Changes in U.S. Medical Students’ Specialty Interests over the Course of Medical School

Background  Studies have examined factors affecting medical students’ specialty choice, but little research exists on stability of these specialty interests. Objective  To describe patterns of change in specialty interests during medical school and examine associations between specialty change patterns and gender, desire for a high-prestige career, and interest in prevention. Design  Medical students (Class of 2003) at 15 representative US schools were invited to complete surveys during freshman orientation, entry to wards, and senior year. Participants  This analysis used data from 942 students who completed all 3 surveys. Measurements  In addition to a number of other items, students were asked to choose the 1 specialty they were most interested in pursuing. Results  The most common specialty choices among freshman students were pediatrics (20%) and surgery (18%); least common choices were psychiatry and preventive medicine (1% each). General internal medicine was the initial specialty choice for 8%. Most students changed their specialty choices, regardless of initial interest. Only 30% of those initially interested in primary care (PC) remained interested at all 3 time points, compared to 68% of those initially interested in non-PC. Female versus male students were more commonly interested in PC at all 3 time points. Senior students interested in non-PC specialties were more likely to desire a high-prestige career (48%) than those interested in PC (31%). Conclusions  Medical students may benefit from more intensive introduction to some specialties earlier in pre-medical and medical education. In addition, increasing the prestige of PC fields may shape the physician workforce.     

St.Jude Medical 人造心脏瓣膜

本文介绍一种新型的二瓣叶结构的机械瓣,它由 St.Jude Medical 器械公司设计制造,因而被命名为 St.Jude Medical 瓣膜(以下简称 SJM 瓣膜)。SJM 瓣膜的结构和性能1972年,Nicoloff 和 Passes 开始研制一种低柱身中央血流型 SJM 机械瓣膜。全部瓣膜结构是由一瓣环、二瓣叶和一瓣膜缝合环制成。瓣环由热解碳制成。瓣叶中掺入5～10%钨,目的是使瓣叶不透 X 线,便于检查。二片瓣叶将瓣口分成三部分。缝合环外包双层带有90～125微米小孔的涤纶布。     

Medical therapy of Crohn’s disease

Opinion statement There is no medical or surgical treatment that provides a permanent cure for Crohn’s disease (CD). However, an evolving understanding of the pathogenesis of CD has provided clinicians with a diversity of medical treatment options for the disease. The goal of therapy is to induce and maintain clinical remission. The efficacy of immune-modifying agents such as azathioprine/6-mercaptopurine and infliximab have supported a paradigm shift in CD treatment in which maintenance agents are introduced earlier in the disease course. At the same time, it is imperative to balance the efficacy, safety, and tolerability of medical therapy. Given the variable and relapsing clinical course of CD, the physician and patient should ideally develop an ongoing relationship that allows for individualization of treatment regimens, monitoring of response and side effects, and modification of the therapeutic strategy in the absence of improvement.     

Medical treatment of chronic anal fissure. where do we stand on reversible chemical sphincterotomy?

Anal fissure is a common problem which can evolve to chronicity. Chronic anal fissure is thought to be an ischemic ulceration related to sphincter hypertonia. Lateral internal sphincterotomy, the most common treatment for chronic anal fissure, may cause permanent injury to anal sphincter leading to fecal incontinence. To avoid such side effect were developed medications producing a temporary or reversible sphincterotomy reducing the sphincter pressure only until the fissure has healed: nitrates, calcium channel antagonists and botulinum toxin. Authors aimed to summary the state of research on such treatments (efficacy, side effects, recurrence risk) and to clarify the role of these different medical options in the current treatment of chronic anal fissure.     

Medical aspects of fitness to drive. What do public hospital doctors know and think?

