Future role of neurologists.

Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson''s disease, multiple sclerosis, Alzheimer''s disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.     

In Memoríam

Mental retardation is a symptom of an underlying disease process. In California state hospitals for the retarded an accurate dynamic diagnosis is possible through utilizing the knowledge of neurology, psychiatry, pediatrics, psychology, social service, rehabilitation, education, the laboratory and trained psychiatric technicians. A program of "custody" is archaic and we are returning to the concept of training, treatment, and turnover. This kind of program is essential in order to avoid building new hospitals at the cost of millions of dollars every few years.Parent organizations for retarded children are expanding in ever increasing number. Special education programs in public schools, foster care homes and sheltered workshops may make admission to hospitals unnecessary and aid return of patients to the community.     

A University/Community Hospital Family Practice Residency Program

A residency program associated with a major university has many obvious advantages. On the other hand, a residency program located in an area of health manpower shortage is a major advantage to that community. This paper describes the development of a university affiliated family practice residency in the Mojave Desert of Southern California. It reports that it is possible to form a successful alliance between a medical center and a rural community, bringing increased primary care to the community, upgrading the quality of medicine practiced in the community and augmenting the staff of the local hospital without sacrificing training for the family practice residents. Furthermore, the residency program can become financially self-sufficient.     

The residency application abyss: insights and advice

Most medical students apply for residency training upon completion of medical school. The choice of specialty is one of a student's first major career decisions, and the application process often results in considerable anxiety, as it is competitive, unpredictable, and requires a significant investment of time and money. This article, which addresses several important facets of the residency application using both experiential and evidence-based data, is organized chronologically into sections that describe a logical approach to applying for residency: choice of a specialty, the personal statement, the interview day, and developing a rank list. A list of relevant websites is also included. This paper is a resource that provides timely and tangible guidance to medical students applying for residency training.     

Morbidity,Mortality and Medical Care in the Keewatin Area of the Central Arctic—1967

The available medical facilities in the Keewatin area of Canada''s Central Arctic have been described, along with the problems relating to provision of medical care. Causes of death and population statistics for 1967 have been detailed. The more frequent disease conditions have been discussed.Recommendations for improvements in medical care have been made; these include research into various conditions, an increased number of specialist visits and the inclusion of Churchill Hospital in a residency training program. Other recommendations relate to community planning, community sanitation and employment opportunities.     

加强军队医院非现役编制医务人员卫生勤务保障能力的重要性

目的:调查军队医院非现役编制医务人员的军事素质和卫勤保障意识,探讨提升该群体卫勤保障能力的重要性和必要性,为军队医院卫勤管理提供参考。方法:采用问卷调查的方式对我院154名非现役编制医务人员进行调查,主要包括军事理论、卫生勤务、突发事件应急管理及战伤急救等,分析非现役编制医务人员缺乏的基本军事素质,并提出针对性的加强军队医院文职人员卫生勤务保障能力的可行性培训计划,在培训结束时对医护人员的军事素质进行测评。结果:问卷调查结果:非现役文职人员的军事素质评分为(3.70±0.46)、卫生勤务能力评分为(2.48±0.91)、突发事件应急管理评分为(2.61±0.53)、战伤急救技能评分为(2.42±1.02)。测评结果:军事理论知识评分为(4.11±1.04)、卫生勤务能力评分为(4.78±1.37)、突发事件应急意识评分为(4.56±0.56)、战伤急救技能评分为(4.68±0.91)。培训后,非现役医务人员的卫勤保障能力显著提高,差异具有统计学意义(P0.05)。结论:非现役文职作为军队医院的聘用制人员已成为医务工作的主要力量,因此军队医院应加强非现役医务人员的卫生勤务保障能力,提高我军后勤医疗保障的坚固力量。     

Hospitals' response to the buckle-up baby legislation in Ontario.

Drivers in Ontario are legally responsible to ensure that infants and toddlers are restrained in a child safety seat or by a lap belt. In 1982 the minister of health sent a memorandum to all medical officers of health and the administrators and medical directors of all public hospitals in Ontario, urging them to encourage and assist parents in protecting their newborn children with safety seats. In 1983 the Toronto General Hospital established the Cooperative Hospital Infant Restraint Program (CHIRP) to study the feasibility of a "loaner" program for hospitals in metropolitan Toronto. The authors describe CHIRP and its objectives. They also report the results of a questionnaire they sent in 1984 to all Ontario hospitals that had a newborn or pediatric service to assess their response to the minister''s memorandum.     

