Direct Clinical Experience Research Articles

"Face-to-face with It": medical students' narratives about their end-of-life education.

Medical schools have been slow to include meaningful end-of-life (EOL) educational experiences in their curricula. As an area of inquiry and focused clinical experience, death is "conspicuous" by its absence, reflecting a medical culture that defines death as failure. The author asked fourth-year medical students at one institution to describe their experiences with dying patients and their families, the skills and attitudes they brought to these encounters, the support they received from attendings and residents while caring for dying patients, and suggestions for the medical curriculum that would help prepare them for care of the dying. Using a qualitative method, she analyzed ten students' written narratives, which dealt with experiences during their third-year clerkships, and compared these reflections with the literature on EOL care in medical education. The themes that emerged provided four organizers for this essay: (1) students' worry and uncertainty about EOL care, (2) guidance and role modeling in EOL care, (3) preparation for EOL care, and (4) conclusions and recommendations for the medical curriculum. In general, students did not feel well prepared or supported as they cared for their first dying patients, including, for example, delivering a terminal prognosis or obtaining a DNR. However, while they did wish for more support and role modeling from residents and attendings, they generally believed that care of the dying can be learned only through direct clinical experience. These beliefs call into question curricular issues of placement of EOL inquiry--most often in the preclinical curriculum--and the teaching of its content, currently overwhelmingly by lectures. The author concludes with recommendations for thoughtful, integrative, interdisciplinary curriculum changes in EOL education.

The Cakras in Transpersonal Psychotherapy

The Indian tradition of Tantra-Yoga and Kundalini-Yoga describes seven major cakras ("discs/wheels"): subtle energy centers in the body that govern different domains of human experience ranging from physical survival to spiritual illumination. After twenty years of direct personal and clinical experience with the cakras, I have come to believe that they offer a remarkable conceptual and perceptual map of the psychospiritual process and play a vital, though often unrecognized, role in psychotherapy. It appears to me that psychotherapy knowingly or unknowingly involves the cakras and that awareness of them facilitates the process of personal transformation,allowing clients to gradually open to their transpersonal depths. In this article I will demonstrate the relevance of the cakras to the practice oftranspersonal psychotherapy and offer some suggestions as to how therapists and clients can consciously work with them. Using the cakrasrequires an ability to focus on subtle body sensations and to understand their meaning, a capacity that many therapists and clients already have. Knowledge of and experience with the cakras help to bridge psychology and spirituality,enriching our understanding of transpersonal psychotherapy and helping to ground it in the body.

In defense of expert opinion.

Evidence-based medicine, centered on the incorporation of evidence from clinical trials and systematic reviews into the teaching and practice of clinical medicine, explicitly attempts to supplant expert opinion, which is viewed as an antiquated and unreliable form of medical authority. The epistemology of evidence-based medicine categorizes expert opinion as the lowest form of medical evidence, superseded even by methodologically flawed clinical research. When derived from direct clinical experience, however, expert opinion represents an alternative form of medical knowledge, one that may be complementary to empirical evidence. Input from clinical experts is vital to informing the context of clinical research and an appeal to alternate forms of medical knowledge, including expert opinion, is necessary to overcome the intrinsic gap between clinical research and the care of individual patients. Even when the quality and quantity of empirical medical evidence are ideal, expert opinion will remain an integral part of the multifaceted knowledge required for the optimal practice of clinical medicine.

Are antidepressants all the same? Surveying the opinions of Australian psychiatrists.

