britain. The organization of the trials, however, turned out to be very difficult, due to ethical problems and the dominance of one form of therapy, surgery. The trial results were deeply disappointing. I argue that these frustrating results contributed to the notion of hopelessness that has come to surround lung cancer, and to the shift of focus from cure to prevention that was triggered by epidemiologic studies identifying tobacco smoke as the main cause of the disease. The paper deals with an important episode in the history of clinical cancer research in postwar Britain, illustrating the ethical and practical problems faced by the organizers.     

What is the impact of structured resuscitation training on healthcare practitioners, their clients and the wider service? A BEME systematic review: BEME Guide No. 20

A large number of resuscitation training courses (structured resuscitation training programmes (SRT)) take place in many countries in the world on a regular basis. This review aimed to determine whether after attending SRT programmes, the participants have a sustained retention of resuscitation knowledge and skills after their initial acquisition and whether there is an improvement in outcome for patients and/or their healthcare organisation after the institution of an SRT programme. All research designs were included, and the reported resuscitation training had to have been delivered in a predefined structured manner over a finite period of time. Data was extracted from the 105 eligible articles and research outcomes were assimilated in tabular form with qualitative synthesis of the findings to produce a narrative summary. Findings of the review were: SRTs result in an improvement in knowledge and skills in those who attend them, deterioration in skills and, to a lesser extent, knowledge is highly likely as early as three months following SRTs, booster or refresher sessions may improve an individual's ability to retain resuscitation skills after initial training and the instigation of resuscitation training in a healthcare institution significantly improves clinical management of resuscitations and patient outcome (including survival) after resuscitation attempts.     

See one, do one, teach one--is this still how it works? A comparison of the medical and nursing professions in the teaching of practical procedures

A survey of 80 junior doctors and nurses was performed to compare the methods of teaching medical and nursing students in eight common practical procedures. Nurses were more likely to have received formal teaching and to be supervised when first performing a procedure. Some 42% percent of doctors felt inadequately trained to carry out a practical procedure safely when performing it alone for the first time compared with 7% of nurses. This study confirms that much of the training of doctors in practical procedures is still received on an informal basis, compared with that of nurses. It also reveals that many doctors view this training as insufficient.     

Can a postgraduate course for general practitioners deliver perceived benefit for learners,patients and the NHS?: a qualitative study

The focus of continuing professional development in general practice is shifting towards professional development and away from following personal areas of interest. Previous work has suggested that much CPD has not had an obvious impact in the three areas of professional development: the needs of individual doctors, patients and the needs of the NHS. We report on the results of a programme of study where developments in all three were perceived as being achieved. This outcome was realized by basing learning around real problems course members encountered in their daily work, using these real situations to identify theory, then reinforcing this learning through practical application.     

With the advent of domestic 3-dimensional (3D) printers and their associated reduced cost,is it now time for every medical school to have their own 3D printer?

Anatomy is the backbone of medical education and new techniques to improve learning are frequently explored. With the introduction of 3D printers specifically for the home market, the price of this technology has reached affordable levels. Using patient scan data, accurate 3D models can be printed that represent real human variation in anatomy to provide an innovative, inexpensive and valuable adjunct to anatomical teaching. Is it now time for every medical school to have their own 3D printer?