Lack of chart reminder effectiveness on family medicine resident JNC-VI and NCEP III guideline knowledge and attitudes

BACKGROUND: The literature demonstrates that medical residents and practicing physicians have an attitudinal-behavioral discordance concerning their positive attitudes towards clinical practice guidelines (CPG), and the implementation of these guidelines into clinical practice patterns. METHODS: A pilot study was performed to determine if change in a previously identified CPG compliance factor (accessibility) would produce a significant increase in family medicine resident knowledge and attitude toward the guidelines. The primary study intervention involved placing a summary of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP III) CPGs in all patient (>18 yr.) charts for a period of three months. The JNC VI and NCEP III CPGs were also distributed to each Wayne State family medicine resident, and a copy of each CPG was placed in the preceptor's area of the involved clinics. Identical pre- and post- intervention questionnaires were administered to all residents concerning CPG knowledge and attitude. RESULTS: Post-intervention analysis failed to demonstrate a significant difference in CPG knowledge. A stastically significant post-intervention difference was found in only on attitude question. The barriers to CPG compliance were identified as 1) lack of CPG instruction; 2) lack of critical appraisal ability; 3) insufficient time; 4) lack of CPG accessibility; and 5) lack of faculty modeling. CONCLUSION: This study demonstrated no significant post intervention changes in CPG knowledge, and only one question that reflected attitude change. Wider resident access to dedicated clinic time, increased faculty modeling, and the implementation of an electronic record/reminder system that uses a team-based approach are compliance factors that should be considered for further investigation. The interpretation of CPG non-compliance will benefit from a causal matrix focused on physician knowledge, attitudes, and behavior. Recent findings in resident knowledge-behavior discordance may direct the future investigation of physician CPG non-compliance away from generalized barrier research, and toward the development of information that maximizes the sense of individual practitioner urgency and certainty

Normative Explanation and Justification

Normative explanations of why things are wrong, good, or unfair are ubiquitous in ordinary practice and normative theory. This paper argues that normative explanation is subject to a justification condition: a correct complete explanation of why a normative fact holds must identify features that would go at least some way towards justifying certain actions or attitudes. I first explain and motivate the condition I propose. I then support it by arguing that it fits well with various theories of normative reasons, makes good sense of certain legitimate moves in ordinary normative explanatory discourse, and helps to make sense of our judgments about explanatory priority in certain cases of normative explanation. This last argument also helps to highlight respects in which normative explanation won't be worryingly discontinuous with explanations in other domains even though these other explanations aren't subject to the justification condition. Thus the paper aims not only to do some constructive theorizing about the relatively neglected topic of normative explanation but also to cast light on the broader question of how normative explanation may be similar to and different from explanations in other domains

Factor markets in early Islamic Iraq, c. 600-1100 AD

AbstractThis paper reconstructs the organization and development of factor markets in early medieval Iraq. It shows that from the late Sasanian period on, and accelerating in the early Islamic period, there was a relatively unrestricted functioning of markets for goods, labour, and capital. This stimulated market exchange, associated with growing monetization of the economy, especially in the towns, but also in the countryside, even though coercion remained more pronounced there. We hypothesize that these developments brought economic dynamism but simultaneously increased inequality and furthered the rise of new, powerful elite groups, causing the decline of the same markets