Can students learn clinical method in general practice? A randomised crossover trial based on objective structured clinical examinations.

OBJECTIVE: To determine whether students acquired clinical skills as well in general practice as in hospital and whether there was any difference in the acquisition of specific skills in the two environments. DESIGN: Randomised crossover trial. SUBJECTS AND SETTING: Annual intake of first year clinical students at one medical school. INTERVENTION: A 10 week block of general internal medicine, one half taught in general practice, the other in hospital. Students started at random in one location and crossed over after five weeks. OUTCOME MEASURES: Students'' performance in two equivalent nine station objective structured clinical examinations administered at the mid and end points of the block: a direct comparison of the two groups'' performance at five weeks; analysis of covariance, using their first examination scores as a covariate, to determine students'' relative improvement over the second five weeks of their attachment. RESULTS: 225 students rotated through the block; all took at least one examination and 208 (92%) took both. For the first half of the year there was no significant difference in the students'' acquisition of clinical skills in the two environments; later, however, students taught in general practice improved slightly more than those taught in hospital (P = 0.007). CONCLUSIONS: Students can learn clinical skills as well in general practice as in hospital; more work is needed to clarify where specific skills, knowledge, and attitudes are best learnt to allow rational planning of the undergraduate curriculum.     

Patients' Attitudes to Medical Students in General Practice

259 consecutive adult patients were interviewed regarding their attitudes to the presence of medical students at consultation, at examination, and at home visits. Few patients declared reluctance to discussing physical illness and smoking or drinking problems in the student''s presence, but many had appreciable inhibitions about discussing almost every other common component of consultation. Over half of the younger women interviewed would prefer students not to be present at physical or pelvic examination.Neither age nor social class showed significant association with declared preference, but previous contact with students did not decrease inhibitions among patients. Only 15% of respondents said that they would be more upset by the presence of two students rather than one.     

Coal mine drainage effects on a lotic ecosystem in Northwest Colorado,U.S.A.

An aquatic biological survey was conducted in 1979–1980 to determine the effects of drainage from an active coal strip-mine on Trout Creek, in northwest Colorado, U.S.A. Sampling was conducted over four seasons at four stations for periphyton, benthic invertebrates and fish. Periphyton in Trout Creek changed in the relative abundance of algae divisions in no apparent relation to mining. Diatoms were the predominant division at all sites. Golden-brown algae were abundant in spring at the stations upstream and adjacent to the mine. Blue-green algae were relatively important at stations upstream and downstream of the mine in winter. Benthic invertebrates exhibited a progressive increase in density, biomass and number of taxa from the upstream station to the downstream station. Shannon-Wiener diversity index for bethic invertebrates decreased slightly downstream of mine drainage but remained indicative of a clean water community. Aquatic insects (especially Trichoptera) were the predominant invertebrates at all stations. Analysis of functional groups of benthic invertebrates revealed increased importance of collector species at the lower sites while shredders were most important upstream of the mine. Unlike the invertebrates, fish exhibited slightly lower biomass at the station adjacent to the mine. The decrease was due to fewer salmonids. However, salmonid density and biomass increased substantially at the station just downstream of the mine. Non-game species (suckers and minnows) increased in numbers downstream and were most abundant at the lowest station. This coal strip-mine had little discernable adverse effects on the periphyton and invertebrates of Trout Creek. Fish populations did not appear to be significantly affected by the mine. Apparently, the presence of settling ponds and a buffer zone of unmined land between the mine and the stream helped to minimize adverse effects.     

Improving the preregistration experience: the New Zealand approach.

There is currently much debate about how to improve undergraduate medical education, and in particular on how best to prepare students for clinical responsibility. For 20 years a period of trainee internship has formed part of New Zealand medical students'' undergraduate training, and the model could have much to offer the United Kingdom. Students take their final examinations at the end of the second clinical year; they spend their final year in a series of eight clinical attachments, during each of which they shadow a preregistration house officer or senior house officer. As trainee interns they are paid 60% of a house officer''s salary for their clinical work, which is supervised by the firm''s registrars and consultants under the overall responsibility of the head of the academic department. The order of the attachments is determined on educational, not service, grounds, and trainees have to attend educational sessions and pass assessments on each attachment. The trainee internship, funded jointly by the education and health departments, offers a more seamless transition from student to house officer and aims at improving both general medical education and clinical training.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Use of Galvanic Skin Responses,Salivary Biomarkers,and Self-reports to Assess Undergraduate Student Performance During a Laboratory Exam Activity

