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Background Our objective was to examine the influence of silence on team action in the operating room. Methods We conducted a constructed grounded theory study with semi-structured interviews with 25 interprofessional surgical team members. Using a framework of silence as communication and performance, transcripts were iteratively team-coded to develop themes and a conceptual model. Results OR silence is expressed verbally and nonverbally. Two contexts of silence were identified: homogenous as collective action, and disparate, as disengagement. Complex and dynamic, two primary themes emerged, Power that often shuts down communication, and Focus during critical moments. Five additional sub-themes included critical moments, respect, self-reflection, personal preference, and, bad mood. Conclusion OR silence is not an absence of communication and requires a response. Whether homogenous through cohesiveness, or desperate as a solitary act, OR silence is a call to action. Examining silence as a part discourse has important implications on surgical team function.

The objective of this study was to identify intraoperative instructional strategies that embody the ways that learning occurs in the social contexts of surgery.We performed a qualitative review of examples of intraoperative teaching from transcripts of ten videotaped surgeries, coupled with interviews with surgical attendings and residents. We coded the examples according to the key tenets of sociocultural learning theories and used these codes to develop instructional strategies aimed at improving resident surgical autonomy.The sociocultural learning theories prompted six intraoperative teaching strategies (Assess Learner Needs, Inquire, Coach, Permit, Entrust, and Debrief) to address residents' learning needs in specific surgical tasks. The six strategies involve identifying procedure-specific learning needs; discussing interventions based on strategies successful with other learners; providing in-the-moment, interactive coaching; allowing the resident to struggle; increasing the resident's graduated responsibility; debriefing about successes and struggles.We argue that these six strategies should improve the quality of intraoperative teaching, and therefore, enhance progression to autonomous practice.

Tetracyclic 6H-naphtho[2,1-c]chromenes are expeditiously synthesized through a BF3·OEt2-mediated, three-step cascade reaction, creating new central pyran and aromatic rings. The cascade involves th...

There is a growing literature on how medical education adapts to the COVID-19 pandemic. However, there is a need to examine the facilitators and barriers of these adaptations. This study explores the strengths, weaknesses, opportunities, and threats (SWOT) of how Italian medical schools adapted their curricula to the COVID −19 pandemic. The authors conducted an online survey of directors of medical curricula in Italy. Free-text responses to open-ended questions about curricular adaptations and reflections on these adaptations were analysed using qualitative thematic analysis. Twenty out of 60 Italian medical school directors completed the survey. Strengths identified were rapid responses and a spirit of cooperation. Weaknesses included dependency on clinical facilities, teachers’ limited skills to use technology, and lack of mental health support for staff. Opportunities highlighted were clear government rules, new ways of teaching and a renewed focus on underrepresented topics. Threats expressed included impaired relationships, difficulties related to online assessment, lack of IT access, and legal and insurance issues. This study, in documenting the curricular adaptations of Italian medical schools during an active global pandemic, and recording the perspectives of medical education leaders, offers important lessons for the future.

Context In the high-stakes, time-critical environment of the operating room (OR), attendings and residents strive to complete safe, effective surgeries and ensure that learning occurs. Yet meaningful resident participation often receives less attention, and that impedes residents' ability to learn and achieve autonomous operative practice. We need a new conceptual framework for understanding progression to autonomous practice that can guide both faculty and residents. Thus, we sought a new conceptualisation of intraoperative teaching and learning (IOT&L) through the lens of Eraut's notion of informal workplace learning and Billett's theory of relational interdependence between social and individual agency. Methods We viewed authentic examples of IOT&L in video and transcripts of live OR cases and interviews with participating attendings and residents. By systematically applying Eraut and Billet's theories to the transcripts and interviews, we developed concrete descriptions about how IOT&L occurs, categorised them into theory-based principles and derived a conceptualisation and related research ideas about IOT&L. Results Established workplace learning theories frame IOT&L as socially negotiated processes transpiring in distinct interdependent interactions between residents' individual cognitive experiences and their OR social experiences that direct their learning. As the surgery unfolds, spontaneous events and the rules of surgery create opportunities for unplanned and informal learning. These authentic interrelated cognitive and social experiences are stimulated when residents reveal a learning need or attendings recognise a learning gap, and efforts ensue to bridge that gap. Through these minute distinct exchanges, labelled here as 'atomic' IOT&L, residents gain crucial knowledge and skill. Conclusion Framing authentic OR interactions between attendings and residents in terms of micro-relational interdependencies shows how granular teaching/learning exchanges yield high-value informal learning. To improve IOT&L, we must examine and change it at this fundamental level by using and testing this new theoretical conceptualisation. These insights produced ideas about IOT&L to test and research.

