Withholding or Withdrawing Extraordinary Life Support—Optimizing Rights and Limiting Liability

For many years physicians, ethicists and members of the legal community have attempted to minimize ambiguity and unpredictability in making decisions to withhold or withdraw extraordinary life support. Recent developments in national and California law now afford medical care providers unparalleled protection from criminal and civil liability in surrogate decision-making situations. They also reinforce the concept of patient''s rights by providing medical care consumers with new and effective mechanisms for enforcing their “right to decide,” even after they have lost decision-making capacity. A case in point is California''s new Durable Power of Attorney for Health Care, which serves as a model for other jurisdictions that do not have such legislation. Thus, the medical and legal professions, working together, can contribute immeasurably to respectful medical decision making by educating the public about these developments and by adopting policies that reinforce these rights.     

Collective Intelligence Meets Medical Decision-Making: The Collective Outperforms the Best Radiologist

While collective intelligence (CI) is a powerful approach to increase decision accuracy, few attempts have been made to unlock its potential in medical decision-making. Here we investigated the performance of three well-known collective intelligence rules (“majority”, “quorum”, and “weighted quorum”) when applied to mammography screening. For any particular mammogram, these rules aggregate the independent assessments of multiple radiologists into a single decision (recall the patient for additional workup or not). We found that, compared to single radiologists, any of these CI-rules both increases true positives (i.e., recalls of patients with cancer) and decreases false positives (i.e., recalls of patients without cancer), thereby overcoming one of the fundamental limitations to decision accuracy that individual radiologists face. Importantly, we find that all CI-rules systematically outperform even the best-performing individual radiologist in the respective group. Our findings demonstrate that CI can be employed to improve mammography screening; similarly, CI may have the potential to improve medical decision-making in a much wider range of contexts, including many areas of diagnostic imaging and, more generally, diagnostic decisions that are based on the subjective interpretation of evidence.     

Ruling out pulmonary embolism across different healthcare settings: A systematic review and individual patient data meta-analysis

BackgroundThe challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings.Methods and findingsWe performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the “failure rate” of each strategy—i.e., the proportion of missed PE among patients categorized as “PE excluded” and “efficiency”—defined as the proportion of patients categorized as “PE excluded” among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust.ConclusionsThe capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

Geert-Jan Geersing and colleagues assess the capability of ruling-out pulmonary embolism by available diagnostic strategies across a range of healthcare settings.     

Resuscitation with an AED: putting the data to use

The increased use of the automated external defibrillator (AED) contributes to the rising survival rate after sudden cardiac arrest in the Netherlands. When used, the AED records the unconscious person’s medical data (heart rhythm and information about cardiopulmonary resuscitation), which may be important for further diagnosis and treatment. In practice, ethical and legal questions arise about what can and should be done with these ‘AED data’. In this article, the authors advocate the development of national guidelines on the handling of AED data. These guidelines should serve two purposes: (1) to safeguard that data are handled carefully in accordance with data protection principles and the rules of medical confidentiality; and (2) to ensure nationwide availability of data for care of patients who survive resuscitation, as well as for quality monitoring of this care and for related scientific research. Given the medical ethical duties of beneficence and fairness, existing (sometimes lifesaving) information about AED use ought to be made available to clinicians and researchers on a structural basis. Creating a national AED data infrastructure, however, requires overcoming practical and organisational barriers. In addition, further legal study is warranted.     