Controlled trials do not suggest differences in efficacy between antidepressant compounds. Psychiatrists, however, frequently express the view that real differences do exist and are relevant to clinical practice. Since multiple comparative trials are not feasible, an alternative method for expanding the evidence base is to survey regularly the opinions of practising psychiatrists. Two surveys of psychiatrists' opinions were conducted. Participants in the first survey were drawn from contact with 'SPHERE: A National Depression Project', while those in the second survey responded to a brief questionnaire distributed with Australasian Psychiatry. Reported volumes of scripts written, ratings of efficacy and tolerability, and preferences in specific clinical situations indicate that clinical psychiatrists now strongly prefer the newer antidepressant agents. They rate serotonin and noradrenalin re-uptake inhibitors (SNRIs) and selective serotonin re-uptake inhibitors (SSRIs) highest for antidepressant efficacy, serotonin receptor subtype 2 (5HT2) antagonists and some SSRIs highest for anti-anxiety efficacy, and some SSRIs and reversible inhibitors of monoamine oxidase inhibitor-A (RIMAs) lowest for side-effect burden. Further, SSRIs were their first preferences for most clinical situations. Serotonin and noradrenalin re-uptake inhibitors were the preferred choice for treatment-resistant depression and patients who had failed to respond to one SSRI. Serotonin receptor subtype 2 antagonists were the second choice to SSRIs for mixed anxiety and depression, and major depression with sleep disturbance. Reversible inhibitors of monoamine oxidase inhibitor-A were the second choice to SSRIs for adolescents with major depression, patients aged over 65 years, patients with serious medical illnesses and patients with chronic fatigue. Tricyclic antidepressants (TCAs) were the preferred choice for patients with chronic pain, and second choice to SSRIs for patients with major depression with panic disorder, postnatal disorders and patients with psychotic depression. Psychiatrists believe that important differences do exist between available antidepressant compounds. Such opinions are divergent from limited controlled data but may be influenced by a wide range of factors other than direct clinical experience. The role of such surveys in ongoing evaluation of clinical practice is emphasised.

THE PRESENT STATUS OF HEART TRANSPLANTATION IN THE USA AND JAPAN PARTICULARLY WITH REFERENCE TO CLINICAL EXPERIENCE

In December, 1967, Barnard transplanted a human heart, thereby ushering in a new era in cardiac surgery. Since then, heart transplantation has generally been the treatment of choice for patients who are severely ill with cardiac disease. However, Japan is the advanced country in which heart transplantation has never been performed.Beginning in January, 1996, the author had two months of direct clinical experience at The Transplantation Center of Pittsburgh University Hospital, a world famous center for organ transplantation. The author actively joined members of the cardiac transplantation team in early morning conferences, going the rounds of patients, participating in outpatient clinics, and so on. The author also assisted in surgical procedures on several occasions and garnered a wealth of information as a result of these experiences. The author reports his valuable experiences during this period and also discusses the present status of heart transplantation in Japan.

Clinical Experiences in Athletic Training

This book provides a systematic approach to athletic training education. It uses a modular approach to ensure that students master the basic skills required by the National Athletic Training Association (NATA) for athletic trainers. The modules are separated into 10 content areas: policies and procedures (2 modules); emergency procedures (3 modules); modality operation (8 modules); advanced modality operation (9 modules); application to athletic training programme (1 module); taping, wrapping, bracing, and padding (8 modules); management of specific injuries (15 modules); examination (1 module); supervision (3 modules); and direct clinical experience (11 modules).

Dealing with dying patients: Difficulties and strategies in final-year medical students

Abstract The study reports on a questionnaire study of final-year medical students' self-reported attitudes to dealing with dying patients. All respondents had some direct clinical experience with dying patients, and reported that such encounters were largely unproblematic. Alleviating patient anxiety and counseling relatives were seen as important aspects of the doctor's role, along with diagnosis, and management of symptoms. “High fear” respondents were more likely to report difficulty in discussing the prognosis with the dying and to experience minor psychological problems.

Homogeneous groups with acutely psychotic schizophrenics

Clinicians and researchers may be chagrined by the absence of good comparative outcome data which could help us all make better informed decisions about assigning schizophrenic inpatients to the most appropriate therapy groups, particularly as regards heterogeneous vs. homogeneous diagnostic groupings. Nonetheless, the preponderance of theoretical, clinical, and pragmatic evidence, as well as the limited empirical data, support homogeneous composition for acutely psychotic schizophrenic inpatients. The present assertions regarding the advantages of homogeneous therapy groupings of schizophrenics are based on direct clinical experience, observations, and data collection from a schizophrenic Dr. Kanas and I began more than four years ago on the Psychiatric Inpatient Unit at the San Francisco VA Medical Center. The patients comprising this have been primarily male, acutely psychotic patients carrying a DSM-III diagnosis of schizophrenia. They stayed an average of about five weeks on this unlocked unit and attended an average of nine sessions. The groups were open and occurred three times weekly the first two years, increasing to four times weekly in the past two years. Despite the current lack of empirical comparative outcomes, it was empirically derived findings that stimulated the interest in and design of this homogeneous schizophrenic at the outset. In a well-controlled outcome study of therapy effectiveness on an acute psychiatric inpatient unit, Kanas et al. (1980) found that while inpatients generally benefited from therapy on objective improvement measures, a significant proportion of schizophrenic patients deteriorated in functioning when compared to those schizophrenics assigned to a no group condition. Interpreting this to mean that heterogeneous, insight-oriented therapy is ineffective or actually countertherapeutic for acutely psychotic schizophrenics, Dr. Kanas and I constructed a model of homogeneous schizophrenic treatment designed specifically for the needs of the poorly functioning schizophrenic inpatient and attempted to examine its usefulness in a series of studies (Kanas & Barr, 1982, 1983, 1984, in press; Kanas et al., in press).