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Background Interprofessional surgical teams must have the ability to cross boundaries. Goffman's theory of performance in the everyday is useful for the multiple personae that attending surgeons assume within the surgical environment and impact on team function. Purpose To examine the effect of attending surgeon personae on surgical team action. Methods The study used direct observation of ten surgeries. Field notes were transcribed, discussed, and iteratively coded using directed content analysis. Results Shifts in personae by attending surgeons altered the behaviors and actions of surgical team members often leading to professional boundary crossing. Discussion The surgical environment informs team action. The personae established by attending surgeons informs team member behaviors, actions and interactions. Conclusion A lens of dramaturgy is useful for understanding the dynamics and various actions of surgical team members. Attending surgeons need to be more mindful about the personae they assume and the impact on team member function.

Background Effective communication in the operating room between the attending and resident surgeon is necessary to prevent surgical errors. Yet, existing studies do not describe what successful intraoperative teaching looks like and how it prevents errors. Our objective was to identify strategies for successful intraoperative teaching by comparing perspectives of the learner and teacher for the same moments. Material and methods We conducted a naturalistic inquiry by filming five live surgical teaching cases and analyzing more than 250 teaching exchanges, centered on steps with high likelihood for error. We interviewed each attending and resident, who separately viewed cued video clips, and asked how they made their teaching more visible. We compared answers, looking for common understandings of the same moment. Answers were coded, compared to each other, refined, and combined into larger themes. Results We identified five successful strategies for communicating avoidance of intraoperative errors: augmenting verbal instruction with small physical actions, pausing the surgical procedure to explain the larger picture, querying the residents’ knowledge about specific steps, creating memorable coined names, and issuing highly specific commands. Strikingly, we found a significant example of miscommunication between the attending surgeon and resident that was a near-miss uterine perforation during a dilation and curettage. Conclusions Attending surgeons are strategic in their intraoperative communications with learners, resulting in a scarcity of surgical errors when the resident is operating. We present real examples of five successful intraoperative teaching strategies. Successful intraoperative teaching relies heavily on tacit information, necessitating that attending and resident share a common understanding about the next step of the case.

Background Surgical residents desire independent operating experience but recognize that attendings have a responsibility to keep cases as short as possible. Methods We analyzed video and interviews of attending surgeons related to more than 400 moments in which the resident was the primary operator. We examined these moments for themes related to timing and pace. Results Our surgeons encouraged the residents to speed up when patient safety could be jeopardized by the case moving too slowly. In contrast, they encouraged the residents to slow down when performing a crucial step or granting independence. Attending surgeons encouraged speed through economical language, by substituting physical actions for words, and through the use of Intelligent Cooperation. Conversely, they encouraged slowing down via just-in-time mini-lectures and by questioning the trainee. Conclusions We present recommendations for safe teaching in the operating room while simultaneously maintaining overall surgical flow. Teaching residents to operate quickly can save time and is likely based on an automaticity in teaching. Slowing a resident down is vital for trainee skill development and patient safety.