Inside the Mind of a Medicinal Chemist: The Role of Human Bias in Compound Prioritization during Drug Discovery

Medicinal chemists’ “intuition” is critical for success in modern drug discovery. Early in the discovery process, chemists select a subset of compounds for further research, often from many viable candidates. These decisions determine the success of a discovery campaign, and ultimately what kind of drugs are developed and marketed to the public. Surprisingly little is known about the cognitive aspects of chemists’ decision-making when they prioritize compounds. We investigate 1) how and to what extent chemists simplify the problem of identifying promising compounds, 2) whether chemists agree with each other about the criteria used for such decisions, and 3) how accurately chemists report the criteria they use for these decisions. Chemists were surveyed and asked to select chemical fragments that they would be willing to develop into a lead compound from a set of ∼4,000 available fragments. Based on each chemist’s selections, computational classifiers were built to model each chemist’s selection strategy. Results suggest that chemists greatly simplified the problem, typically using only 1–2 of many possible parameters when making their selections. Although chemists tended to use the same parameters to select compounds, differing value preferences for these parameters led to an overall lack of consensus in compound selections. Moreover, what little agreement there was among the chemists was largely in what fragments were undesirable. Furthermore, chemists were often unaware of the parameters (such as compound size) which were statistically significant in their selections, and overestimated the number of parameters they employed. A critical evaluation of the problem space faced by medicinal chemists and cognitive models of categorization were especially useful in understanding the low consensus between chemists.     

2009 Society for Medical Anthropology Conference: Training,Communication, and Competence: The Making of Health Care Professionals

The role of medical anthropology in tackling the problems and challenges at the intersections of public health, medicine, and technology was addressed during the 2009 Society for Medical Anthropology Conference at Yale University in an interdisciplinary panel session entitled Training, Communication, and Competence: The Making of Health Care Professionals.The discipline of medical anthropology is not very formalized in the health setting. Although medical anthropologists work across a number of health organizations, including schools of public health, at the Centers for Disease Control (CDC), and at non-governmental organizations (NGOs), there is an emerging demand for an influential applied medical anthropology that contributes both pragmatically and theoretically to the health care field.The role of anthropology at the intersections of public health, medicine, and technology was addressed during the 2009 Society for Medical Anthropology Conference at Yale University in September. In a conference session entitled Training, Communication, and Competence: The Making of Health Care Professionals, health professional career issues, including training and education, medical entrepreneurship, and the maintenance of clinical relationships with patients were examined. The presentations encompassed macro approaches to institutional reform in training, education, and health care delivery, as well as micro studies of practitioner-patient interaction. Seemingly disparate methodological, disciplinary, and theoretical orientations were united to assess the increasing relevance of medically oriented anthropology in addressing the challenges of health care delivery, health education, and training.Margaret Bentley, a professor of public health at the University of North Carolina, Chapel Hill, spoke about the increasing “epidemic of global health” in universities, noting a doubling of global health majors within the past three years. Despite this expansion of the field, a common discipline of global health continues to be developed. In September, the Association of Schools of Public Health (ASPH) and the University of Minnesota hosted a Global Health Core Competency Development Consensus Conference with the initiative to explore “workforce needs, practice settings, and to identify core constructs, competency domains, and a preliminary global health competency model”¹. Given the current variability in training, Bentley believes medical anthropology is uniquely suited to inform training in global health because of its offerings in the way of interdisciplinary methods and team-based applied field experience.Anthropologists Carl Kendall of Tulane University and Laetitia Atlani of Université