Another Look at the Medical “Generation Gap”—Second Triennial Survey of Attitudes of Medical Students and Recent Graduates

A 1969 survey of attitudes held by medical students and recent graduates was repeated in 1972, using the same samples of respondents and adding a new freshman group. Findings from both surveys showed that a “generation gap” existed on many issues.Furthermore, a comparison of the two studies suggested that two kinds of attitude change are occurring simultaneously. On some issues, the next generation of physicians will probably continue to differ from their predecessors. Perhaps the primary thread woven through this cluster of attitudes is that today''s medical students and young physicians perceive themselves as members of a larger structure for providing health care.However, many of the students'' attitudes held early in their medical careers appear to have been modified in the process of becoming physicians. It appears that medical education continues to convey many traditional professional values to students, and it seems likely that tomorrow''s physicians will retain a core of those values.     

Education and Eminence in British Medicine

The educational background of eminent members of the British medical profession was examined by recourse to Who''s Who. Substantial differences in background were found among the various medical specialties. Members of specialties enjoying high prestige within the profession—physicians, surgeons—were more likely than other members of the sample to have been to an English school as opposed to one in Scotland, Wales, or Northern Ireland, and to a headmasters'' conference school as opposed to a grammar school. Educational background was also found to relate to the aspect of the patient''s body on which specialists normally worked. Specialists coming from English headmasters'' conference schools were more likely than others to work on living bodies rather than dead bodies or parts of bodies, on the head rather than on the lower trunk, on male bodies rather than female bodies, and on the body''s surface rather than its inside.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Culture and Disability Behavior

A substantial amount of literature suggests that illness behavior in the United States is a product of a patient''s core culture; equally credible findings do not support this contention. Most students and graduates in the health care professions believe that illness and disability behavior are affected by a patient''s culture, but they are hard put to find convincing examples of that relationship. In experience with medical students studying the social and cultural bases of illness behavior, with patients who are disabled and with persons who claim disability in the absence of physical disease or disabling psychopathology, I observed no deviant disability behavior that was typical for the members of any cultural group, and no behavior was displayed by the members of one cultural group that was not seen in members of other cultural groups. No cultural stereotypes were upheld. I did find evidence that disability behavior is influenced by personality factors, social situations and the gains derived from the disability status. Evolving concepts of “entitlement,” which are closely related to socioeconomic status, also have a significant influence. The impact of feedback from others in a person''s many social and medical subcultures is a more crucial determinant of illness and disability behavior, except in those for whom illness and disability behavior is determined by the limitations imposed by the disease or by a personality structure resistant to cultural expectations and social feedback.     

Withholding or Withdrawing Extraordinary Life Support—Optimizing Rights and Limiting Liability

For many years physicians, ethicists and members of the legal community have attempted to minimize ambiguity and unpredictability in making decisions to withhold or withdraw extraordinary life support. Recent developments in national and California law now afford medical care providers unparalleled protection from criminal and civil liability in surrogate decision-making situations. They also reinforce the concept of patient''s rights by providing medical care consumers with new and effective mechanisms for enforcing their “right to decide,” even after they have lost decision-making capacity. A case in point is California''s new Durable Power of Attorney for Health Care, which serves as a model for other jurisdictions that do not have such legislation. Thus, the medical and legal professions, working together, can contribute immeasurably to respectful medical decision making by educating the public about these developments and by adopting policies that reinforce these rights.     

Writing In and Reading ICU Diaries: Qualitative Study of Families' Experience in the ICU

Purpose

Keeping an ICU patient diary has been reported to benefit the patient''s recovery. Here, we investigated the families'' experience with reading and writing in patient ICU diaries kept by both the family and the staff.

Methods

We conducted a qualitative study involving 32 semi-structured in-depth interviews of relatives of 26 patients (34% of all family members who visited patients) who met our ICU-diary criterion, i.e., ventilation for longer than 48 hours. Grounded theory was used to conceptualise the interview data via a three-step coding process (open coding, axial coding, and selective coding).

Results

Communicative, emotional, and humanising experiences emerged from our data. First, family members used the diaries to access, understand, and assimilate the medical information written in the diaries by staff members, and then to share this information with other family members. Second, the diaries enabled family members to maintain a connection with the patient by documenting their presence and expressing their love and affection. Additionally, families confided in the diaries to maintain hope. Finally, family members felt the diaries humanized the medical staff and patient.

Conclusions

Our findings indicate positive effects of diaries on family members. The diaries served as a powerful tool to deliver holistic patient- and family-centered care despite the potentially dehumanising ICU environment. The diaries made the family members aware of their valuable role in caring for the patient and enhanced their access to and comprehension of medical information. Diaries may play a major role in improving the well-being of ICU-patient families.     

The Role of the University in Modern Society

President Odegaard here presents some stimulating thoughts for medical educators and for other members of the medical profession. Although a historian by profession, he has considerable familiarity with medical matters from his membership in the Citizens Commission on Graduate Medical Education (Millis Commission), the President''s National Advisory Commission on Health Manpower and the Natonal Advisory Health Council.     

Conclusions--scientific research and its implications.

The organizers of this meeting felt that it would be appropriate to have two short papers at the end of this volume to summarize the key points that are of relevance to scientists and the insurance and actuarial professions. This was felt to be of particular importance given the very heterogeneous backgrounds of members of the audience at the meeting, namely, scientific, medical, legal, social and financial. The objectives are to summarize the key issues in layman''s terms-trying to avoid jargon, exaggeration and a partisan approach. In some ways my task is somewhat easier than Chris Daykin''s job, since there are only four scientific and medical presentations compared with seven from the actuarial, social and legal side. I will organize this brief report, which by definition will involve repetition of some of the points made in the scientific and medical papers in this volume, into three areas: (1) introductory comments on demography and evolution relevant to human genetics; (2) the scientific opportunities; and (3) a brief comment on their implications for the health and care of individuals.     