Objectives To illuminate surgical teaching at a fine level of detail by filming intraoperative communication between surgical attending physicians and trainees and provide a naturalistic categorization and analysis of verbal teaching behaviors. Design Live, intraoperative verbal exchanges between surgical attending physicians and their trainees (residents and fellows) were filmed, and key verbal teaching moments were transcribed. In follow-up interviews, attending physicians and trainees watched video clips of their teaching case and answered open-ended questions about their surgical teaching methods. Using a grounded theory approach, we examined the videos and interviews for what might be construed as a teaching behavior and refined verbal teaching categories through constant comparison. Setting We filmed 5 cases in the operating suite of a university teaching hospital that provides gynecologic surgical care. Participants We included 5 attending gynecologic surgeons, 3 fellows, and 5 residents for this study. Results More than 6 hours of film, 3 hours of interviews, and more than 400 verbal teaching utterances from our participating attending surgeons were transcribed. We found that attending surgeons used unique types of verbal guidance to describe relevant anatomy, explain the rationale behind a specific surgical action, command the trainee to perform the next step, reference a specific aspect of the surgery, and provide an indirect verbal construct. Attending physicians prefixed speech with polite terms and used terse language, colorful verbal analogies, and sometimes humor. Our participants denied a significant Hawthorne effect. Interrater reliability was high using Cohen κ with 0.77 for the verbal categories. Conclusions Our categorization of live intraoperative verbal teaching can provide a measurable, replicable basis for studying how spoken guidance can lead to the best intraoperative learning. Because surgical teaching occurs on a microscopic level, film review is important when analyzing intraoperative teaching behaviors.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.

To identify medical school factors graduates in major leadership positions perceive as contributing to their leadership development.Using a phenomenological, qualitative approach, in August-November 2015 the authors conducted semistructured interviews with 48 medical leaders who were 1976-1999 baccalaureate-MD graduates of the University of Missouri-Kansas City School of Medicine (UMKC). At UMKC, they participated in longitudinal learning communities, the centerpiece for learning professional values and behaviors plus clinical skills, knowledge, and judgment, but received no formal leadership instruction. The authors subjected interview comments to directed, largely qualitative content analysis with iterative coding cycles.Most graduates said their experiences and the people at UMKC positively influenced their leadership growth. Medical school factors that emerged as contributing to that growth were the longitudinal learning communities including docents, junior-senior partners, and team experiences; expectations set for students to achieve; a clinically oriented but integrated curriculum; admission policies seeking students with academic and nonacademic qualifications; supportive student-student and student-faculty relationships; and a positive overall learning environment. Graduates viewed a combination of factors as best preparing them for leadership and excellence in clinical medicine; together these factors enabled them to assume leadership opportunities after graduation.This study adds medical leaders' perspective to the leadership development literature and offers guidance from theory and practice for medical schools to consider in shaping leadership education: Namely, informal leadership preparation coupled with extensive longitudinal clinical education in a nurturing, authentic environment can develop students effectively for leadership in medicine.

Background Surgeons who work with trainees must address their learning needs without compromising patient safety. Methods We used a constructivist grounded theory approach to examine videos of five teaching surgeries. Attending surgeons were interviewed afterward while watching cued videos of their cases. Codes were iteratively refined into major themes, and then constructed into a larger framework. Results We present a novel framework, Intelligent Cooperation, which accounts for the highly adaptive, iterative features of surgical teaching in the operating room. Specifically, we define Intelligent Cooperation as a sequence of coordinated exchanges between attending and trainee that accomplishes small surgical steps while simultaneously uncovering the trainee's learning needs. Conclusions Intelligent Cooperation requires the attending to accurately determine learning needs, perform real-time needs assessment, provide critical scaffolding, and work with the learner to accomplish the next step in the surgery. This is achieved through intense, coordinated verbal and physical cooperation. Summary sentences for table of contents Intelligent Cooperation is defined as a sequence of coordinated exchanges between attending and trainee that accomplishes small surgical steps while simultaneously uncovering the trainee's learning needs. Intelligent Cooperation is achieved through intense, coordinated verbal and physical cooperation and requires the attending to accurately determine learning needs, perform real-time needs assessment, provide critical scaffolding, and work with the learner to accomplish the next step in the surgery.