Background: In Australia medical practitioners are often required to assume the responsibility for assessing fitness to drive. However the clinical practice, knowledge and attitudes of doctors with regards to this responsibility are unknown. The aim of this study was to determine the clinical practice, knowledge and attitudes of public hospital doctors in the area of fitness‐to‐drive decision‐making. Methods: A survey of public hospital doctors in Adelaide, South Australia was undertaken in 2003, shortly after the promulgation nationwide of guidelines to assist in the assessment of patients’ fitness to drive. The survey sought details on medical practitioners’ clinical practice in this regard, as well as their knowledge of the guidelines. In addition, it sought their attitudes to undertake this responsibility. Results: Eighty‐four per cent of respondents had at some time in their working career at least discussed the issue of fitness to drive with their patients. Seventy per cent acknowledged that they had received the recently published guidelines on fitness to drive. Despite this, knowledge of the contents of the guidelines was poor. Attitudes to the responsibility were equivocal with several significant reservations expressed. Conclusion: Public hospital doctors in Australia have poor knowledge of the content of published guidelines in the area of fitness to drive. If this situation is to be improved, alternative approaches to the education of this group with respect to this significant public health problem should be considered. Many doctors are uncomfortable with their responsibilities in this area and alternative models of decision‐making should be considered.     

Financial Responsibility of Hospitalized Patients Who Left Against Medical Advice: Medical Urban Legend?

BACKGROUND

Physicians may counsel patients who leave against medical advice (AMA) that insurance will not pay for their care. However, it is unclear whether insurers deny payment for hospitalization in these cases.

OBJECTIVE

To review whether insurers denied payment for patients discharged AMA and assess physician beliefs and counseling practices when patients leave AMA.

DESIGN

Retrospective cohort of medical inpatients from 2001 to 2010; cross-sectional survey of physician beliefs and counseling practices for AMA patients in 2010.

PARTICIPANTS

Patients who left AMA from 2001 to 2010, internal medicine residents and attendings at a single academic institution, and a convenience sample of residents from 13 Illinois hospitals in June 2010.

MAIN MEASURES

Percent of AMA patients for which insurance denied payment, percent of physicians who agreed insurance denies payment for patients who leave AMA and who counsel patients leaving AMA they are financially responsible.

KEY RESULTS

Of 46,319 patients admitted from 2001 to 2010, 526 (1.1%) patients left AMA. Among insured patients, payment was refused in 4.1% of cases. Reasons for refusal were largely administrative (wrong name, etc.). No cases of payment refusal were because patient left AMA. Nevertheless, most residents (68.6%) and nearly half of attendings (43.9%) believed insurance denies payment when a patient leaves AMA. Attendings who believed that insurance denied payment were more likely to report informing AMA patients they may be held financially responsible (mean 4.2 vs. 1.7 on a Likert 1–5 scale, in which 5 is “always” inform, p < 0.001). This relationship was not observed among residents. The most common reason for counseling patients was “so they will reconsider staying in the hospital” (84.8% residents, 66.7% attendings, p = 0.008)

CONCLUSIONS

Contrary to popular belief, we found no evidence that insurance denied payment for patients leaving AMA. Residency programs and hospitals should ensure that patients are not misinformed.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-1984-x) contains supplementary material, which is available to authorized users.KEY WORDS: patient discharge, financial responsibility, hospital reimbursement     

Changes in Medical Students’ Attitudes Towards End-of-Life Decisions Across Different Years of Medical Training

BACKGROUND  Decisions to forgo life-sustaining medical treatments in terminally ill patients are challenging, but ones that all doctors must face. Few studies have evaluated the impact of medical training on medical students’ attitudes towards end-of-life decisions and none have compared them with an age-matched group of non-medical students. OBJECTIVE  To assess the effect of medical education on medical students’ attitudes towards end-of-life decisions in acutely ill patients. DESIGN  Cross-sectional study. PARTICIPANTS  Four hundred and two students at The Chinese University of Hong Kong. MEASUREMENTS  Completion of a questionnaire focused on end-of-life decisions. MAIN RESULTS  The number of students who felt that cardiopulmonary resuscitation must always be provided was higher in non-medical students (76/90 (84%)) and medical students with less training (67/84 (80%) in year 1 vs. 18/67 (27%) in year 5) (p < 0.001). Discontinuing life-support therapy was more accepted among senior medical students compared to junior medical and non-medical students (27/66 (41%) in year 5 vs. 18/83 (22%) in year 1 and 20/90 (22%) in non-medical students) (p = 0.003). An unexpectedly large proportion of non-medical students (57/89 (64%)) and year 1 medical students (42/84 (50%)) found it acceptable to administer fatal doses of drugs to patients with limited prognosis. Euthanasia was less accepted with more years of training (p < 0.001). When making decisions regarding limitation of life-support therapy, students chose to involve patients (98%), doctors (92%) and families (73%) but few chose to involve nurses (38%). CONCLUSIONS  Medical students’ attitudes towards end-of-life decisions changed during medical training and differed significantly from those of non-medical students.     

