Hypothetical Clinical Case Research Articles

Intern Prescribing for Common Clinical Conditions.

To examine the ability of interns to prescribe appropriately for common clinical conditions at the commencement and completion of the intern year. Interns' perceptions of their ability to prescribe and the perceived influences on their practices were also assessed. The study was conducted at a teaching hospital in urban New South Wales, Australia. A self-complete questionnaire was administered to 56 interns at the beginning and end of internship. At the beginning of the year respondents were asked to identify how equipped they felt they were to perform specific functions related to prescribing practice. Interns were also asked to write hospital prescriptions for four common clinical cases scenarios: post-operative pain, urinary tract infection, asthma, and community-acquired pneumonia. At the end of the year interns were asked to prescribe for the same clinical scenarios and also asked to identify the main influences on their practice. At the beginning of the year 54% of interns felt equipped to choose an appropriate drug for common clinical conditions, however, few felt they were able to determine the appropriate dose (23% of respondents) or dose frequency (25%). A previously validated four-point rating scale was used by two assessors to judge appropriateness of prescribing [Kappa = 0.6]. At the beginning of the year at least two-thirds of interns were prescribing 'inappropriately' for all clinical conditions. By the end of the year 75% were prescribing 'appropriately' for all conditions. The main perceived influences on prescribing practices were registrars, consultants, books and pharmacists.The use of hypothetical clinical cases to explore prescribing ability has shown that doctors are ill-equipped to perform various aspects of prescribing on graduating from medical school. Although our findings may not translate into practice directly they highlight the existence of a potential problem that warrants further study, especially in the areas of actual practice and the influences on it in the early postgraduate years.

Using Problem-Based Learning to Teach Forensic Psychiatry

Problem-based learning (PBL) is a method of teaching that uses hypothetical clinical cases, individual investigation, and group process. This pilot project used a PBL approach to teach forensic psychiatry to psychiatric residents. The change in the residents’ level of comfort with five major domains of forensic psychiatry were evaluated at pre- and posttraining stages. The residents’ level of comfort with the educational issues of testimony, liability, and competence, as well as subjective ratings of their forensic knowledge base, improved significantly. Postcourse satisfaction with the PBL method was moderately high.

Clinical Evaluation of Failure to Thrive in Older People

The purpose of this article is to outline a clinical approach to patients with failure to thrive in old age. The article starts with a hypothetical clinical case presentation epitomizing the problem seen in an outpatient clinic by geriatricians. This case is then used as a basis to discuss salient features of failure to thrive which may be different from patient to patient. The focus is on using standard outpatient evaluation methods to identify common problems causing failure to thrive.

MOTHERS AND FATHERS: DIFFERING APPROACHES TO MEDICAL ETHICAL DECISION MAKING? • 154

When parents are thrust into new and uncharted territory with the birth of a critically ill or malformed infant, unanticipated medical ethical decisions are often required. We sought to study whether mothers and fathers approach medical ethical decision making differently. Methods Attitudes of parents who have had a neonate in the NICU were assessed using a 3 part questionnaire: 1-sociodemographic assessment; 2-rating of importance of theoretical principles in determining medical ethical decisions; and 3-choice of treatment options for hypothetical clinical cases. Results 80 mothers and 40 fathers were studied anonymously. Significant differences were observed in responses to the importance of theoretical principles.% of mothers vs. fathers rating a given value as extremely important in decision making are presented: Table Conversely, there were no differences in the treatment choices of mothers vs. fathers to any of the hypothetical cases. Percentages of each desiring most aggressive treatment in Down's Syndrome (90% vs 80%); extreme prematurity (90% vs 90%); asphyxia (90% vs 82%); congenital heart disease (93% vs 89%); and trisomy 18 (60% vs 76%); were all similar (p>0.05). Speculation Despite differences in theoretical approach, practical therapeutic strategies of both parents were similar. This may reflect gender differences in the decision making process.

A survey of methods to calculate monitor settings

Purpose : The results of a survey of how radiation oncology institutions calculate the monitor setting (or time) to deliver the prescribed dose in a photon-beam treatment are presented. Methods and Materials : The participants in the mail survey were 94 institutions in the Pediatric Oncology Group. They were asked to calculate for a hypothetical clinical case requiring the use of photon beams with corner blocks. A questionnaire was also distributed to gather supplemental information. Results : Of the 94 institutions whose responses were analyzed, 77% selected an isocentric setup while the others used a “fixed-SSD” approach. The proportions were reversed for the choice of the reference geometry and the majority of the participants set one monitor unit equal to 1 cGy at depth of electron equilibrium with isocenter placed at the surface. The tissue-maximum ratio was the most popular quantity for description of beam characteristics, but several other choices were common. Different names were sometimes used for the same concept. Conclusion : The variation among institutions made the review time-consuming, but no serious systematic errors were detected. Some standardization of nomenclature and techniques may be desirable.

Red cell, plasma and albumin transfusion decision triggers.

Hypothetical clinical cases were used to investigate transfusion-related decision-making. Three red cell, three fresh frozen plasma (FFP) and three albumin transfusion decision cases were administered by questionnaire to 228 medical staff. The transfusion decision triggers were identified and comparisons made between resident and specialist groups and between Melbourne and Sydney participants. Factors important in red cell transfusion decisions included haemoglobin, symptoms of anaemia, presence of co-morbidities or surgery, gender, period of hospitalisation and the degree of documented blood loss. FFP administration was influenced by an abnormal coagulation test, the presence of co-morbidities and by the number of red cell units transfused. The administration of albumin, concentrated or 5% SPPS, was influenced by the period of hospitalisation and clinical circumstances such as a falling urine output postoperatively, and by the presence of hypotensive complications. Different transfusion responses were noted: resident staff transfused red cells and FFP earlier than specialists; Sydney specialists were more conservative of red cell transfusion; Melbourne specialists more conservative of FFP administration and surgeons were four times more likely to transfuse patients than physicians or anesthetists at certain haemoglobin values.

The Acceptability of Behavioral Treatments for Marital Problems

Married female undergraduates were asked to provide ratings of the acceptability of two treatment components commonly used within the framework of behavioral marital therapy. The study compared subjects' evaluations of detailed taped descriptions of behavioral exchange/contracting procedures and communication/problem-solving skills training as they were applied to two hypothetical clinical marital cases. The study also evaluated the extent to which the severity of the marital problems influenced treatment acceptability evaluation. Communication/problem-solving skills training was judged as more acceptable than behavioral exchange/contracting procedures and received a higher score on the Evaluative and Potency dimensions of the Semantic Differential. Judgments of treatment Potency were also found to be influenced by idiosyncratic features of the cases described in association with problem severity. Implications and directions for future research are briefly discussed.