Professionalism and medical education: a theme issue

clinanat.gif  The July 2006 issue of Clinical Anatomy is a theme issue on professionalism. Here are the abstracts of several of the articles, with links to full text.  PubMed Records

Swick HM. Medical professionalism and the clinical anatomist. Clin Anat 2006; 19(5):393-402.

Abstract: Medical professionalism has become an important issue for medical education and practice. The core attributes of professionalism derive from the roles and responsibilities of professions and from the nature of medicine as a healing profession. In medical education, most of the focus on professionalism has been directed to the clinical arena, yet it is critically important that the attributes of professionalism be manifested in basic science courses–especially anatomy–as well as in clinical experiences, because the transformation from medical student to physician begins at the outset of medical school. Throughout history, anatomists have exemplified many of the attributes and values of professionalism, and clinical anatomists today still have much to offer. Anatomy faculty have an important responsibility to nurture and exemplify professionalism.

Page DW. Professionalism and team care in the clinical setting. Clin Anat 2006; 19(5):468-472.

Abstract: The introduction of an 80-hr work week mandates frequent sign-out or transfer of patient information sessions among training physicians. At the same time, patients are increasingly more complex and cared for by teams employing technologically driven interventions. In order for team care to work, residents and medical students must master the elements of professionalism, upon which solid leadership and clear communication rests. Early instruction should include topics, such as clarity of language, cultural sensitivity, a subordination of self-interest to the needs of the patient, and a dedication to lifelong learning of cognitive and motor skills. This exposure to professionalism may begin in the dissection room and continue seamlessly through residency and into practice.

Holsinger JW, Jr., Beaton B. Physician professionalism for a new century. Clin Anat 2006; 19(5):473-479.

Abstract: During the past 50 years, physicians have become increasingly dissatisfied with certain aspects of their profession. Dissatisfaction has intensified with the advent of managed care in the late 20th century, the medical liability crisis, and the growing divergence between the professional and personal expectations placed upon physicians and their practical ability to meet these expectations. These and other factors have encroached on physician autonomy, the formerly ascendant professional value within medicine. As the underlying values and practical realities of the broader American health care system have changed, the professional values and practices of physicians have failed to adapt correspondingly, resulting in a “professionalism gap” that contributes to physician dissatisfaction. To improve the outlook and efficacy of modern American physicians, the profession must adopt a new values framework that conforms to today’s health care system. This means foregoing the 20th century’s preferred “independent physician” model in favor of a new professional structure based on teamwork and collaboration. Convincing established physicians to embrace such a model will be difficult, but opportunities exist for significant progress among a new generation of physicians accustomed to the realities of managed care, flexible practice models, and health information technology. The teaching of clinical anatomy, given its incorporation of student collaboration at the earliest stages of medical education, offers a prime opportunity to introduce this generation to a reinvigorated code of professionalism that should reduce physician dissatisfaction and benefit society.

Krych EH, Vande Voort JL. Medical students speak: a two-voice comment on learning professionalism in medicine. Clin Anat 2006; 19(5):415-418.

Abstract: We are two medical students. For one of us, medical school is just beginning; for the other, it is coming to an end. Our experiences are different, but our message is the same. Professionalism is a vital component in the field of medicine. Characteristics such as trustworthiness, compassion, integrity, honesty, leadership, and social responsibility must be embraced by the next generation of doctors so the future healthcare system will be one that patients and physicians admire and respect. To reach this goal, it is important to understand how medical students today view professionalism and how such a construct is integrated into medical education. We hope to provide insight into this area by reflecting on the lessons we have learned regarding professionalism in medical school. Professionalism, like the medical field itself, is a life-long learning process. By encouraging this process early in medical training, future doctors will be able to provide their patients with highest quality care.

Lachman N, Pawlina W. Integrating professionalism in early medical education: the theory and application of reflective practice in the anatomy curriculum. Clin Anat 2006; 19(5):456-460.