de Paris X Nanterre have seen medical anthropologists examine models of health strictly within a clinical experience. Understanding of the social determinants of epidemiology, methodological issues of population health, and survey research is crucial. However, training individuals through a more formalized program (currently in development in Europe) will allow anthropologists to better understand context, explain complex models, humanize aggregate statistics, and articulate methods of the multidimensional “social field” of health outside of the clinical experience.The social field of health, however, as Robert Like of the University of Medicine and Dentistry of New Jersey explained, shares an uncomfortable interface with clinical medicine. Recent efforts by the New Jersey Board of Examiners to incorporate cultural competency legislation have been robustly criticized. Evaluations of six-hour training sessions on cultural competency training have revealed health professionals’ frustration with the health care system’s inability to deal with “culturally different” individuals. In fact, the majority of health professionals who were required to complete the training believe cultural competency to be an area of study that is a “waste of time.”This opposition to cross-cultural education and the value of “cultural competence” training also has been a topic of great debate among anthropologists and health researchers. Despite the ubiquitous use of the term among research and health professionals, cultural competency is a term that cannot be defined precisely enough to operationalize.In “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It,” Arthur Kleinman and Peter Benson asserted that the static notion of culture in the medical field “suggests that a culture can be reduced to a technical skill for which clinicians can be trained to develop expertise” [1]. T.S. Harvey, a linguistic and medical anthropologist at the University of California, Riverside, expounded on Kleinman’s opposition to competence as an acquired “technical skill” [1] and suggested reconceptualizing the approach to competence as communication. Although Kleinman’s explanatory models approach [2] provides a health care professional with what to ask the patient, Harvey pulls from Dell Hymes’ communicative competence [3] to understand how to ask it. Harvey recommended viewing competence as a “sociolinguistic acquisition … like a foreign language” where competencies are rule-governed and communication and speech events are formulaic.Harvey also noted that the “onus of cultural competency” is too often placed on the practitioner. Inevitably, there is an asymmetry in every clinical encounter, whereby the “would-be patient” is perpetually considered the “passive receptor.” Patients also share a stake in their health and, as such, should be taught communicative competence as well.Harvey also noted that the “onus of cultural competency” is too often placed on the practitioner. Inevitably, there is an asymmetry in every clinical encounter, whereby the “would-be patient” is perpetually considered the “passive receptor.” Patients also share a stake in their health and, as such, should be taught communicative competence as well.The role of the patient is made ever more complex by the power relationship that exists in the patient-provider context. Through ethnographic research, Sylvie Fainzang, director of research in the Inserm (Cermes), examines how doctors and patients lie. She argues that lying, in the context of secrecy, is an indication of a power relationship [4]. Fainzaing’s further research on the relationship between doctors and patients has yielded additional information on how patients learn about their diagnoses and how they will react to these diagnoses. Though a clinical encounter between a doctor and patient is expected to be one of informed consent, doctors often judge patients upon their ability to “intellectually understand” [4] and assess who is “psychologically ready” [4] to bear the information. This leads to manipulated, misinformed, and “resigned consent” [4]. This sort of social training of obligation of a subject to medical authority provides the patient with the choice either to conform or overthrow the rules as defined by society.Collectively, this interdisciplinary panel worked to inform the discussion on how medical anthropology can address training, communication, and competence at the intersections of medicine, public health, and education. By reviewing health professionals’ growing interest in public health, training in health education and competence, and the patient-provider relationship, medical anthropology can be seen as both relevant and necessary to addressing the challenges faced by the medical and health community today.     

