Changing premedical requirements.
Explore the source record for details and available documents.
Curriculum↗
Biomedical subjects
Virginia U Collier
Publications and source records attributed to Virginia U Collier.
Redesigning training for internal medicine.
The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. Suggested priorities for undergraduate medical education include redesigning curricular experiences to afford students earlier and more exposure to career opportunities in internal medicine, improving ambulatory education, exposing students to outstanding faculty role models in internal medicine, and incorporating educational experiences during the fourth year that optimize its value and relevance to the student's future career plans in internal medicine. Internal medicine residency training should remain a 3-year experience, with a component of core education common to all trainees and a component of customized training in the third year targeted toward the resident's career goals. Residency programs should be designed around educational rather than institutional service needs. The ambulatory component of training requires substantial reform in its structure, sites, content, and timing. Team-based models should be used both for patient care and for flexibility in design of residency training. Better faculty models must be developed that build on the concept of a "core faculty," improve the rewards for teaching faculty, and provide appropriate faculty development focusing on a necessary set of educator competencies.
Ambulatory Care↗
Physicians' decisions to withhold and withdraw life-sustaining treatment.
BACKGROUND: Few data are available about physicians' decisions in regard to withholding or withdrawing life-sustaining measures. We therefore studied internists' views on this subject. METHODS: We surveyed 1000 generalist and subspecialist internists about their views on withholding or withdrawing life-sustaining treatment. Thirty-two hypothetical cases were included. The effect of the demographic data on withholding or withdrawing treatment was analyzed via analysis of covariance and multiple logistic regression. RESULTS: Of 1000 internists, 407 (41%) completed and returned surveys. A majority of respondents (51%) were willing to withhold or withdraw treatment in all 32 scenarios; 49% were unwilling to withhold or withdraw in at least 1 scenario. Respondents were likely to withhold treatment in 14 of 16 scenarios compared with 13.7 of 16 scenarios for withdrawing treatments (P<.001). Respondents withheld or withdrew feeding tubes in 6.6 of 8 scenarios (P<.001) and antibiotics in 6.7 of 8 scenarios (P = .001) compared with ventilators (7.1 of 8 scenarios) and dialysis (7.3 of 8 scenarios). Respondents were less likely to withhold or withdraw treatments in nonterminally ill (12.9 of 16 scenarios) (P = .02) and alert patients (13.2 of 16 scenarios) (P<.001) compared with terminally ill patients (14.9 of 16 scenarios) and patients with dementia (14.5 of 16 scenarios). CONCLUSIONS: A large percentage of internists would be unwilling to adhere to some of patients' wishes to withhold or withdraw life-sustaining treatment. The clinical scenario and type of treatment affect internists' decisions about whether they would withhold or withdraw such treatment.
Advance Directives↗
BRIEF REPORT: health care provided by program directors to their resident physicians and families.
BACKGROUND: Who provides health care to resident physicians is not well studied. OBJECTIVE: To determine whether residency program directors (PDs)provide health care to their own residents and residents' families. DESIGN: An anonymous survey mailed to 1,345 PDs in Emergency Medicine, Family Medicine, Internal Medicine, Medicine-Pediatrics,and Obstetrics-Gynecology in the United States in 2003. RESULTS: Six hundred nineteen PDs (46%) responded. Half had taken care of their own residents for acute conditions. Less commonly, directors had written prescriptions for acute (40%) or chronic needs (15%}or provided ongoing care (22%). Only 3% believed this conflicted with their ability to be effective directors. Responders more likely to provide future care to residents considered this kind of care generally appropriate(P< .001), or appropriate under certain circumstances {P< .001).Most of these spent > 31% of their time seeing patients. There was no difference among types of programs, gender of the director, or the years as director. Twenty-five percent of directors provided care to their residents' families. CONCLUSIONS: Substantial numbers of directors provided healthcare to their own residents. Few believed this conflicted with their director role. We believe organizations of PDs should develop positions about this practice.
Family Practice↗
Primary care practitioners' understanding of physiatric practice: effects on intention to refer.
OBJECTIVES: To learn what family practice and internal medicine physicians understand about the scope of practice of physical medicine and rehabilitation (PM&R) and to study what effect that understanding and various demographic variables have on their intention to refer to physiatrists. DESIGN: Survey-based. SETTING: National survey. PARTICIPANTS: One thousand internal medicine and family practice physicians were contacted, with 460 respondents. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Intention to refer patients to physiatrists using 13 case scenarios (10 appropriate referrals, 4 inappropriate referrals) and self-reported number of referrals per year associated with understanding of 7 skills of physiatrists analyzed by multiple logistic regression analyses. RESULTS: Although most respondents were likely to refer to physiatrists, a wide variation existed in the types of patients referred. Physicians with a greater understanding of the scope of physiatric practice were more likely to refer ( P =.003). Female physicians were more likely to refer than male physicians ( P =.003). CONCLUSIONS: There appears to be an association between an understanding of physiatric practice and primary care practitioners' willingness to refer to PM&R. Primary care physicians should be educated about the benefits of referring patients to physiatrists.
Analysis of Variance↗
Physicians' willingness to report impaired colleagues.