Medical education literature has been found to lack key components of scientific reporting, including adequate descriptions of literature searches, thus preventing medical educators from replicating and building on previous scholarship. The purpose of this study was to examine the reproducibility of search strategies as reported in medical education literature reviews.The authors searched for and identified literature reviews published in 2009 in Academic Medicine, Teaching and Learning in Medicine, and Medical Education. They searched for citations whose titles included the words "meta-analysis," "systematic literature review," "systematic review," or "literature review," or whose publication type MEDLINE listed as "meta-analysis" or "review." The authors created a checklist to identify key characteristics of literature searches and of literature search reporting within the full text of the reviews. The authors deemed searches reproducible only if the review reported both a search date and Boolean operators.Of the 34 reviews meeting the inclusion criteria, 19 (56%) explicitly described a literature search and mentioned MEDLINE; however, only 14 (41%) also mentioned searches of nonmedical databases. Eighteen reviews (53%) listed search terms, but only 6 (18%) listed Medical Subject Headings, and only 2 (6%) mentioned Boolean operators. Fifteen (44%) noted the use of limits. None of the reviews included reproducible searches.According to this analysis, literature search strategies in medical education reviews are highly variable and generally not reproducible. The authors provide recommendations to facilitate future high-quality, transparent, and reproducible literature searches.

The authors present an overview of the educational programs, infrastructure to support them, and the assessment strategies of 128 medical schools in the United States and Canada, based on reports submitted by those schools and published in this supplement to Academic Medicine. The authors explore many important changes that have occurred since the publication of the Flexner Report in 1910 as well as the progress that is evident since a similar collection of medical school reports was published in September 2000, also as a supplement to Academic Medicine. Drawing on the reports, the authors summarize, among other topics, the advances that have taken place in the support for faculty, the funding of medical student education, changes in pedagogy and assessment, and the expansion of medical education to distributed models and regional campuses.The authors observe that the reports from the 128 schools illustrate that medical student education has undergone and continues to undergo substantive change, has advanced markedly since the reforms stimulated by the Flexner Report, and has continued to evolve during the past decade. The reports illustrate the strength of support for the educational programs, even in a time of financial constraints, and the increasing recognition of the scholarly contributions of faculty through teaching. The authors provide examples of the changes in pedagogy and new topics in the required curriculum in the past decade and describe selected highlights of the 128 educational programs.

Misperceptions of stock and flow relationships are pervasive and an important problem to solve in system dynamics. Prior studies have shown that individuals perform poorly on accumulation problems, even when considering relatively simple systems, an effect termed the Stock–Flow (SF) failure. This study examines the effects of domain experience in overcoming the SF failure. We compared performance of medical students and undergraduates with no medical education on accumulation problems in medical and general domains. Medical students performed better than undergraduates only in some of the problems (including the general domain problems), and they performed equally poorly as undergraduates in problems that required medical domain experience. There was no correlation between performance in the stock and flow problems and either duration of medical education or age. Thus we conclude that domain experience is not a strong indicator for overcoming the SF failure. Copyright © 2010 John Wiley & Sons, Ltd.

How axon regeneration is controlled in both PNS and CNS remains elusive. Mechanistic studies of axon growth during development and axon regeneration after injury reveal the PTEN dependent molecular mechanism as a commonality. This pathway could impact the processes occurring in the neuronal soma, such as mTOR-regulated protein translation, and in the axons, such as cytoskeleton assembly. In this review, we will discuss the current understanding of the involvement of these processes in the regulation of axon growth and the potential implication in promoting axon regeneration after injury.

Background Prolonged exposure to ketamine results in accelerated neurodegeneration and neurocognitive deficits in the neonatal rats. Experimental models of neurodegeneration have implicated reentry of postmitotic neurons into the cell cycle, leading to cell death. The authors hypothesize that the ketamine-induced neuroapoptosis is partially due to aberrant cycle cell reentry. To explore this hypothesis, the authors characterized the effect of ketamine on the cell cycle signaling pathway in the developing rodent brain in vivo and in vitro. Methods Postnatal day 7 rat pups and primary neurons were used for the experiments. Each rat pup received five intraperitoneal doses of either saline or ketamine (5, 10, and 20 mg/kg/dose) at 90-min intervals over 6 h. Primary neurons were exposed to varying concentrations of ketamine to determine the dose and duration effects. The expression of cell cycle proteins (cyclin D1, cyclin-dependent kinase 4, and E2F1), Bcl2-interacting mediator of cell death (Bim), and activated caspase-3 was determined. The effect of cyclin D1 knockdown by small interfering RNA was also examined in primary neurons incubated in ketamine. Results Ketamine mediated a dose- and time-dependent increase in expression of cell cycle proteins and activated caspase-3. Cyclin D1, cyclin-dependent kinase 4, E2F1, Bim, and cleaved caspase-3 expression increased at 12 h and peaked at 24 h in vitro. Knockdown of cyclin D1 by small interfering RNA attenuated Bim and cleaved caspase-3 expression. Conclusion These findings support a model in which ketamine induces aberrant cell cycle reentry, leading to apoptotic cell death in the developing rat brain.