Abstract: Renewed emphases on teaching professionalism require physicians to develop the ability to critically reflect upon their own decisions. Innovative programs that address teaching professionalism within medical curricula have been implemented in almost all medical schools. The foundation for many of these programs is “reflection,” which is regarded as a core skill in professional competence. In order to achieve the desired outcomes and meet the demands of a required curriculum, an understanding of educational concepts in the designing of medical curricula is essential. Educators recognize that, for most medical students, professional growth is initiated during the first year of the medical curriculum and, therefore, traditionally pure content delivery courses such as first year anatomy course are being utilized now in order to explore issues related to critical thinking and professionalism. As a result, learning strategies such as “reflective practice” are beginning to play an important role in curriculum design. This article provides an overview of the theory of reflective practice, and demonstrates how reflective practice may be integrated into the anatomy curriculum. In order to incorporate reflective exercises into a curriculum, the basic elements of a reflective process are defined, strategies to implement reflective exercises within the course are described, and the benefits of reflective practice are highlighted. Therefore, in creating an environment that fosters reflective learning, the gap between theory and practice may be consolidated, which in the context of anatomy promotes the issue of teaching for relevance and clinical application.

I wonder who’s at the watering hole?

africam.jpg   Ever since a friend sent me a link to, I’ve been hooked. This is a webcam that shows Nkorho Pan, a watering hole in South Africa. The site includes sound and is on day and night. I have seen and heard birds and insects, bats, a lightning storm, the moon shining on the water, a group (herd?) of antelope, some water buffalo (bison?), an elephant, a turtle, a monkey, some insects feasting on a very large spider, and more.

The controller of the special night-sensitive camera is located in the bar of the Nkorho Bush Lodge (see above photograph) and the panning is controlled by one of the staff. Infrared spotlights enable us to see the wildlife at night.  (Thanks to Campbell Scott for the information and the photograph, which appears here with his permission.)

Be sure to turn up your sound, and click on the little square for a full screen view.

From the Web site:
Nkorho Pan is a natural water hole in the prestigious Sabi Sands Private Game Reserve, in South Africa. Nkorho Pan is named after Nkorho Bush Lodge which gets it name from the Shangaan derivative for the call of the yellow-billed hornbill, a common and unusual looking bird from this area.

You can support Africam by subscribing to the various levels of services.

Research Review Service for Chiropractors: Dr. Shawn Thistle

shawn_thistle.jpg    The December 2006 issue of Canadian Chiropractor includes an article about Dr. Shawn Thistle’s Research Review Service. I recommend this weekly review service to any chiropractor interested in staying up to date with current research. On my blog I tell you about the existence of newly published research, but Dr. Thistle critically appraises this research. (Read a couple of sample reviews and find out how how to register.)

Here is an excerpt from the Canadian Chiropractor article:

While attending various seminars, conferences and courses after graduating, Thistle heard repeatedly from his colleagues about how difficult it was to find time to browse relevant journals, not to mention read pertinent articles. With hundreds of journals publishing thousands of articles every year, there seemed to be a general sense of “falling behind” or not being able to “stay current.” Furthermore, only some of these articles are relevant to chiropractic and manual medicine, and isolating the important ones can be extremely laborious. Thistle recognized a distinct disconnect between emerging science and practising clinicians. …

By scanning more than 50 chiropractic, physical therapy and medical journals, Thistle hopes to assist the busy clinician by removing some of the burden of staying current, while increasing the awareness about interesting and significant studies. He spends an estimated 15 to 20 hours per week searching tables of contents and reading papers. Fortunately, this is something he enjoys doing. Acknowledging that nothing can replace continuing education, he hopes the service will bridge a knowledge gap to help practising doctors gain exposure to recent literature. Subscribing is a short and simple process, and payment can be handled either offline or online with PayPal. A receipt for income tax purposes will be issued.

Do chiropractic college faculty understand informed consent?

bmc.gif   Just published online in Chiropractic & Osteopathy, a BioMed Central journal:

Lawrence DJ, Hondras MA. Do chiropractic college faculty understand informed consent: a pilot study. Chiropr Osteopat 2006; 14(1):27.