Typically, self-reports are used in educational research to assess student response and performance to a classroom activity. Yet, addition of biological and physiological measures such as salivary biomarkers and galvanic skin responses are rarely included, limiting the wealth of information that can be obtained to better understand student performance. A laboratory protocol to study undergraduate students'' responses to classroom events (e.g., exams) is presented. Participants were asked to complete a representative exam for their degree. Before and after the laboratory exam session, students completed an academic achievement emotions self-report and an interview that paralleled these questions when participants wore a galvanic skin sensor and salivary biomarkers were collected. Data collected from the three methods resulted in greater depth of information about students'' performance when compared to the self-report. The work can expand educational research capabilities through more comprehensive methods for obtaining nearer to real-time student responses to an examination activity.     

Stereotypes of autism

In their landmark papers, both Kanner and Asperger employed a series of case histories to shape clinical insight into autistic disorders. This way of introducing, assessing and representing disorders has disappeared from today''s psychiatric practice, yet it offers a convincing model of the way stereotypes may build up as a result of representations of autism. Considering that much of what society at large learns on disorders on the autism spectrum is produced by representations of autism in novels, TV-series, movies or autobiographies, it will be of vital importance to scrutinize these representations and to check whether or not they are, in fact, misrepresenting autism. In quite a few cases, media representations of talent and special abilities can be said to have contributed to a harmful divergence between the general image of autism and the clinical reality of the autistic condition.     

开展临床指导教师对普通专科医师培训情况的调查结果分析

目的:调查我院专科医师培训开展的整体情况,为继续做好专科医师培训工作提供依据。方法:随机调查我院参与普通专科医师培训轮转科室的指导教师,发放自制调查表。结果:90%以上导师认为科室带教质量高;48.78%导师认为临床科室应为学员每月发放1000元以上生活补助;60.98%导师认为硕士研究生普通专科医师培训时间应为二年;60%以上导师认为应着重硕士研究生临床操作技能、医患沟通能力、病历书写能力及阅片能力等方面能力的培训;50%以上导师认为目前培训中存在的主要问题是生活无保障;图书馆国内外最新文献不足;监管力度不强;临床技能培训针对性不强等。结论:我院开展普通专科医师培训整体情况较好。但仍存在很多问题,在今后的培训过程中应继续为学员的生活提供更多保障,继续加强管理监督,保证培训按计划、按质量完成。     

Taking medical histories through interpreters: practice in a Nigerian outpatient department.

Consultations through interpreters in the medical outpatient department of a Nigerian hospital were tape-recorded. These recordings were translated completely into English and transcribed, and the performance of the interpreters was analysed. The interpreters often did not provide word-for-word translations of what the doctor or patient had said. Some of these deviations were helpful, but others were confusing or incorrect. In particular, interpreters were inclined to conduct much of the consultations themselves. Hospitals using interpreters should ensure that they have no conflicting duties during consultations and that they have some training in language and interpretation. The quality of interpretation should be checked by native-speaking doctors and by using recordings. Doctors using interpreters should try to make sure that everything said is translated and check the patient''s answers by asking questions in several ways.     

Psychoactive substance use among medical students in a Nigerian university

The study was aimed at determining the prevalence, pattern and factors associated with psychoactive substance use among medical students in the University of Ilorin, Nigeria. All consenting medical students were requested to compile a 22-item modified, pilot-tested semi- structured self-report questionnaire based on the World Health Organization''s guidelines for student substance use survey. It was found that the most currently used substances were mild stimulants (33.3%), alcohol (13.6%), sedatives (7.3%) and tobacco (3.2%). Except for tobacco, the use of these substances seemed to be only instrumental. Substance use was directly associated with male gender, living alone, self-reported study difficulty, being a clinical student, and being aged 25 years or more. There was an inverse relationship of substance use with religiosity and good mental health.     