The ability to understand and integrate new knowledge into clinical practice is a necessary quality of good physicians. Student participation in in-depth scholarship could enhance this skill in physicians while also creating a larger cadre of physician-scientists prepared to advance the field of medicine. However, because no definitive data exist demonstrating that in-depth scholarship in medical school leads to improved patient care or to productive academic careers, whether such scholarship should be required as part of the medical school curriculum is unclear. In this article, the authors present both sides of this debate. Theoretical benefits to students of a required scholarly program include closer mentorship by individual faculty, enhanced capabilities in critical interpretation of research findings, and increased confidence to investigate conundrums encountered in clinical care. Society may also benefit by having physicians available to create and apply new knowledge related to biomedicine. These theoretical benefits must be balanced, however, by pragmatic considerations of required scholarly projects including their impact on medical school applications, their effect on the medical curriculum, their costs, the availability of mentors, and their effects on the school's educational culture.

Approaches that use a simulated patient case to study and assess diagnostic reasoning usually use the correct diagnosis of the case as a measure of success and as an anchor for other measures. Commonly, the correctness of a diagnosis is determined by the judgment of one or more experts. In this study, the consistency of experts' judgments of the correctness of a diagnosis, and the structure of knowledge supporting their judgments, were explored using a card sorting task. Seven expert pediatricians were asked to sort into piles the diagnoses proposed by 119 individuals who had worked through a simulated patient case of Haemophilus influenzae Type B (HIB) meningitis. The 119 individuals had varying experience levels. The expert pediatricians were asked to sort the proposed diagnoses by similarity of content, and then to order the piles based on correctness, relative to the known correct diagnosis (HIB meningitis). Finally, the experts were asked to judge which piles contained correct or incorrect diagnoses. We found that, contrary to previous studies, experts shared a common conceptual framework of the diagnostic domain being considered and were consistent in how they categorized the diagnoses. However, similar to previous studies, the experts differed greatly in their judgment of which diagnoses were correct. This study has important implications for understanding expert knowledge, for scoring performance on simulated or real patient cases, for providing feedback to learners in the clinical setting, and for establishing criteria that define what is correct in studies of diagnostic error and diagnostic reasoning.

Mission-based budgeting has been touted as the preferred method of assessing and assigning departmental budgets in academic medical centers. Mission-based budgeting in its simplest form is a methodology that allows an institution's finance department to align costs with actual activities (typically clinical care, administration, research, and teaching). Despite its intuitive appeal, a minority of the academic medical centers across the country have embraced it. Mount Sinai School of Medicine was among the first to incorporate this approach, and we have almost a decade of experience with its risks and benefits. This article focuses on the education component of mission-based budgeting. We review all aspects of mission-based budgeting, including (1) the many variables that must be factored into a metric and how those variables differ among institutions, (2) the metric itself and how it reflects institutional philosophy, (3) the impact of mission-based budgeting on faculty and chairs of departments, (4) existing processes that ensure the quality, reliability, and validity of the different mission-based budgeting systems, and (5) a comparative perspective.

