Annals of internal medicine
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Patients, families, and physicians frequently decide that a hospitalized patient will forgo cardiopulmonary resuscitation and document this decision with a do-not-resuscitate (DNR) order. In community settings (home, nursing home, hospice), these orders may conflict with paramedics' standing orders to provide cardiopulmonary resuscitation whenever it is medically indicated. We did a nationwide telephone survey of state offices for coordination of emergency medical services (EMS) to see how the states deal with this potential conflict. ⋯ State officials identified administrative complexities and legal concerns as the primary barriers to enacting prehospitalization DNR policies. We also identified 21 local EMS systems that have developed policies for accepting orders to withhold life-sustaining treatment. Four types of policy models, characterized according to procedure for validating DNR orders and telephone accessing the EMS system, show that regulatory reform can address policy barriers in the absence of enabling legislation.
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To determine the number and distribution of internists in subspecialty training and compare with data collected since 1976; to determine the distribution of activity of subspecialty fellows; and to focus on hematology and oncology. ⋯ The number of internists entering subspecialty training has risen at a considerably slower rate in the last 5 years compared with the 5 years before that. The length of subspecialty training has increased significantly since 1976. There has been a shift in subspecialty choice from hematology to oncology and toward joint programs offering both subspecialties.
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To determine the factors that attract students toward and push students away from a career in internal medicine. ⋯ Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents.