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OBJECTIVE: The norms governing surgical training warrant a deeper understanding of students' experiences and interpretations of professionalism issues in their learning environment. However, there is scant empirical evidence to describe this process. To fill this gap, we analyzed students' perceptions related to professionalism, moral distress, and communication in the surgical clerkship, particularly regarding their clinical supervisors, whom we refer to as mentors. DESIGN: We retrospectively evaluated written case vignettes and survey responses from medical students on their surgical clerkships regarding their experiences of cases which raised professionalism concerns. Vignettes and surveys were part of standard curricular exercises and analyzed using both qualitative and quantitative methods. SETTING: Our study was conducted at a private academic medical college in the northeast with an affiliated institute of bioethics. PARTICIPANTS: Two-hundred forty-one third year medical students on their surgical clerkships participated through required curricular submissions of case vignettes and surveys. RESULTS: Vignettes and surveys from all 241 students were collected and analyzed. Of these, 106 (43.9%) were identified by the students as relating to professionalism, whereas the research team identified 148 (61.4%) cases as such. Major subtypes of professionalism concerns were categorized as "not showing proper respect" (38.5%), bias (30.4%) and "failure to meet medical standards of care" (29.1%). In professionalism cases, only 27.7% of students would emulate their mentor, 19.7% shared concerns with the mentor, and 58.8% experienced moral distress, all significantly worse than in nonprofessionalism cases (p < 0.001). CONCLUSIONS: With an abundance of professionalism concerns noted, students experienced high rates of moral distress and were unlikely to share concerns with clinical mentors who they generally did not wish to emulate. Attention should be paid to providing a formal curricular venue in which students can discuss their concerns, as untoward experiences in the learning environment risk harming their learning and professional identity development.

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Medical educators agree that training in end-of-life care (EOLC) must be an integral part of medical education at all levels. While progress in this area of education has taken place, many gaps still exist. This article describes the self-reported impact of a required one-week hospice rotation for third-year medical students. Students completing their hospice rotation during a one-year period were asked to write an essay describing the most important lessons they learned. Qualitative analyses of the essays revealed 10 core themes and generated a coding schema for detailed analysis. Students' essays reflected knowledge gained, emotional reactions, cognitive insights, and relationship-centered skills. Comments focused on the following themes: benefits and philosophy of hospice; impact on future practice; interdisciplinary team approach; management of pain and suffering; facts about hospice; personal impact; communication with patients and families; dedication and skill of staff; role of families; and value of home care. Students consistently recognized the significance of positive role models. Learning about a new field of medicine helped broaden students' knowledge, skills, and beliefs, and expanded their assumptions about illness and suffering, the role of health care professionals, and the goals of medicine. Reflection and writing brought about self-awareness of the learning process itself. The study demonstrates that a robust clinical EOLC exposure can be effectively incorporated into undergraduate education and that student self-reports constitute a valuable mode of evaluation. Longitudinal assessments of trainees' competencies in EOLC are needed to optimize these educational endeavors.

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BACKGROUND: Families' experiences in the hospital influence their decisions about donating organs of brain-dead relatives. Meeting families' support needs during this traumatic time is an obligation and a challenge for critical care staff. OBJECTIVES: (1) To elicit family members' accounts of various types of support received and perceived quality of care for themselves and their loved ones when they made the donation decision, and (2) to examine the relationship between these factors and the families' donation decision. METHODS: Retrospective telephone interviews of 199 families from different regions of the country were completed. Aside from demographic data, the survey addressed perceptions of informational, emotional, and instrumental support and quality of care. RESULTS: One hundred fifty-four study participants consented to donation; 45 declined. White next of kin were significantly more likely than African Americans to consent. Specific elements of reported support were significantly associated with consent to donate. Donor and nondonor families had differing perceptions of quality care for themselves and their loved ones. Receiving understandable information about organ donation was the strongest predictor of consent. CONCLUSIONS: Specific supportive behaviors by staff as recounted by family members of potential donors were significantly associated with consent to donation. These behaviors lend themselves to creative training and educational programs for staff. Such interventions are essential not only for next of kin of brain-dead patients, but also for staff and ultimately for the public as a whole.

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IN CLINICAL TRIALS WITH EXCEPTION from informed consent, the Final Rule stipulates that investigators inform and consult with the community. A random-digit-dialing survey of 200 individuals assessed the effectiveness of public disclosure via press releases, notices in local newspapers, local radio and television stations and the host hospital's website, as well as a series of community meetings regarding a pending clinical trial of this kind. Results showed a 10% awareness level of the public trial, which is higher than surveys using convenience samples. Understanding of the nature of the trial was generally poor, while opinions about participating in this type of research were more favorable among individuals aware of the trial. Our findings suggest that adherence to the intent of the Final Rule is dependent on uniform guidelines for what constitute effective public disclosure methods and adequate community awareness and understanding and the use of rigorous sampling methods for evaluation.

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OBJECTIVES: To explore attitudes surrounding exception from informed consent enrollment into research studies. In addition, the authors sought to determine the level of awareness of such an ongoing study among potential subjects, as defined by their presence in an emergency department (ED). METHODS: A convenience sample of urban academic ED patients and visitors was surveyed during a visit regarding their attitudes and awareness of an emergency exception from informed consent, blood-substitute trial ongoing in the community. RESULTS: There was a 13% refusal rate, and 32% of those approached had characteristics that met exclusion criteria. There were 497 surveys analyzed. There was a predominance of women, Caucasians, and persons with at least some college education. Only 39 (8%) of respondents reported awareness of the ongoing blood substitute trial, and only 19 (4%) were able to list a risk or benefit of participation. Education, income, and age were not associated with reported awareness. Male gender, younger age, awareness of the existing exception from informed consent study, and being married were associated with greater acceptability for such enrollment practices. CONCLUSIONS: The overall awareness of an ongoing exception from informed consent trial after community consultation and notification was low. A population with potential for enrollment in such a study did not demonstrate a high degree of acceptance of such practices. There were differences among certain demographic groups in the degree of acceptance. These differences may guide institutional review boards and investigators in community-consultation strategies for future waiver of or exception from informed consent studies.

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Families must make decisions about organ donation for a loved one during intensely emotional circumstances in the hospital, where support from others is crucial to their coping. Research about families' experiences during the decision-making process regarding donating their loved ones' organs has shown that quality of hospital care and receiving psychosocial support are important factors influencing their decision. Typically, a donation coordinator from the local organ procurement organization approaches the family about the option of donation, whereas the role of medical and nursing staff is to convey diagnostic and prognostic information to the family. Currently, no requirement is in place for training of professional staff in communication skills for approaching and interacting with families about organ donation. This article discusses a simulated training method in empathic communication used for supporting families who are approached about organ donation. This innovative method can be adapted to and should be tested with professional audiences.

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Fewer than half of families approached about organ donation provide consent. Identifying specific support needs of family members in these situations is critical to help them cope and for improving consent rates. This focus group study retrospectively investigated donor and non-donor family members' perceived social support needs while facing the death of their loved one. Implications for nursing care and other interventions are discussed for interested healthcare providers.

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