In an effort to use model fluid membranes for immunological studies, we compared the formation of planar phospholipid bilayers supported on silicon dioxide surfaces with and without incorporation of glycolipids as the antigen for in situ antibody binding. Dynamic light scattering measurements did not differentiate the hydrodynamic volumes of extruded small unilamellar vesicles (E-SUVs) containing physiologically relevant concentrations (0.5-5 mol%) of monosialoganglioside GM1 (GM1) from exclusive egg yolk L-alpha-phosphatidylcholine (egg PC) E-SUVs. However, quantifiable differences in deposition mass and dissipative energy loss emerged in the transformation of 5 mol% GM1/95 mol% egg PC E-SUVs to planar supported lipid bilayers (PSLBs) by vesicle fusion on thermally evaporated SiO2, as monitored by the quartz crystal microbalance with dissipation (QCM-D) technique. Compared to the 100 mol% egg PC bilayers on the same surface, E-SUVs containing 5 mol% GM1 reached a approximately 12% higher mass and a lower dissipative energy loss during bilayer transformation. PSLBs with 5 mol% GM1 are approximately 18% heavier than 100 mol% egg PC and approximately 11% smaller in projected area per lipid, indicating an increased rigidity and a tighter packing. Subsequent binding of polyclonal immunoglobulin G anti-GM1 to the PSLBs was performed in situ and showed specificity. The anti-GM1 to GM1 ratios at equilibrium were roughly proportional to the concentrations of anti-GM1 administered in the solution. Fluorescence recovery after photobleaching was utilized to verify the retained, albeit reduced lateral fluidity of the supported membranes. Five moles percentage of GM1 membranes (GM1 to PC ratio approximately 1:19) decorated with 1 mol% N-(Texas Red sulfonyl)-1,2-dihexadecanoyl-sn-glycerol-3-phosphoethanolamine (Texas Red DHPE) exhibited an approximately 16% lower diffusion coefficient of 1.32+/-0.06 microm2/s, compared to 1.58+/-0.04 microm2/s for egg PC membranes without GM1 (p0.01). The changes in vesicle properties and membrane lateral fluidity are attributed to the interactions of GM1 with itself and GM1 with other membrane lipids. This system allows for molecules of interest such as GM1 to exist on a more biologically relevant surface than those used in conventional methods such as ELISA. Our analysis of rabbit serum antibodies binding to GM1 demonstrates this platform can be used to test for the presence of anti-lipid antibodies in serum.

Recent studies suggest that increased T-cell and autoantibody reactivity to lipids may be present in the autoimmune demyelinating disease multiple sclerosis. To perform large-scale multiplex analysis of antibody responses to lipids in multiple sclerosis, we developed microarrays composed of lipids present in the myelin sheath, including ganglioside, sulfatide, cerebroside, sphingomyelin and total brain lipid fractions. Lipid-array analysis showed lipid-specific antibodies against sulfatide, sphingomyelin and oxidized lipids in cerebrospinal fluid (CSF) derived from individuals with multiple sclerosis. Sulfatide-specific antibodies were also detected in SJL/J mice with acute experimental autoimmune encephalomyelitis (EAE). Immunization of mice with sulfatide plus myelin peptide resulted in a more severe disease course of EAE, and administration of sulfatide-specific antibody exacerbated EAE. Thus, autoimmune responses to sulfatide and other lipids are present in individuals with multiple sclerosis and in EAE, and may contribute to the pathogenesis of autoimmune demyelination.

Many U.S. medical schools offer students the opportunity to undertake laboratory or clinical research or another form of scholarly project over the summer months, yet few require this as a prerequisite for graduation, and even fewer provide comprehensive didactic material in preparation for the performance of such a project as an integrated component of their curricula. The authors describe the Scholarly Project Initiative of the University of Pittsburgh School of Medicine, a novel, longitudinal, and required program. The program will aim to provide all students with structured preparatory coursework, foster critical analytical and communication skills, and introduce the breadth and depth of the research and scholarly enterprise engendered by modern academic medicine in the contexts of both the classroom and an individual, mentored experience. The initiative has two goals: encouraging an interest in academic medicine in an era marked by the continuing decline in the number of physician-investigators, and fostering the development of physicians who have confidence in their abilities to practice medicine with creativity, original and analytical thought, and relentless attention to the scientific method. Planning for the Scholarly Project Initiative began officially at the University of Pittsburgh School of Medicine's Curriculum Colloquium in May 2003. The initiative was implemented with the first-year class of July 2004 as part of the new "Scientific Reasoning and Medicine" block of the School of Medicine's curriculum. The block as a whole includes traditional lectures, small-group laboratory and problem-based sessions, and mentored independent study components.

The relationship between learner and teacher is fundamental to medical education, yet there has been limited research on the subject. We explore how analogies to theories from two other fields—evolutionary biology and social theory—may help us understand some of the tensions in this relationship and may offer guidance on how to solve problems between learners and teachers.