Teacher training for medical faculty and residents.

Since 1984 the University of British Columbia''s School of Medicine has offered teaching improvement project systems (TIPS) workshops on effective teaching techniques; two workshops a year are given for medical faculty members and two a year for residents. The faculty members who conduct the workshops have received training on how to present them. The most powerful learning experience offered by TIPS is the opportunity for participants to present 10-minute teaching segments that are videotaped and later viewed privately by the participants. Eight workshops have been attended by 166 faculty members, and two others have been attended by 42 residents. This project demonstrates faculty development for both the participants and the people who teach the workshops.     

When families cannot "let go": ethical decision-making at the bedside.

Shared decision-making at the bedside is now a regular feature of medical practice. When disagreements arise between a patient and family members caregivers sometimes find themselves caught in a complex tangle of human relationships that strains monochrome ethical thinking. The patient''s expressed wishes are often compromised for the sake of the family''s needs. Conversely, a unilateral appeal for patient autonomy may prove insensitive to the hurt and the needs of the family. We describe a relatively unsuccessful attempt by a patient''s caregivers to buy time to maximize the interests of the patient and her family and discuss the way in which the family dynamics militated against the rather obvious solution of promoting the patient''s right to refuse treatment. The purpose of this article is not to evoke sympathy for health care professionals in dealing with such conflicts but rather to heighten awareness of the issues at stake and to stimulate thinking about ways and means to bring about a more favourable outcome than the one described here.     

Observations on a Medical Teacher Training Program

An increasing interest in educational science as applied to medical education is apparent in the past decade. Recently, a six-week teacher training program was held at the Center for the Study of Medical Education at the University of Illinois. Fifteen medical faculty members, including five Canadians, participated. During this period there was an opportunity to engage in discussions and independent study of several aspects of medical education, using the personnel from the Center''s four major divisions as resource people. Training in educational science is important for all teachers, and a centre to provide this type of instruction should be available in Canada.     

Ethics of a predictive test for Huntington's chorea.

"Index Medicus" and 18 other publications have been consulted in an attempt to provide an easily assimilated selection of the recently published and widely dispersed material relevant to the ethical debate the editors of the "BMJ" called for on 4 March 1978. The medical profession is shown to be deeply divided on the ethics of a predictive test for Huntington''s chorea. Some members are already using the prospect of a reliable test as an inducement to potential transmitters of this incurable hereditary disease to postpone procreation. Other members would prefer to see any future test withheld from every applicant until such time as radically improved means of treatment or a cure is discovered. The evolution of generally acceptable professional guidelines requires further informed debate.     

Marfan's Syndrome: The S. Family Re-visited

Marfan''s syndrome has been transmitted by a single pleiotropic autosomal gene through six generations of a Canadian family. At least 42 members of this family have been affected to date. The natural history of this inherited affliction in this family supports the hypothesis that Marfan''s syndrome is an abiotropic disorder of the connective tissues. Premature degeneration of the connective tissues is responsible for the serious ocular and cardiovascular complications of Marfan''s syndrome, for the shortened life span of affected individuals, and indirectly, for the economic distress of affected members of this family. Because no definitive treatment is available for Marfan''s syndrome, an educational approach to the restriction of child-bearing by affected individuals is proposed.     

The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

INDUSTRY CALLING!—Is There a Doctor in the House?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite—between management, labor and medicine—if we are to continue to strive for medicine''s traditional ideals: The best of medical care for all alike.This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.     

Withholding cardiopulmonary resuscitation: proposals for formal guidelines.

Working with members of the Royal London Trust and its medical council, Len Doyal and Daniel Wilsher have composed a set of guidelines governing the making of decisions to withhold resuscitation from patients. The guidelines describe the procedures that should be followed when giving orders for non-resuscitation and the clinical, legal, and moral criteria that should be satisfied before such orders are issued. The authors hope that these guidelines will be of help to those responsible for the creation of hospitals'' policies for non-resuscitation.     

Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems.

This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 114 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted disease. The most frequent difficulties were with the patient''s noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician''s own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physician''s perceptions of their difficulties can be useful in the planning of initial training and continuing medical education.     

Fighting the odds in the UK.

Caroline Richmond reports on miscellaneous winners and losers from the health care scene in the United Kingdom. The winners include a young patient who is holding her own against formidable medical odds after receiving heroic treatment for leukemia, and the country''s osteopaths, who have won the right to compile a statutory register. The losers are the venerable St. Bartholomew''s Hospital, which appears to have lost its battle to stay open, and a 32-year-old man who almost made it to medical school by posing as a teenager.     

Releasing the spindle assembly checkpoint without tension

Proteins of the Bcl-2 family are critical regulators of apoptosis, but how its BH3-only members activate the essential effectors Bax and Bak remains controversial. The indirect activation model suggests that they simply must neutralize all of the prosurvival Bcl-2 family members, whereas the direct activation model proposes that Bim and Bid must activate Bax and Bak directly. As numerous in vitro studies have not resolved this issue, we have investigated Bim''s activity in vivo by a genetic approach. Because the BH3 domain determines binding specificity for Bcl-2 relatives, we generated mice having the Bim BH3 domain replaced by that of Bad, Noxa, or Puma. The mutants bound the expected subsets of prosurvival relatives but lost interaction with Bax. Analysis of the mice showed that Bim''s proapoptotic activity is not solely caused by its ability to engage its prosurvival relatives or solely to its binding to Bax. Thus, initiation of apoptosis in vivo appears to require features of both models.