Teaching and Research at Marine Stations: Present Priorities, Future Directions

SYNOPSIS. A conflict exists at many universities today betweenthe demand to maintain a competitive position as a researchinstitution, contributing to the rapidly advancing scholarshipin science, and the need to provide available and sympatheticcommunication between undergraduate students and the most vigorousfaculty. This conflict is especially apparent at marine stations.A marine station is usually geographically and politically isolatedfrom the main campus with its advantage of size and opportunitiesto obtain and share sophisticated equipment used in today'sscience. There is also a historical trend of smaller teachinglaboratories evolving into larger research-oriented facilities.And, financial support is not as readily available for researchand education in natural history and whole animal biology, idealsubjects for study at marine stations, as it is for some otherfields. In this presentation I examine the following questions:1. What is the role of teaching at marine stations today? 2.What are some of the current pressures that conflict with thisrole? and 3. What are some solutions to these conflicts? I approachthese questions from my experience as a teacher and researchscientist at a small marine station which has been concernedwith undergraduate teaching. I propose that marine field stationsof diverse sizes and roles, both teaching and research, canbe and should be supported financially and that this supportof diversity will return strong health to marine science nationallyand internationally.     

磁共振成像对乳腺肿瘤的诊断价值

乳腺癌是危及女性健康的常见恶性肿瘤之一,病死率较高,且发病年龄呈年轻化趋势。目前临床对乳腺疾病的检查方法很多,既往检查主要包括钼靶、超声等,因价格便宜、操作方便,已成为常规的乳腺疾病检查方法,但两者的敏感性和特异性较低并有自身的局限性。CT软组织分辨率较高,但检查过程中的X线剂量较大,并且动态增强时间较长,故作为乳腺钼靶的补充检查手段。这些检查方法对乳腺疾病均有不同的诊断意义,在当前众多诊断乳腺疾病方法中,具有无辐射,较高软组织分辨力及可多方位多层面成像的乳腺磁共振(MRI)成像有其独到的优势,某些方面能弥补超声和钼靶检查的局限性,乳腺磁共振可提供病灶形态学和增强血流动力学表现,可用于常规检查方法不能确诊病灶的鉴别诊断。乳腺肿瘤MRI成像对临床诊断、鉴别诊断及手术方案的选择有着极其重要的作用。本文就乳腺MRI影像技术、MRI影像学表现及其临床应用予以综述,探讨MRI在乳腺肿瘤中的应用。     

Response of Daphnia's Antioxidant System to Spatial Heterogeneity in Cyanobacteria Concentrations in a Lowland Reservoir

Many species and clones of Daphnia inhabit ecosystems with permanent algal blooms, and they can develop tolerance to cyanobacterial toxins. In the current study, we examined the spatial differences in the response of Daphnia longispina to the toxic Microcystis aeruginosa in a lowland eutrophic dam reservoir between June (before blooms) and September (during blooms). The reservoir showed a distinct spatial pattern in cyanobacteria abundance resulting from the wind direction: the station closest to the dam was characterised by persistently high Microcystis biomass, whereas the upstream stations had a significantly lower biomass of Microcystis. Microcystin concentrations were closely correlated with the cyanobacteria abundance (r = 0.93). The density of daphniids did not differ among the stations. The main objective of this study was to investigate how the distribution of toxic Microcystis blooms affects the antioxidant system of Daphnia. We examined catalase (CAT) activity, the level of the low molecular weight antioxidant glutathione (GSH), glutathione S-transferase (GST) activity and oxidative stress parameters, such as lipid peroxidation (LPO). We found that the higher the abundance (and toxicity) of the cyanobacteria, the lower the values of the antioxidant parameters. The CAT activity and LPO level were always significantly lower at the station with the highest M. aeruginosa biomass, which indicated the low oxidative stress of D. longispina at the site with the potentially high toxic thread. However, the low concentration of GSH and the highest activity of GST indicated the occurrence of detoxification processes at this site. These results demonstrate that daphniids that have coexisted with a high biomass of toxic cyanobacteria have effective mechanisms that protect them against the toxic effects of microcystins. We also conclude that Daphnia''s resistance capacity to Microcystis toxins may differ within an ecosystem, depending on the bloom''s spatial distribution.     

Education and training of preregistration house officers: the consultants' viewpoint.