This article was migrated. The article was marked as recommended. Brazilian educator Paulo Freire argues that the purpose of education is to liberate human potential and, thus, is much more than a teacher simply depositing information into the mind of a learner. His ideas are important to medical education because 1) they strengthen the philosophical underpinning of practices in medical education (for example, Freire's dialogical approach to learning vis-à-vis the banking model of education adds philosophic strength to the use of problem-based learning as a primary learning modality); 2) they encourage medical educators to confront directly the tension between teaching for conformity, which many would argue is key to performing a good and reliable physical examination, and teaching to liberate human potential, which is critical to preparing physicians to question current assumptions, practices, and knowledge; and 3) they encourage expanded thought about approaches to medical education, for example in the choice of pedagogical method, defining the role of the educator, and the use of experiences like service learning.

Results (Scientific Abstract)/Collaborative Partners (Programmatic Abstract): We initially identified 33 EV indictors grouped in six categories: 1) geographic setting (eight, e.g., urban vs. rural); 2) study population (seven, e.g., gender); 3) implementation characteristics (six, e.g., adherence efforts); 4) institutional and legal context (three e.g., stigma); 5) ability to scale with quality (two e.g., implementation scale); and 6) HTC-specific indicator (seven, e.g., service delivery mode). After the first round of expert elicitation, we added one indicator and dropped one. Four (12%) indicators were excluded due to lack of variability (>90% studies reported the same characteristics) and four (12%) due to excessive (>70%) missing data, cumulatively comprising 27% of total weights. Seventeen of 25 (68%) remaining indicators comprised the top 80% of the total renormalized weights. The bottom five least weighted indicators were: 1) WHO region 0.4 %; 2) WHO subregion 0.8%; 3) country 0.8%; 4) national per capita government health spending 1.5%; and 5) country-level income 1.7%, and the top most weighted indicators: 1) target age group 6.4%; 2) service delivery mode 5.7%; 3) type of post-test counseling 5.5%; 4) stigma for intervention 5.5%; and 5) HIV epidemic type 5.4%. Summary/Conclusion: More attention should be given to EV for translation of evidence to real-world global health practice. Our study proposes a target-specific definition for EV: The likelihood that intervention effects observed in a set of studies will be replicated if implemented in a different target setting. Intervetion-specific indicators should be carefully explored for other EV tools. Validation of our tool is underway.

Two dissimilar U.S. medical schools—the University of Pittsburgh School of Medicine and the University of Texas Medical Branch at Galveston—changed their curricula for the first two years of medical education from ones that were lecture-dominated and departmentally run to ones that are centrally governed, multi-modal, goaloriented, and fully integrated, with mechanisms to continue curricular change into the last two years of medical education. The change at each school was in response to national education philosophy, the recommendations of the Liaison Committee for Medical Education after the most recent site visit, and faculty’s and students’ concerns and interests. The change process took place over a three- to fouryear period at each school, involved students, faculty, and administration, and utilized task forces and retreats as communication vehicles. The barriers encountered (e.g., belief by some that the curriculum needed no change; concern over loss of departments’ control) and the processes employed to overcome them and to radically change the curricula (e.g., commitment of the central administration and dean to the change, involvement of all segments of the school in the change process, appointment of department chairs on task forces, and creation of a strong curriculum committee that gave authority to faculty and students) were essentially identical. The resulting curricula were also largely similar in their main characteristics, but there were notable differences, based on the goals and concerns of the two institutions. Acad. Med. 2000;75:595‐601.

Purpose: A previous cohort study of 759 women with invasive T1‐T2 breast cancer operated on with breast‐conserving surgery in Stockholm between 1976 and 1986 indicated that age 30%, 2.1 (CI = 1.0–4.4). In women ≥50 years, MIB-1-index >30% was associated with an OR of 3.5 (CI = 1.4–8.8) compared to those who were younger. Patients ≥50 years with MIB-1-index ≤30% were thus identified as a low-risk group with an OR of 0.2 (CI = 0.1–0.5). A possible high-risk group was patients