Attitudes toward the use of gender-inclusive language among residency trainees

OBJECTIVE: To explore postgraduate medical trainees'' attitudes toward the use of gender-inclusive language. DESIGN: Self-administered questionnaire. SETTING: Seven residency training programs at McMaster University, Hamilton, Ont., from July 1993 to June 1994. PARTICIPANTS: Of 225 residents in the programs, 186 responded to the survey, for a response rate of 82.7%. Men and women were equally represented among the respondents. OUTCOME MEASURES: Categorization of attitudes about the use of language as gender-inclusive or gender-exclusive; characteristics predicting a gender-inclusive attitude. RESULTS: Factor analysis and Cronbach''s alpha (0.90) supported the existence of a construct related to attitudes about language use, the poles of which were categorized as gender-inclusive and gender-exclusive. The authors classified residents with respect to their attitudes to language use from their responses to the questionnaire. In univariate analyses, sex, residency program and country of graduation significantly predicted a gender-inclusive attitude (p < 0.01). Only the first 2 variables were significant in a multivariate model; residency program explained 18% of the variance and sex 3%. Residents in obstetrics and gynecology and psychiatry had the most gender-inclusive attitudes, whereas residents in surgery and anesthesia had the most gender-exclusive attitudes. CONCLUSIONS: Residents'' values are reflected in the language they choose to use. Language use may provide an index of underlying attitudes that may create hostile environments for female trainees.     

Establishing a robust chimeric antigen receptor T-cell therapy program in Australia: the Royal Prince Alfred Hospital experience

>himeric antigen receptor (CAR) T-cell therapy is a novel approved cancer treatment that has shown remarkable efficacy in the treatment of patients with relapsed leukemia and lymphoma. Implementation of CAR T-cell therapy in a hospital setting requires careful and detailed planning because of the complexities in delivering this specialist service. A multi-disciplinary approach with dedicated funding is required to meet clinical, scientific, logistic and regulatory requirements. Tisagenlecleucel was the first approved CAR T-cell therapy in Australia. The treatment has been made available to Australian patients in specialist public hospitals through federal and state funding. Royal Prince Alfred Hospital (RPAH) is one of Australia's oldest tertiary referral public health care institutions and was approved for the provision of CAR T-cell therapy service in 2019. A multi-disciplinary clinical program has been established for the collection and cryopreservation of donor cells shipped for manufacturing as well as for the receipt, storage and administration of CAR T-cell therapy and patient management. The program encompasses a Therapeutic Goods Administration-accredited apheresis unit and a state-of-the-art facility for cell processing, cryopreservation and storage. The program's clinical expertise extends to hematology, oncology, intensive care, pharmacy, neurology and radiology services with direct experience in managing patients receiving CAR T-cell therapies. The introduction of CAR T-cell therapies at RPAH was a complex undertaking facilitated by the existing infrastructure and clinical expertise.     

Denny-Brown, Boston City Hospital, and the history of American neurology

Harvard University's Neurological Unit at Boston City Hospital (BCH) became the premier center for neurological training in the United States during the middle part of the 20th century. During part of this period (1939-1967), it was directed by Derek Denny-Brown, who had been recruited from England by Harvard president James Conant. The training program that Denny-Brown initiated at BCH emphasized neurology as a medical specialty, independent of psychiatry and neurosurgery. This program, which reflected Denny-Brown's British training, was remarkably effective and served as a model for rest of the country.     

Clinical skills of medical residents: a review of physical examination.

Students are introduced to techniques of physical examination at medical school. However, their skills are deficient at the time of graduation, and with the increasing shift of clinical teaching away from the bedside and into the conference room it is expected that these skills will weaken in succeeding generations of physicians. A practical and satisfactory method of addressing this problem during internship and residency training has not been forthcoming because of the lack of a regular forum for the teaching of clinical skills in busy tertiary referral hospitals and the shortage of teachers with the necessary skills and commitment to teaching a large number of house staff. We describe a program whose unique hierarchical approach has permitted a detailed ongoing review of physical examination. One clinician was able to teach 24 residents by instructing a small group of senior residents, who in turn, after practising with clinical clerks, taught groups of junior residents.     

Conducting clinical research in the new NHS: the model of cancer. United Kingdom Coordinating Committee on Cancer Research.

The United Kingdom Coordinating Committee on Cancer Research represents the major organizations funding cancer research in the United Kingdom. The deliberations of a working party convened by the committee to evaluate recently expressed concerns that the changes in the NHS threaten research, especially clinical trials to evaluate new treatments, are reported. A survey of contributors to trials coordinated by the committee showed that half are now experiencing difficulties in continuing to participate in clinical trials. The two major problems identified were lack of time and of staff, especially for NHS staff in non-teaching hospitals. Recent changes in junior doctors'' hours and proposed reductions in the length of time for training will exacerbate this. It is possible to identify the direct and indirect excess costs of conducting research in the NHS, but currently the mechanism does not exist to designate funds specifically for this purpose. Consultation with the regional directors of research and development confirmed that the service increment for teaching and research is not the solution for this. Proposals are made to secure future clinical research in the NHS, including finance, indemnity, the licensing of new drugs, the greater use of nurse counsellors, and the value of cancer registries.     

