Faculty Bibliography

PURPOSE: Although medical students are expected to adopt and practice the ideals stated in the Hippocratic Oath, little is known about whether these values are actually taught during clinical training. The purpose of this study was to examine the "recommended curriculum" of medical values and compare it with values that are actually taught. SUBJECTS AND METHODS: The recommended curriculum was identified through content analysis of curriculum documents and interviews with individuals responsible for teaching. The taught curriculum of values was identified through naturalistic observations and audio taping of inpatient internal medicine teams at an academic medical center. RESULTS: The values most consistently recommended in the medical curriculum are honesty, accountability, compassion, the importance of public health, and self-policing. While accountability and caring were found frequently in the taught curriculum, self-policing and the importance of public health were emphasized less. Interprofessional respect and the importance of service were present in the recommended curriculum, but were taught as interprofessional disrespect and as the burden of service. The importance of industry (working hard) was not found in the recommended curriculum, but frequently identified in the taught curriculum. CONCLUSION: This study indicates that one reason medical students are not learning the intended norms of the profession may be that the teachers are not consistently teaching the recommended values of the profession. Future research should concentrate on confirming these findings in other settings and on understanding why these values are not consistently taught.

BACKGROUND: Limited success of efforts to improve residents' critical appraisal skills may be due to poor understanding of their preintervention conceptual framework. DESCRIPTION: To describe internal medicine residents' a priori conceptual approach to critical appraisal of intervention trials, we performed an exploratory content analysis of 41 residents' unprompted descriptions of strengths and weaknesses of a randomized trial of spa therapy for back pain. EVALUATION: Eighty-eight percent of responses were assigned independently by 2 reviewers to 23 categories ( kappa .65). Residents agreed on some important characteristics (e.g., blinding), disagreed on others (e.g., similarity of treatment and control groups), frequently mentioned some irrelevant characteristics (e.g., "objective" vs. "subjective" outcomes), and rarely mentioned some important criteria (e.g., intention to treat). CONCLUSIONS: An open-ended questionnaire reliably revealed both expected and unexpected conceptions and misconceptions among residents who had received minimal or no formal instruction in critical appraisal. We propose a classification model for residents' critical appraisal concepts that can be tested in future studies and used to identify areas for focusing interventions to improve resident physicians' critical appraisal skills.

BACKGROUND: Measuring critical-appraisal skills is a key step in assessing physicians' abilities to engage in self-directed learning. The authors developed an instrument to evaluate the abilities of residents to critically appraise a journal article. METHOD: In 1991, 62 residents in the categorical internal medicine program at the New England Medical Center were asked to respond to a questionnaire, evaluate a sample article, and complete a self-assessment of competence in evaluation of research. Critical-appraisal skill was determined by calculating the resident's deviations from a "gold standard" critique developed through a modified Delphi technique, using a panel of five physicians. Spearman correlation coefficients were used to compare the residents' actual and self-perceived abilities. RESULTS: Twenty-eight residents returned the questionnaire, for a response rate of 45%. The composite score for the residents' objective assessments was 63% of the gold standard, and was not significantly correlated with post-graduate year, prior journal club experience, or self-assessed critical-appraisal skill. CONCLUSION: After further validation in other settings, the assessment instrument in this study may be used to objectively assess critical-reading skills. It may also provide feedback and measure outcomes for interventions designed to improve critical reading.

The effect of comprehensive prenatal care on birth weight was examined using a prospective randomized design. A total of 428 pregnant women were randomly assigned to comprehensive prenatal care (n = 217) or standard prenatal care (n = 211). Comprehensive care was provided by a multidisciplinary team of nurse-midwives, social workers, a nutritionist, paraprofessional home visitors, and a psychologist. Standard prenatal care consisted of medical care provided by obstetric residents. Multiple regression analysis using behavioral, demographic, and medical variables showed a strong relationship between the set of predictors and birth weight. Comprehensive care was related to higher birth weights for primiparous but not multiparous mothers. Separate analyses of variance for primiparas and multiparas similarly showed a favorable effect of comprehensive care on birth weight for primiparous but not multiparous mothers.

Although fractional calcium absorption is known to vary inversely with calcium intake, the extent and timing of individual hormonal and calcium absorption responses to altered calcium intake have not been defined. We measured fractional whole body retention of orally ingested 47Ca, an index of calcium absorption, in nine normal women after they had eaten a 2000-mg calcium diet for 8 weeks and a 300-mg calcium diet for 1, 2, 4, and 8 weeks. After the diet change, serum intact PTH (32.2% increase; P = 0.005), serum 1,25-dihydroxyvitamin D [1,25-(OH)2D; 43.8% increase; P = 0.003], and fractional whole body calcium retention (42.8% increase; P = 0.004) increased within 1 week. Although the PTH and calcium retention responses remained fairly constant throughout the low calcium intake period, serum 1,25-(OH)2D concentrations declined toward baseline after week 1. Thus, the late increase in calcium retention may have resulted from calcium absorption that was independent of 1,25-(OH)2D stimulation.