Medical Education and Research: The Foundations of Quality Health Care

In May 1964 the Royal Commission on Health Services declared that “health research is essential to health progress”. However, since that time the means of providing adequate health care have received far less attention than have methods of payment for physicians'' services. Because medical education and research is the source from which all other health benefits flow, urgent attention must be paid to the adequate support of teacher-scientists, as set forth in the Woods, Gordon (Gundy) report. It is the numbers and quality of these men and women, more than any other factor, that will determine the shape of medical science and, hence, medical practice in Canada in the future. Expensive as it is, Canadian medicine and Canadian medical scientists must have generous support if medical care in this country is to be of high quality.     

ANALYSIS OF ABSENTEEISM IN INDUSTRY

There are many nonmedical factors that contribute to employee absenteeism in industry. An employee''s total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.The role of a private physician in determining and certifying the true state of a patient''s health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners.     

When Action Meets Emotions: How Facial Displays of Emotion Influence Goal-Related Behavior

Many authors have proposed that facial expressions, by conveying emotional states of the person we are interacting with, influence the interaction behavior. We aimed at verifying how specific the effect is of the facial expressions of emotions of an individual (both their valence and relevance/specificity for the purpose of the action) with respect to how the action aimed at the same individual is executed. In addition, we investigated whether and how the effects of emotions on action execution are modulated by participants'' empathic attitudes. We used a kinematic approach to analyze the simulation of feeding others, which consisted of recording the “feeding trajectory” by using a computer mouse. Actors could express different highly arousing emotions, namely happiness, disgust, anger, or a neutral expression. Response time was sensitive to the interaction between valence and relevance/specificity of emotion: disgust caused faster response. In addition, happiness induced slower feeding time and longer time to peak velocity, but only in blocks where it alternated with expressions of disgust. The kinematic profiles described how the effect of the specificity of the emotional context for feeding, namely a modulation of accuracy requirements, occurs. An early acceleration in kinematic relative-to-neutral feeding profiles occurred when actors expressed positive emotions (happiness) in blocks with specific-to-feeding negative emotions (disgust). On the other hand, the end-part of the action was slower when feeding happy with respect to neutral faces, confirming the increase of accuracy requirements and motor control. These kinematic effects were modulated by participants'' empathic attitudes. In conclusion, the social dimension of emotions, that is, their ability to modulate others'' action planning/execution, strictly depends on their relevance and specificity to the purpose of the action. This finding argues against a strict distinction between social and nonsocial emotions.     

Contact Trees: Network Visualization beyond Nodes and Edges

Node-Link diagrams make it possible to take a quick glance at how nodes (or actors) in a network are connected by edges (or ties). A conventional network diagram of a “contact tree” maps out a root and branches that represent the structure of nodes and edges, often without further specifying leaves or fruits that would have grown from small branches. By furnishing such a network structure with leaves and fruits, we reveal details about “contacts” in our ContactTrees upon which ties and relationships are constructed. Our elegant design employs a bottom-up approach that resembles a recent attempt to understand subjective well-being by means of a series of emotions. Such a bottom-up approach to social-network studies decomposes each tie into a series of interactions or contacts, which can help deepen our understanding of the complexity embedded in a network structure. Unlike previous network visualizations, ContactTrees highlight how relationships form and change based upon interactions among actors, as well as how relationships and networks vary by contact attributes. Based on a botanical tree metaphor, the design is easy to construct and the resulting tree-like visualization can display many properties at both tie and contact levels, thus recapturing a key ingredient missing from conventional techniques of network visualization. We demonstrate ContactTrees using data sets consisting of up to three waves of 3-month contact diaries over the 2004-2012 period, and discuss how this design can be applied to other types of datasets.     

Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt

California''s Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.     

Facial EMG Responses to Emotional Expressions Are Related to Emotion Perception Ability

Although most people can identify facial expressions of emotions well, they still differ in this ability. According to embodied simulation theories understanding emotions of others is fostered by involuntarily mimicking the perceived expressions, causing a “reactivation” of the corresponding mental state. Some studies suggest automatic facial mimicry during expression viewing; however, findings on the relationship between mimicry and emotion perception abilities are equivocal. The present study investigated individual differences in emotion perception and its relationship to facial muscle responses - recorded with electromyogram (EMG) - in response to emotional facial expressions. N° = °269 participants completed multiple tasks measuring face and emotion perception. EMG recordings were taken from a subsample (N° = °110) in an independent emotion classification task of short videos displaying six emotions. Confirmatory factor analyses of the m. corrugator supercilii in response to angry, happy, sad, and neutral expressions showed that individual differences in corrugator activity can be separated into a general response to all faces and an emotion-related response. Structural equation modeling revealed a substantial relationship between the emotion-related response and emotion perception ability, providing evidence for the role of facial muscle activation in emotion perception from an individual differences perspective.     