OBJECTIVE--To determine the opinions, attitudes, and requirements of consultants responsible for preregistration house officers in the light of the General Medical Council''s Recommendations on General Clinical Training. DESIGN--A questionnaire was piloted asking 28 questions under the headings professional details, present training arrangements, effectiveness of current training, and perceived help required for implementing the recommendations. SETTING--Two teaching hospitals and nine district general hospitals in the Yorkshire region. SUBJECTS--33 consultants (19 physicians, 14 surgeons) responded to an hour long interview. RESULTS--The traditional teaching ward round, with clinical meetings, was the main educational provision for house officers. Under a quarter of respondents provided specific teaching, which rarely exceeded 30 minutes weekly. Many delegated teaching to other junior or non-medical staff. Few consultants assessed the effectiveness of teaching, and feedback to juniors was rudimentary. There was strong support for the apprenticeship system and concern that it should not be downgraded. Appointing educational supervisors and introducing a structured educational programme were approved theoretically. Pressure on consultants to work faster, participate in audit and management, and accept financial responsibility for their clinical work, coupled with the reduction in junior doctors'' hours, were considered to militate against educational developments. Many respondents felt frustrated and powerless. They would welcome an increased educational role but considered there must be conceptual, contractual, and financial changes. CONCLUSIONS--Fundamental changes are required by both consultants and management before the preregistration year can have proper educational value. Training in educational methods for consultants and a structured curriculum and formative assessment for trainees require recognition and financial support.     

National survey of hospital patients.

OBJECTIVE--To survey patients'' opinions of their experiences in hospital in order to produce data that can help managers and doctors to identify and solve problems. DESIGN--Random sample of 36 NHS hospitals, stratified by size of hospital (number of beds), area (north, midlands, south east, south west), and type of hospital (teaching or non-teaching, trust or directly managed). From each hospital a random sample of, on average, 143 patients was interviewed at home or the place of discharge two to four weeks after discharge by means of a structured questionnaire about their treatment in hospital. SUBJECTS--5150 randomly chosen NHS patients recently discharged from acute hospitals in England. Subjects had been patients on medical and surgical wards apart from paediatric, maternity, psychiatric, and geriatric wards. MAIN OUTCOME MEASURES--Patients'' responses to direct questions about preadmission procedures, admission, communication with staff, physical care, tests and operations, help from staff, pain management, and discharge planning. Patients'' responses to general questions about their degree of satisfaction in hospitals. RESULTS--Problems were reported by patients, particularly with regard to communication with staff (56% (2824/5020) had not been given written or printed information); pain management (33% (1042/3162) of those suffering pain were in pain all or most of the time); and discharge planning (70% (3599/5124) had not been told about warning signs and 62% (3177/5119) had not been told when to resume normal activities). Hospitals failed to reach the standards of the Patient''s Charter--for example, in explaining the treatment proposed and giving patients the option of not taking part in student training. Answers to questions about patient satisfaction were, however, highly positive but of little use to managers. CONCLUSIONS--This survey has highlighted several problems with treatment in NHS hospitals. Asking patients direct questions about what happened rather than how satisfied they were with treatment can elucidate the problems that exist and so enable them to be solved.     

网络云交互技术辅助外科实践教学的创新应用探索

目的:探索传统教学模式结合网络云交互技术在外科实践教学中的应用效果。方法:于我校2011级五年制临床医学专业本科生中选取76人,随机平均分为两组,分别采取单纯传统大课教学模式、传统教学结合网络云交互技术教学模式;课程结束后进行闭卷理论考试和实践操作考试,综合两项成绩进行评定。同时向两组学员发放调查问卷,以此评价使用网络云交互技术辅助教学的效果。结果:采取传统教学结合网络云交互技术教学模式组的成绩优于采取单纯传统教学模式组,两组成绩差异具有统计学意义(P0.05)。结论:在传统教学模式的基础上添加网络云交互技术更能激发学生的学习兴趣,大大提高了学习效率,更有利于本科生外科实践的教学以及教学资源的整合及教学档案的建立。     

Choosy reef fish select cleaner fish that provide high-quality service

Reef fish that actively visit cleaner fish to have parasites and dead or infected tissue removed face two potential problems: they might have to wait while cleaners inspect other clients, and cleaners might feed on healthy body tissue, a behaviour that is referred to as cheating. Individuals of some ‘client’ species have large home ranges, which cover several cleaning stations, while others have small territories or home ranges with access to only one cleaning station. The former can thus choose between cleaners, while the latter cannot. We investigated whether clients with large home ranges change cleaning partners to outplay cleaners against each other to achieve (1) priority of access over clients with no choice at cleaning stations and (2) control over cheating by cleaners. We followed individuals of longnosed parrotfish, Hipposcarus harid, for up to 120 min in their natural environment and noted their interactions with cleaner wrasses, Labroides dimidiatus. Individuals were likely to return to the same cleaning station if the previous interaction had ended without conflict but changed cleaners for the next inspection if they had been either cheated or ignored, at least if the time between two consecutive visits was short. The overall attractiveness of a cleaning station seemed to be largely independent of service quality, which appeared to be similar at all stations. This is the first empirical evidence that the option to change partners is used as a control mechanism to stabilize cooperative behaviour.     