The advent of new medical education (ME) journals makes evident the growth of the field of ME. However, the nature and context of growth is undefined.To analyze the evolution of publication in ME.MEDLINE retrieval using medical subject headings was used to analyze patterns of ME publications from 1960-2010: changes in number of ME publications; number of journals publishing ME articles; co-topics occurring frequently in ME articles; differences among journals' publication of co-topics.Annual publication of ME articles increased from 279 in 1960 to 3760 in 2010. 81,531 articles were published in 4208 different journals. 104 journals published ME articles in 1960, 855 in 2010. Despite an increase in journals in all fields, ME journals now account for a larger proportion of all journals indexed in MEDLINE than in 1960. One-quarter of all ME articles were indexed as internship/residency; 16% as graduate ME; 15% as undergraduate ME; and 14% as continuing ME. The five journals that published the most ME articles distinguished themselves by publishing some topics with greater or less frequency.The increase in the number of ME publications and in the number of journals publishing ME articles suggests a supportive environment for a growing field; but variation in journals' foci has implications for readers, editors and authors.

In the present study we have investigated the utility of the proliferation marker MIB 1 in distinguishing between benign naevocellular naevi and naevocellular naevus-like lesions with malignant potential. Percentages of MIB 1 immunoreactivity in the intradermal portion of the lesions were determined. In benign congenital and acquired naevi, as well as in dysplastic naevi, there was no or only a slight intradermal melanocytic proliferation (0-2%), whereas vertical growth phase melanomas exhibited a substantial proliferative activity (11-48%). In five cases of naevus-lke lesions, which had all relapsed as unmistakable malignant melanomas (locally or metastatically) after primary surgery, there was also clear proliferative activity (9-67%). Our findings suggest that MIB 1 may be a useful tool in the routine histopathological examination of problematic naevocellular lesions.

This article describes a novel course that was designed to bridge the gap between the basic science years and clinical experiences in medical school by using information science and computer technology as major components of problem-based learning (PBL) sessions. The course, Integrated Case Studies and Medical Decision Making, was first given to second-year students at the University of Pittsburgh School of Medicine in the spring of 1994. It consists of 13 PBL exercises, each of which explores a clinical case. The cases, including images and gated access to information, are housed on a computer. Using one of 16 networked terminals in specially designed small-group rooms, groups of nine students progress through the cases with a faculty facilitator. The responses of students and faculty to the initial year of the course were favorable. In comparison with traditional PBL sessions, enhanced quality of and access to images and accountability for accessing case information in sequential fashion were cited as major strengths of the course. Juxtaposition of basic science and clinical material and utility in reviewing for the United States Medical Licensing Examination were also cited as strengths. The diversity of the basic science material involved in completing the cases drew overwhelming enthusiasm from students and facilitators alike. In conclusion, the course successfully employs computer and information science technology, which will be of increasing importance to future physicians. The course also serves as an effective bridge to the clinical years of medical school and as a study adjunct for the USMLE.

Electrical activation of the heart requires intercellular transfer of current through gap junctions connecting individual cardiac myocytes. Using a combination of light and electron microscopic techniques and molecular approaches, we have characterized the number, size, and spatial distribution of intercellular connections at gap junctions in cardiac myocytes and have also cloned, sequenced, and elucidated the subcellular distribution of three physiologically distinct gap junction channel proteins. In this review, we present evidence to suggest that the spatial distribution of myocyte interconnections and the molecular composition of gap junction channels may confer distinct conduction properties on specific tissues of the mammalian heart such as atrial and ventricular myocardium, and the nodes and bundles of the cardiac conduction system. © 1995 Wiley-Liss, Inc.

Lipids comprise 70% of the myelin sheath, and autoantibodies against lipids may contribute to the demyelination that characterizes multiple sclerosis (MS). We used lipid antigen microarrays and lipid mass spectrometry to identify bona fide lipid targets of the autoimmune response in MS brain, and an animal model of MS to explore the role of the identified lipids in autoimmune demyelination. We found that autoantibodies in MS target a phosphate group in phosphatidylserine and oxidized phosphatidylcholine derivatives. Administration of these lipids ameliorated experimental autoimmune encephalomyelitis by suppressing activation and inducing apoptosis of autoreactive T cells, effects mediated by the lipids’ saturated fatty-acid side chains. Thus, phospholipids represent a natural anti-inflammatory class of compounds that have potential as novel therapeutics for MS.