Neurofunctional Correlates of Ethical,Food-Related Decision-Making

For consumers today, the perceived ethicality of a food’s production method can be as important a purchasing consideration as its price. Still, few studies have examined how, neurofunctionally, consumers are making ethical, food-related decisions. We examined how consumers’ ethical concern about a food’s production method may relate to how, neurofunctionally, they make decisions whether to purchase that food. Forty-six participants completed a measure of the extent to which they took ethical concern into consideration when making food-related decisions. They then underwent a series of functional magnetic resonance imaging (fMRI) scans while performing a food-related decision-making (FRDM) task. During this task, they made 56 decisions whether to purchase a food based on either its price (i.e., high or low, the “price condition”) or production method (i.e., with or without the use of cages, the “production method condition”), but not both. For 23 randomly selected participants, we performed an exploratory, whole-brain correlation between ethical concern and differential neurofunctional activity in the price and production method conditions. Ethical concern correlated negatively and significantly with differential neurofunctional activity in the left dorsolateral prefrontal cortex (dlPFC). For the remaining 23 participants, we performed a confirmatory, region-of-interest (ROI) correlation between the same variables, using an 8-mm3 volume situated in the left dlPFC. Again, the variables correlated negatively and significantly. This suggests, when making ethical, food-related decisions, the more consumers take ethical concern into consideration, the less they may rely on neurofunctional activity in the left dlPFC, possibly because making these decisions is more routine for them, and therefore a more perfunctory process requiring fewer cognitive resources.     

Uncovering a Microbial Enigma: Isolation and Characterization of the Streamer-Generating,Iron-Oxidizing,Acidophilic Bacterium “Ferrovum myxofaciens”

A betaproteobacterium, shown by molecular techniques to have widespread global distribution in extremely acidic (pH 2 to 4) ferruginous mine waters and also to be a major component of “acid streamer” growths in mine-impacted water bodies, has proven to be recalcitrant to enrichment and isolation. A modified “overlay” solid medium was devised and used to isolate this bacterium from a number of mine water samples. The physiological and phylogenetic characteristics of a pure culture of an isolate from an abandoned copper mine (“Ferrovum myxofaciens” strain P3G) have been elucidated. “F. myxofaciens” is an extremely acidophilic, psychrotolerant obligate autotroph that appears to use only ferrous iron as an electron donor and oxygen as an electron acceptor. It appears to use the Calvin-Benson-Bassham pathway to fix CO₂ and is diazotrophic. It also produces copious amounts of extracellular polymeric materials that cause cells to attach to each other (and to form small streamer-like growth in vitro) and to different solid surfaces. “F. myxofaciens” can catalyze the oxidative dissolution of pyrite and, like many other acidophiles, is tolerant of many (cationic) transition metals. “F. myxofaciens” and related clone sequences form a monophyletic group within the Betaproteobacteria distantly related to classified orders, with genera of the family Nitrosomonadaceae (lithoautotrophic, ammonium-oxidizing neutrophiles) as the closest relatives. On the basis of the phylogenetic and phenotypic differences of “F. myxofaciens” and other Betaproteobacteria, a new family, “Ferrovaceae,” and order, “Ferrovales,” within the class Betaproteobacteria are proposed. “F. myxofaciens” is the first extreme acidophile to be described in the class Betaproteobacteria.     

Psychiatry and Psychotherapy: Is a Divorce Imminent?

Despite the long tradition of psychiatrists practicing psychotherapy, many psychiatric and medical leaders are predicting and urging a reorientation of psychiatry toward the medical model. They would leave psychotherapy to psychologists, social workers and the like. Many social, governmental and institutional factors favor such a change. The marriage of psychiatry and psychotherapy has always been an uneasy one, and the push for divorce may be irresistible. The author cautions that a divorce could be detrimental to medicine by substituting, in the name of “science,” a dehumanized, technological psychiatry for the current “moral” treatment. One alternative to divorce is a broader approach to psychiatry, combining biological, neuromedical, socioenvironmental and psychodynamic factors. The divorce, though imminent, should be resisted.     

