The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Health care Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.

OBJECTIVE: Culture may have an important impact on a patient's decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis‐generating study begins to characterize those attitudes in 3 American ethnic cultures. DESIGN: Structured, open‐ended interviews with blinded content analysis. SETTING: Two general medicine wards in San Antonio, Texas. PATIENTS: Purposive sampling of 26 Mexican‐American, 18 Euro‐American, and 14 African‐American inpatients. MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed “the patient deserves a say in treatment,” and “advance directives (ADs) improve the chances a patient's wishes will be followed.” But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed “the health system controls treatment,” trusted the system “to serve patients well,” believed ADs “help staff know or implement a patient's wishes,” and wanted “to die when treatment is futile.” Few Euro Americans believed “the system controls treatment,” but most trusted the system “to serve patients well,” had particular wishes about life support, other care, and acceptable outcomes, and believed ADs “help staff know or implement a patient's wishes.” Most African Americans believed “the health system controls treatment,” few trusted the system “to serve patients well,” and most believed they should “wait until very sick to express treatment wishes.” CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient's specific ethnic views.

Healthcare professionals often face clinical and ethical challenges when charged with making decisions related to provision or lack of provision of artificial nutrition and hydration. The intent of this review is to supply a framework of clinical practices, ethical principles, legal precedents, and professional guidelines that will impart information and can assist decision making regarding artificial nutrition and hydration. Comprehensive understanding of the theory and practice of informed consent for competent adults, decisionally incompetent adults, and minors is necessary for making valid clinical judgments and for guiding patients and their families or surrogates in choosing options related to initiating, withholding, or withdrawing artificial nutrition and hydration. The framework offered in this review can serve as a basis for evaluation of appropriateness of artificial nutrition and hydration in 3 common conditions in which decision making is particularly challenging: terminal illness, advanced dementia, and a persistent vegetative state. The framework facilitates guidance for institutional policy makers and individual nutrition support professionals dealing with situations in which personal values often create ethical dilemmas related to artificial nutrition and hydration and its utility.

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The literature is voluminous, but has focused primarily in a few areas. Common findings included an inverse relationship between religiosity and substance use/abuse, reduced use among those practising meditation and protective effects of 12-Step group involvement during recovery. Although sound instruments are available for measuring spirituality, studies have tended to use simplistic, often single-item measures.

Objective-Ethics training has become a core component of medical student and resident education. Curricula have been developed without the benefit of data regarding the views of physicians-intraining on the need for ethics instruction that focuses on practical issues and professional development topics.Methods-A written survey was sent to all medical students and PGY1-3 residents at the University of New Mexico School of Medicine. The survey consisted of eight demographic questions and 124 content questions in 10 domains. Responses to a set of 24 items related to ethically important dilemmas, which may occur in the training period and subsequent professional practice, are reported. Items were each rated on a 9-point scale addressing the level of educational attention needed compared to the amount currently provided.Results-Survey respondents included 200 medical students (65% response) and 136 residents (58% response). Trainees, regardless of level of training or clinical discipline, perceived a need for more academic attention directed at practical ethical and professional dilemmas present during training and the practice of medicine. Women expressed a desire for more education directed at both training-based and practice-based ethical dilemmas when compared to men. A simple progression of interest in ethics topics related to level of medical training was not found. Residents in diverse clinical specialties differed in, perceived ethics educational needs. Psychiatry residents reported a need for enhanced education directed toward training stage ethics problems.Address correspondence to Dr. Roberts, Professor and Chair, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226; RoberteL@mcw.edu (E-mail).. Editor-in-Chief of Academic Psychiatry.Manuscripts authored by an Editor of Academic Psychiatry or a member of its Editorial Board undergo the same editorial review process, including blinded, peer review, applied to all manuscripts. Additionally, the Editor is recused from any editorial decision making.The authors wish to acknowledge the recent passing of Dr. W. Sterling Edwards. Conclusions-This study documents the importance placed on ethics education directed at practical real-world dilemmas and ethically important professional developmental issues by physicians-in-training. Academic medicine may be better able to fulfill its responsibilities in teaching ethics and professionalism and in serving its trainees by paying greater attention to these topics in undergraduate and graduate medical curricula. NIH Public AccessHow does one become a good doctor? Mastery of knowledge and acquisition of technical skill are the principal emphases of formal medical training, but it is clear that these achievements, while necessary, are not sufficient (1,2). It is the ability to make and enact sound decisions with professionalism that defines the truly good doctor (3,4). Preparing physicians-in-training to become independent decision makers dedicate...

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To characterize predictors of impairment in research decision-making capacity, we undertook a direct comparison of schizophrenia/schizoaffective (n=52), medically ill (diabetic; n=51), and non-ill (n=57) subjects. Scores on the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) were correlated with demographic variables and scores on the Positive and Negative Syndrome Scale (PANSS), Mini-Mental State Examination (MMSE), and Short-Form-36 (SF-36). Across diagnoses, cognitive capacity, physical functioning, and a diagnosis of mental illness had the greatest impact on decision-making capacity, with level of education also having an impact. 69-89% of schizophrenia/schizoaffective subjects attained MacCAT-CR subscale scores achieved by almost all comparison (98-100%) and medically ill (94-100%) subjects. Positive, negative, and general psychotic symptoms correlated with poorer scores. Prior research experience, number of queries used during interview, and emotional functioning also predicted MacCAT-CR scores. These data suggest that investigators and IRBs should consider a number of variables, many of which reach across diagnoses, as they decide which populations and individual subjects may require more intensive screening for decisional impairment or educational interventions to improve their abilities to make capable decisions about research participation.