We surveyed physicians to determine what factors were associated with their reporting of impaired colleagues to Physician Health Programs (PHPs). We conducted a cross-sectional mail survey of 1000 randomly selected practicing physicians in the United States. A survey instrument asked the physicians whether they would report 10 hypothetical impaired colleagues to a PHP. The results show that a majority of the physicians would report physicians to PHPs, but were more likely to report hypothetical physicians involved in substance abuse than those who were emotionally or cognitively impaired (p<0.001). Respondents who felt they had a societal obligation as opposed to an obligation to protect the rights of the individual (p=0.006) were more likely to report hypothetical physicians. Those respondents who stated they knew of guidelines on reporting impaired physicians had more frequently reported impaired colleagues (p<0.001). We conclude that physicians should be educated on the availability and functioning of PHPs and the ethical and legal obligations of assisting impaired colleagues.
Confidentiality↗
Frequency and perceived competence in providing palliative care to terminally ill patients: a survey of primary care physicians.
We surveyed primary care physicians about their involvement and perceived skills in palliative care. A survey instrument asked how frequently internal medicine and family practice physicians performed 10 palliative care items. Subjects rated their skills in each area. A majority of physicians always or frequently performed all 10 palliative care items, but fewer than 50% of respondents adequately attended to the spiritual needs and economic problems of patients. Interest in palliative care was associated with an increased frequency in performing palliative care items (P = 0.036), while training in palliative care was associated with better perceived performance (P = 0.05). Only 36% of respondents had received training in palliative care. Internists and family practitioners provide palliative care to patients, but feel their skills are lacking in certain areas. Training may improve care to patients at the end of life.
Data Collection↗
Residents' prescription writing for nonpatients.
CONTEXT: Writing prescriptions is one of the most tangible new responsibilities that residents acquire after graduating from medical school. During their regular duties, house officers' prescription writing is carefully monitored. Little is known, however, about residents' patterns of prescription writing outside of supervision or about residents' knowledge of the ethical and legal guidelines that regulate prescription writing. OBJECTIVE: To study what factors influence residents' decision to write prescriptions for nonpatients. DESIGN, SETTING, AND PARTICIPANTS: Survey distributed in December 1997 to 92 internal medicine and family practice residents at a US community-based teaching hospital. Eighty percent responded. MAIN OUTCOME MEASURES: Self-reported prescribing activities for nonpatients and for individuals in 12 hypothetical vignettes. RESULTS: Eighty-five percent of respondents reported having written prescriptions for nonpatients. Based on their responses to the vignettes, under certain circumstances, up to 95% of residents would write a prescription for an individual who is not their patient (eg, a sibling). Thirteen percent of residents believed that some ethical guidelines on prescription-writing activity existed. Only 4% of residents reported being aware of federal or state laws addressing the appropriateness of physician prescription writing for nonpatients. None of the residents were able to describe the circumstances that make prescription writing for nonpatients illegal or unethical based on legal statutes or ethical guidelines, respectively. CONCLUSIONS: In a sample of community-based internal medicine and family practice residents, unsupervised prescription writing by residents for individuals who are not their patients is a common occurrence. Since residency training is a time when practice habits are established, it is important that all residents learn about the ethical, legal, and liability implications of writing prescriptions for nonpatients.
Data Collection↗
Stress in medical residency: status quo after a decade of reform?
BACKGROUND: Although curricular reforms have attempted to address sources of stress in medical residency, no recent studies have examined the financial or emotional situations of current medicine residents. OBJECTIVE: To question medicine residents about financial status, educational debt, moonlighting, and psychological issues. DESIGN: Survey distributed in a nonrandomized fashion to medicine residents. SETTING: All 415 U.S. medicine residency programs. RESULTS: According to the questionnaire responses submitted by the 4128 (18%) participating residents, a substantial number of residents had financial and emotional distress that could have interfered with training. The reported educational debt was at least $50 000 for 1657 (42%) of the respondents and at least $100 000 for 737 (19%). The monthly disposable income was $100 or less for 1620 (43%) of the residents, and 637 residents (16%) could not afford safe housing. Among respondents in their 2nd through 5th year of postgraduate training, 2187 (52%) had insufficient funds to purchase books and equipment, and 678 (29%) could not afford the required fees for the American Board of Internal Medicine certifying examination; 2659 (33%) worked as moonlighters, and this percentage increased progressively with increasing educational debt. Four or five depressive symptoms during residency were reported by 1461 (35%) residents. Eight hundred ninety-nine residents (23%) thought they had become less humanistic over the course of their residency training; 2347 (61%) reported becoming more cynical. Female residents were more likely than male residents to report increased cynicism and multiple depressive symptoms. Increased cynicism and depressive symptoms were associated with increasing educational debt. CONCLUSIONS: Despite recent curricular reforms, an alarming number of current medicine residents report depressive symptoms, increasing cynicism, and decreasing humanism, which were associated with increasing educational debt and a need to moonlight for financial survival. Ongoing curricular reform, legislative relief from early loan repayment, and salary increases may be necessary to address these problems.
Employment↗
The good news about giving bad news to patients.
BACKGROUND: There are few data available on how physicians inform patients about bad news. We surveyed internists about how they convey this information. METHODS: We surveyed internists about their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression analysis. RESULTS: More than half of the internists reported that they always or frequently performed 10 of the 11 emotionally supportive items and 6 of the 9 environmentally supportive items while giving bad news to patients. The average time reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the number of emotionally supportive items reported (P <.05), only 25% of respondents had any previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities. CONCLUSIONS: Internists report that they inform patients of bad news appropriately. Some deficiencies exist, specifically in discussing prognosis and referral of patients to support groups. Physician educational efforts should include discussion of prognosis with patients as well as the availability of support groups.
Attitude of Health Personnel↗