BACKGROUND: The purpose of this study was to survey full-time faculty at a single chiropractic college concerning their knowledge of Institutional Review Board (IRB) policies in their institution as they pertain to educational research.
METHODS: All full-time faculty were invited to participate in an anonymous survey. Four scenarios involving educational research were described and respondents were asked to select from three possible courses of action for each. In addition, respondents were queried about their knowledge of IRB policies, how they learned of these policies and about their years of service and departmental assignments.
RESULTS: The response rate was 55%. In no scenario did the level of correct answers by all respondents score higher than 41% and in most, the scores were closer to just under 1 in 3. Sixty-five percent of respondents indicated they were unsure whether Palmer had any policies in place at all, while 4% felt that no such policies were in place. Just over one-quarter (27%) were correct in noting that students can decline consent, while more than half (54%) did not know whether there were any procedures governing student consent.
CONCLUSION: Palmer faculty have only modest understanding about institutional policies regarding the IRB and human subject research, especially pertaining to educational research. The institution needs to develop methods to provide knowledge and training to faculty. The results from this pilot study will be instrumental in developing better protocols for a study designed to survey the entire chiropractic academic community.  PubMed Record

Teaching surgical skills: changes in the wind

surgeon.jpg  This article was published in the December 21 issue of the New England Journal of Medicine. Free full text is available.

Reznick RK, MacRae H. Teaching surgical skills: changes in the wind. N Engl J Med 2006; 355(25):2664-2669.   [editorial commentary]  [videos]

Excerpt: Sir William Halsted introduced a German-style residency training system with an emphasis on graded responsibility at Johns Hopkins Hospital in 1889. This system remains the cornerstone of surgical training in North America more than a century later. However, advances in educational theory, as well as mounting pressures in the clinical environment, have led to questions about the reliance on this approach to teaching technical skills.

Those pressures include a move toward a shorter workweek for residents and an emphasis on operating room efficiency, both of which diminish teaching time. Yet the patients in our teaching hospitals are generally much sicker and have more complex problems than in times past. The increasing complexity of cases and a greater emphasis on mitigating medical error limit a faculty’s latitude in assisting residents with technical procedures.

Adverse events associated with pediatric spinal manipulation: A systematic review

aap.jpg  This systematic review was published online in the journal Pediatrics on December 18. It will appear in print in the January 2007 issue. The review was produced by members of the Complementary and Alternative Research and Education Program at the University of Alberta (Edmonton).

On January 18 the FCER (Foundation for Chiropractic Education and Research) has issued a response to this article,  and has just published it on the FCER Web site.  An excerpt:

Unfortunately, the review by Vohra falls short of its goals in its pursuits:
·      Important studies involving pediatric patients who have successfully undergone spinal manipulation in resolving their complaints of ear infections (otitis media) have gone unnoticed.
·      Another study in which the authors attribute adverse events to chiropractors in the
United States instead involves physical therapists, most likely practicing in
·      Yet another citation of adverse events occurring in a clinical trial describes nothing more than a short period of mid-back soreness and irritability, difficult to distinguish from a period of extended crying in another subject who was not even manipulated but was instead assigned to the placebo group.
·      A final group of patients suffered from delayed diagnosis—which the authors erroneously attribute to one study that made no such mention of diagnoses at all but rather focused upon the direct consequences of manipulation per se.

Vohra S, Johnston BC, Cramer K et al. Adverse events associated with pediatric spinal manipulation: A systematic review. Pediatrics 2007;119 (1):e275-e283. [Published online December 18 2006] PubMed Record

BACKGROUND: Spinal manipulation is a noninvasive manual procedure applied to specific body tissues with therapeutic intent. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates.
OBJECTIVE: Our goal was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation.
METHODS: A comprehensive search was performed of 8 major electronic databases (eg, Medline, AMED, MANTIS) from inception to June 2004 irrespective of language. Reports were included if they (1) were a primary investigation of spinal manipulation (eg, observation studies, controlled trials, surveys), (2) included a study population of children who were aged 18 years or younger, and (3) reported data on adverse events. Data were summarized to demonstrate the nature and severity of adverse events that may result rather than their incidence.
RESULTS: Thirteen studies (2 randomized trials, 11 observational reports) were identified for inclusion. We identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), 2 involved moderately adverse events that required medical attention (eg, severe headache), and 3 involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma) and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma).
CONCLUSIONS: Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients.

BMJ Christmas issues

xmas05.gif  Around this time of year I always look forward to the publication of the BMJ Christmas issue. For your viewing pleasure, below are some links to issues of Christmases past.  The essence of the Christmas BMJ is strangeness. It’s our left brain issue.  From A pile of strangeness

1999199819971996; 1995 (Why do old men have big ears?)