Development and modification of a required family medicine clerkship.

A new required clinical clerkship in family medicine at Duke University School of Medicine is described in terms of planning, implementation, and modification in response to students' evaluations. Seventy-five percent of the eight-week course involves direct clinical experience both in academic practices and community sites, and 25 percent is spent in small group seminars and workshops. Evaluations by students have been highest for the clinical experience, the clinical competence of the faculty, the teaching effectiveness of the faculty and house staff, and the overall learning experience. The ratings have been lowest for seminars, workshops, and required written projects. Several modifications made in the clerkship over a three-year period have raised the students' ratings to near their ratings of the five traditional clerkships. The data demonstrate that family medicine can be taught effectively as a core clinical rotation and can broaden the general education of medical students.

Medical Students’ Attitudes Toward Electroconvulsive Therapy

A seven-item multiple-choice questionnaire assessing attitudes toward electroconvulsive therapy was given to twenty-nine students of the Cornell University Medical College at the start and conclusion of their six-week clerkship in psychiatry. Attitudes toward ECT, which were generally favorable initially, shifted largely in a positive direction following direct clinical experience with patients undergoing ECT. Factors responsible for students’ attitudes at the beginning and conclusion of the clerkship are discussed, and the importance of students having an opportunity to observe and follow patients with ECT during the course of a psychiatric clerkship is emphasized.

Teaching Infant Development by Observation

A COURSE of child development centered around direct observation was first integrated into our career child psychiatry training curriculum in 1960. 1 Further experiences and elaborations are now presented. The purpose of the course is to give residents a continuing direct clinical experience of normal infant maturation and development in the framework of the mother-child interaction and to correlate these observations with current theoretical considerations. 2-9 Program and Initial Experiences The course consists primarily of direct observation of a mother prenatally, then of the mother-baby unit in the hospital during the lying-in period, and followed by home visits for the remainder of the year. Some families with young siblings were selected to observe reactions before the arrival of the new baby and also to study material of child development beyond the first year. At first, the residents are prepared by a two-month period of general

PULMONARY TUBERCULOSIS WITH SPECIAL REFERENCE TO DIET.

The purpose of this paper is to set forth some practical observations acquired by direct clinical experience upon the treatment of pulmonary tuberculosis with special reference to the effect exerted upon it by a due application of certain dietary regulations. THE NATURE OF PULMONARY TUBERCULOSIS. Pulmonary tuberculosis is a true inflammatory process set up by a specific morbific influence in the delicate lung tissue and terminating in true ulceration and suppuration of the lung substance. I will briefly recall the anatomy of the lung. The trachea divides into the right and left bronchi. These divide again into secondary and tertiary bronchi, and the subdivision continuing, the bronchial tubes grow more attenuated and more numerous as they subdivide. They also grow more delicate in structure, and when finally they reach a minute size, they are comprised only of a thin membrane lined with pavement epithelium resting upon an elastic fibrous layer.

REPORT OF THE COMMITTEE ON PRACTICAL MEDICINE AND EPEIDMICS, OF THE ILLINOIS STATE MEDICAL SOCIETY FOR 1882-3.

[From Advance Sheets of the Transactions of the Illinois State Medical Society.] The By-laws of this Society make it the duty of the Standing Committee on Practical Medicine to report annually concerning such improvements as may have been made during the year in the management of individual diseases, and on the prevalence and special character of epidemics in all parts of this State. Improvements in the management of any given disease may arise, either from a better knowledge of its causes, a more accurate understanding of its special pathology and tendencies, a more perfect comprehension of the action of remedies, and from direct clinical experience or observation at the bedside of the sick. By a full knowledge of the causes capable of producing a disease, the physician is often able to direct such remedies, or adopt such hygienic measures, as will neutralize or suspend their further operation, very much to