Clinical Decision Support: Effectiveness in Improving Quality Processes and Clinical Outcomes and Factors That May Influence Success

The use of electronic health records has skyrocketed following the 2009 HITECH Act, which provides financial incentives to health care providers for the “meaningful use” of electronic medical record systems. An important component of the “Meaningful Use” legislation is the integration of Clinical Decision Support Systems (CDSS) into the computerized record, providing up-to-date medical knowledge and evidence-based guidance to the physician at the point of care. As reimbursement is increasingly tied to process and clinical outcomes, CDSS will be integral to future medical practice. Studies of CDSS indicate improvement in preventive services, appropriate care, and clinical and cost outcomes with strong evidence for CDSS effectiveness in process measures. Increasing provider adherence to CDSS recommendations is essential in improving CDSS effectiveness, and factors that influence adherence are currently under study.     

Primum Utilis Esse: The Primacy of Usefulness in Medicine

The famous and oft-quoted maxim “Do no harm” should not be thought of as the first principle of medical ethics. The documents of the Hippocratic tradition and clinical experience indicate that a more appropriate and helpful first principle would be “Above all, be useful.” The concept of usefulness implicitly rests at the very heart of medicine itself and the physician-patient relationship. The failure to adhere to this concept undermines the physician-patient relationship, dissolves the distinction between quacks and physicians, and destroys the integrity of the medical profession. The determination of useful medical treatment belongs to both physicians and patients. Any decision to initiate, continue, or discontinue diagnostic or therapeutic action has both a medical and a personal value component; the former properly belongs to physicians and the latter to patients. Practicing medicine with the intent of producing benefit and being useful to the patient is far more fundamental than practicing medicine to avoid harm.     

The Invisible Prevalence of Citizen Science in Global Research: Migratory Birds and Climate Change

Citizen science is a research practice that relies on public contributions of data. The strong recognition of its educational value combined with the need for novel methods to handle subsequent large and complex data sets raises the question: Is citizen science effective at science? A quantitative assessment of the contributions of citizen science for its core purpose – scientific research – is lacking. We examined the contribution of citizen science to a review paper by ornithologists in which they formulated ten central claims about the impact of climate change on avian migration. Citizen science was never explicitly mentioned in the review article. For each of the claims, these ornithologists scored their opinions about the amount of research effort invested in each claim and how strongly the claim was supported by evidence. This allowed us to also determine whether their trust in claims was, unwittingly or not, related to the degree to which the claims relied primarily on data generated by citizen scientists. We found that papers based on citizen science constituted between 24 and 77% of the references backing each claim, with no evidence of a mistrust of claims that relied heavily on citizen-science data. We reveal that many of these papers may not easily be recognized as drawing upon volunteer contributions, as the search terms “citizen science” and “volunteer” would have overlooked the majority of the studies that back the ten claims about birds and climate change. Our results suggest that the significance of citizen science to global research, an endeavor that is reliant on long-term information at large spatial scales, might be far greater than is readily perceived. To better understand and track the contributions of citizen science in the future, we urge researchers to use the keyword “citizen science” in papers that draw on efforts of non-professionals.     

What can experience add to early medical education? Consensus survey

Objective To provide a rationale for integrating experience into early medical education (“early experience”).Design Small group discussions to obtain stakeholders'' views. Grounded theory analysis with respondent, internal, and external validation.Setting Problem based, undergraduate medical curriculum that is not vertically integrated.Participants A purposive sample of 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom.Results Without early experience, the curriculum was socially isolating and divorced from clinical practice. The abruptness of students'' transition to the clinical environment in year 3 generated positive and negative emotions. The rationale for early experience would be to ease the transition; orientate the curriculum towards the social context of practice; make students more confident to approach patients; motivate them; increase their awareness of themselves and others; strengthen, deepen, and contextualise their theoretical knowledge; teach intellectual skills; strengthen learning of behavioural and social sciences; and teach them about the role of health professionals.Conclusion A rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualise, and integrate medical education. This is partly a process of professional socialisation that should start earlier to avoid an abrupt transition. “Experience” can be defined as “authentic human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional.”