St.Jude Medical人造心脏瓣膜临床应用近况

St.Jude Medical人造心脏瓣膜(以下简称SJM瓣)是一种新型的两瓣叶结构的机械瓣.自1977年1月临床首次应用以来到1983年9月为止,全世界应用SJM瓣行瓣膜替换术共45,000余人次.它具有良好的血流动力学功能,低血栓栓塞率,经久耐用,极少引起溶血及心内膜炎等优点,在目前临床应用的50余种人造心脏瓣膜中崭露头角,成为最受欢迎的人造瓣膜之一.1984年3月11日至14日在美国召开了关于SJM瓣临     

Native-born Chinese Women’s Experiences in Medical Encounters in the U.S.

Native-born Chinese women’s experiences with medical help seeking in the U.S. is poorly understood, including how life phase affects it. Focus groups with middle-aged and older immigrant Chinese women explored: a) behaving assertively with doctors, b) strategies for assertiveness, c) characteristics of “ideal” doctors. Assertiveness was described as a reciprocal behavioral process between patient and doctor. Responsibility for initiating the process was seen as resting with doctors. Patient assertiveness goals included obtaining information and referrals. Strategies for achieving goals included not mentioning low-priority medical concerns in order to increase odds of obtaining referrals, and switching doctors when dissatisfied with communication. Older women reported refusing medical treatment due to language barriers. Cultural values, reported to be rooted in Confucianism, were identified by participants as shaping their help seeking. “Ideal” doctors were described as unhurried, and fully responsive to patient symptoms. Older women viewed “direct speaking” by doctors as always desirable around general information, and sometimes desirable around serious diagnoses. Older women perceived cultural differences with American-born Chinese providers. Findings are discussed in relation to continuity of care issues.

Medical students’ views on peer assessment of professionalism

Background: Although peer assessment holds promise for assessing professionalism, reluctance and refusal to participate have been noted among learners and practicing physicians. Understanding the perspectives of potential participants may therefore be important in designing and implementing effective peer assessment.
Objective: To identify factors that, according to students themselves, will encourage or discourage participation in peer assessment.
Design: A qualitative study using grounded theory to interpret views shared during 16 focus groups that were conducted by leaders using a semi-structured guide.
Participants: Sixty-one students in Years 1, 3, and 4 in 2 mid-western public medical schools.
Results: Three themes students say would promote or discourage peer assessment emerged: personal struggles with peer assessment, characteristics of the assessment system itself, and the environment in which the system operates. Students struggle with reporting an unprofessional peer lest they bring harm to the peer, themselves, or their clinic team or work group. Who receives the assessment and gives the peer feedback and whether it is formative or summative and anonymous, signed, or confidential are important system characteristics. Students' views of characteristics promoting peer assessment were not unanimous. Receptivity to peer reports and close positive relationships among students and between students and faculty mark an environment conducive to peer assessment, students say.
Conclusions: The study lays a foundation for creating acceptable peer assessment systems among students by soliciting their views. Merely introducing an assessment tool will not result in students' willingness to assess each other.     

Medical News

Dr. Cheng Xiaoci, in Collaboration with Five Experts from Shanghai, Lends Experimental Confirmation to the Fundamental Theory of Traditional Chinese Medicine. Jin Yueyuan, journalist of the newspaper Jiankangbao, has learnt from the International Symposium on Traditional Chinese Medicine and Pharmacology held recently in Nanjing while a considerable number of foreign scholars are still pondering over the fundamental theory of classical     

Data sharing: A new editorial initiative of the International Committee of Medical Journal Editors. Implications for the editors’ network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors’ Network of the European Society of Cardiology.