Prevalence of Gardnerella vaginalis: an estimate

To assess the prevalence of Gardnerella vaginalis in the community 300 women aged 16-59 were randomly selected from a general practice''s age-sex register and invited to attend for a health check. Out of 282 women who were eligible to attend, 192 did so. They were asked whether they had any vaginal symptoms, and swabs were taken from 182 women for culture for G vaginalis. Sixty women were positive for G vaginalis, of whom 26 had symptoms.Infections with G vaginalis may be present in women who have no symptoms. By careful questioning, examination, and side room testing general practitioners may be able to diagnose these infections in such women consulting them for other reasons.     

Can primary prevention or selective screening for melanoma be more precisely targeted through general practice? A prospective study to validate a self administered risk score.

OBJECTIVES: To establish whether a questionnaire incorporating MacKie''s risk factor flow chart can identify patients at high risk for melanoma so that they can be targeted for primary and secondary prevention. To validate the risk score derived from the questionnaire and test the feasibility of self completion by comparing patients'' self reported skin characteristics with a skin examination performed by an experienced general practitioner. DESIGN: Prospective questionnaire survey followed by a comparative study. SETTING: 16 randomly selected group practices in a health district in Cheshire, United Kingdom. SUBJECTS: Questionnaire survey--3105 consecutive patients aged 16 years and over attending for a primary care consultation; comparative study--a self selected subsample of 388 of the 3,105 patients. MAIN OUTCOME MEASURES: MacKie risk group for melanoma. Comparison of high risk skin characteristics reported by patients and those noted during a skin examination by a doctor (kappa statistic). RESULTS: 4.3% of patients (87% women) were in the highest risk group and 4.4% (79% men) were in the second highest risk group, as defined by the MacKie score. Agreement between patients'' self appraisal of skin characteristics and clinical skin examinations was reflected in kappa values of 0.67 for freckles, 0.60 for moles, and 0.43 for atypical naevi. CONCLUSION: This questionnaire helped to identify a group at high risk for melanoma. Furthermore, good agreement was found when the patient''s risk scores were compared with results of the clinical skin examination. This risk score is potentially useful in targeting primary and secondary prevention of melanoma through general practice.     

Winter bait stations as a multispecies survey tool

Winter bait stations are becoming a commonly used technique for multispecies inventory and monitoring but a technical evaluation of their effectiveness is lacking. Bait stations have three components: carcass attractant, remote camera, and hair snare. Our 22,975 km² mountainous study area was stratified with a 5 × 5 km sampling grid centered on northern Idaho and including portions of Washington, Montana, and British Columbia. From 2010–14, we conducted 563 sampling sessions at 497 bait stations in 453 5 × 5 km cells. We evaluated the effectiveness of cameras and hair snare DNA collection at stations to detect species and individual animals, factors affecting DNA viability, the effectiveness of re‐visiting stations, and the influence of elevation, seasonality, and latency on species detections. Cameras were more effective at detecting multiple species than DNA hair snaring. Length of deployment time and elevation increased genetic species ID success but individual ID success rates were increased only by collecting hairs earlier in the season. Re‐visiting stations did not change camera or genetic species detection results but did increase the number of individual genotypes identified. Marten and fisher were detected quickly while bobcat and coyote showed longer latency to detection. Seasonality significantly affected coyote and bobcat detections but not marten, fisher, or weasel. Multispecies bait station study design should incorporate mixed elevation sites with stratified seasonality. Priority should be given to including cameras as components of bait stations over hair snares, unless there is a specific genetic goal to the study. A hair snare component should be added, however, if individual ID or genetic data are necessary. Winter stations should be deployed a minimum of 45–60 days to allow for detection of low density species and species with long latency to detection times. Hair samples should be collected prior to DNA‐degrading late season rain events. Re‐visiting stations does not change which species are detected at stations; therefore, studies with objectives to delineate species presence or distribution will be more effective if they focus on deploying more stations across a broader landscape in lieu of surveying the same site multiple times.