WORKMEN'S COMPENSATION—Emphasis on Rehabilitation

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled.An effective workmen''s compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned.It is the physician''s responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.     

基于微课的翻转课堂在神经病学教学中的探索和实践

随着人口老龄化、人类工作与生存等各种压力增大以及生存环境的恶化,神经系统疾病的发病率呈逐年上升的趋势,如何 使医学生在掌握神经系统基础理论的同时,提高对神经系统疾病独立分析与判断的能力,为今后更好地胜任临床工作打下扎实 的基础是神经病学教学面临的重要问题。在神经病学教学中通过探索和实践基于微课的翻转课堂教学模式,把传统的学习过程 翻转过来,把知识传授的过程放在教室之外,而把知识内化的过程放在教室之内,改正了以往神经病学教学中学习内容枯燥难 懂、信息量大,学生难以消化、疲于上课等缺点,实现了“以学生为中心”的教学理念,激发了医学生学习兴趣和自主学习的能力, 大大提高学习效果,对培养他们将来成为具备国际竞争力的高素质医学人才打下了扎实的基础,为其他教学的临床教学提供一 定的经验和借鉴。     

Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989.

Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.     

Medical students as medical educators: opportunities for skill development in the absence of formal training programs

All physicians, at some point in their career, are responsible for the education of their peers and junior colleagues. Although medical students are expected to develop clinical and research skills in preparation for residency, it is becoming clear that a student should also be expected to develop abilities as a teacher. A handful of institutions have student-as-teacher programs to train medical students in education, but most students graduate from medical school without formal training in this area. When such a program does not exist, medical students can gain experience in education through participation in peer teaching, course design, educational committees, and medical education scholarship. In doing so, they attain important skills in the development, implementation, and evaluation of educational programs. These skills will serve them in their capacity as medical educators as they advance in their careers and gain increasing teaching responsibility as residents, fellows, and attending physicians.     

Establishment of a General Medicine Residency Training Program in Rural West Africa

Ghana, a developing country in West Africa, has major medical burdens in taking care of a large population with limited resources. Its three medical schools produce more than 200 graduates per year, but most emigrate to developed lands after training. Ghana is working to educate and retain locally trained physicians, but it is difficult to get them to work in rural settings where the need is greatest. This article details the establishment of a General Medicine residency at a 150-bed hospital in rural Ghana. Early training comprises 6 months each in Medicine, Surgery, OB/GYN, and Pediatrics; the hospital in Techiman also has a Surgery residency. House officers choose the program for more hands-on experience than they can get in larger centers. They perform many tasks, including surgery, sooner and more independently than do residents in developed countries. The training program includes a morning report, clinical teaching rounds, and rotations on in-patient wards and in the Emergency Department and clinics. Teaching focuses on history, physical examination, good communication, and proper follow-up, with rigorous training in the OR and some clinical research projects pertinent to Ghana. Trainees work hard and learn from one another, from a dedicated faculty, and by evaluating and treating very sick patients. Ghana’s rural residencies offer rigorous and attractive training, but it is too soon to tell whether this will help stem the “brain drain” of young physicians out of West Africa.     

Prélèvements à coeur arrêté : problèmes organisationnels

Non heart beating donor is now available in France. Pilots hospitals have tested the organisation in the french environment, and confirmed an increase of 20% of renal transplant. Educational program is necessary, as a good synchronisation between between medical emergency service (SAMU) which include not paramedics but french doctors. The last problems concern financial aspect, and probably the need to change the surgical teams to a multiorgan approach. A last ethical problem due to the developpement of therapeutical ECMO program is probably related to wrong informations.     

Increasing the effectiveness of clinical supervision.

Effective use of preceptors in the clinical training and supervision of residents involves four essential steps: careful screening of the preceptor''s practice to ensure it reflects the goals of the residency program and teaching the preceptor about the goals; setting a realistic contract for learning between resident and preceptor; teaching the preceptor to use constructive feedback techniques in the day-to-day supervision of residents; and developing the preceptor''s skills in the reliable and valid evaluation of the resident''s performance. Clinical preceptors must be trained to become effective teachers and evaluators in residency programs.     

Demonstrating social accountability in medical education

The author considers the University of Toronto''s Health, illness and the Community course for undergraduate medical students, described in this issue by Wasylenki and associates (see pages 379 to 383). Social accountability in medical education demands a community orientation and hence an emphasis on outreach. Medical schools should expand their clinical service to the community, provide community-based residency placements and offer continuing medical education in rural and regional centres. Accountability also requires community involvement in planning and implementing research projects. Placing students in a community setting as part of the curriculum is praiseworthy, but it is not sufficient to ensure social accountability. What is needed now is a more comprehensive acceptance by faculties of medicine of the mandate of community-centred learning, together with well-targeted funding for education and research initiatives.