How optional should regional anatomy be in a medical course? An opinion piece

The use of optional (elective) courses within the medical curriculum is increasingly being seen as a way of allowing students to pursue their studies according to their personal interests. For anatomy, particularly where the subject is being taught in an integrative curriculum and by means of a systemic approach, the development of elective regional anatomy courses is being employed to reintroduce regional anatomy and/or dissection by students. However, there is presently little evidence that objectively evaluates optional/elective courses. In this paper we critique the concept and practice of using elective courses and assess whether their deployment is ultimately in the interests of medical education, the medical profession, society in general and the layperson (potential patient) in particular. Clin. Anat. 29:702–710, 2016. © 2016 Wiley Periodicals, Inc.     

Do we need dissection in an integrated problem-based learning medical course? Perceptions of first- and second-year students

BACKGROUND: The introduction of a problem-based learning (PBL) curriculum at the School of Medicine of the University of Melbourne has necessitated a reduction in the number of lectures and limited the use of dissection in teaching anatomy. In the new curriculum, students learn the anatomy of different body systems using PBL tutorials, practical classes, pre-dissected specimens, computer-aided learning multimedia and a few dissection classes. The aims of this study are: (1) to assess the views of first- and second-year medical students on the importance of dissection in learning about the anatomy, (2) to assess if students' views have been affected by demographic variables such as gender, academic background and being a local or an international student, and (3) to assess which educational tools helped them most in learning the anatomy and whether dissection sessions have helped them in better understanding anatomy. METHODS: First- and second-year students enrolled in the medical course participated in this study. Students were asked to fill out a 5-point Likert scale questionnaire. Data was analysed using Mann-Whitney's U test, Wilcoxon's signed-ranks or the calculation of the Chi-square value. RESULTS: The response rates were 89% for both first- and second-year students. Compared to second-year students, first-year students perceived dissection to be important for deep understanding of anatomy (P < 0.001), making learning interesting (P < 0.001) and introducing them to emergency procedures (P < 0.001). Further, they preferred dissection over any other approach (P < 0.001). First-year students ranked dissection (44%), textbooks (23%), computer-aided learning (CAL), multimedia (10%), self-directed learning (6%) and lectures (5%) as the most valuable resources for learning anatomy, whereas second-year students found textbooks (38%), dissection (18%), pre-dissected specimens (11%), self-directed learning (9%), lectures (7%) and CAL programs (7%) as most useful. Neither of the groups showed a significant preference for pre-dissected specimens, CAL multimedia or lectures over dissection. CONCLUSIONS: Both first- and second-year students, regardless of their gender, academic background, or citizenship felt that the time devoted to dissection classes were not adequate. Students agreed that dissection deepened their understanding of anatomical structures, provided them with a three-dimensional perspective of structures and helped them recall what they learnt. Although their perception about the importance of dissection changed as they progressed in the course, good anatomy textbooks were perceived as an excellent resource for learning anatomy. Interestingly, innovations used in teaching anatomy, such as interactive multimedia resources, have not replaced students' perceptions about the importance of dissection.     

General medical practice as a guideline for preclinical anatomy teaching? The veins

Summary The amount of time assigned for teaching anatomy to medical undergraduates has been drastically reduced in all countries of the world during the 'sixties. This restriction has intensified the debate about the contents to be taught. The present study is intended to be a contribution to defining, against this background, a tronc commun, a basic stock of anatomical knowledge that should be required from every medical student, whatever clinical speciality he may eventually engage in. The criterion proposed is the need of anatomical knowledge in general medical practice. With regard to the veins, the following conclusions have emerged from a questionnaire directed to general practitioners: 1) 92.8% of the vessels were agreed upon by the physicians asked. 2) General medical relevance was granted to 9.6% of the vessels mentioned in the international anatomical nomenclature. These results, which are in accordance with those recorded for the other chapters investigated so far, suggest that an adaptation of the amount of information taught to the time disponible in our days is possible, without endangering the basic knowledge necessary for general clinical practice. But the results also show that any reduction beneath the time necessary for teaching these notions jeopardizes the fundamental education indispensable to every physician. Thus, they clearly contradict tendencies considering that anatomy has become a branch that can be neglected in modern medical curricula.

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L'enseignement préclinique de l'anatomie : la médecine générale pour fil conducteur? L'exemple des veines

Résumé Le temps imparti à l'enseignement préclinique de l'anatomie a universellement subi une forte réduction dans les années soixante. Cette amputation a ravivé les controverses sur les programmes à enseigner, quantitativement et qualitativement. La présente étude essaye, dans ce contexte, de contribuer à la définition d'untronc commun d'anatomie, devant être exigé de tout étudiant en médecine, indépendamment d'une éventuelle spécialisation clinique ultérieure. Le critère proposé est celui du besoin de connaissances anatomiques enpratique médicale générale. Reposant sur une enquête faite auprès d'un échantillon de généralistes, les résultats suivants concernant les veines ont été obtenus : 1) 92,8 % des veines ont fait l'objet d'une appréciation unanime par les médecins interrogés. 2) 9,6 % des veines répertoriées dans l'actuelle nomenclature anatomique internationale ont été jugées indispensables à la pratique de la médecine générale. Ces résultats, qui concordent avec ceux enregistrés pour les autres éléments ou systèmes examinés jusqu'à présent, suggèrent qu'une adaptation de l'enseignement de l'anatomie aux horaires disponibles de nos jours est possible, sans que les connaissances nécessaires à la pratique de la médecine générale soient compromises. Ces résultats montrent aussi que l'on ne peut pas enseigner l'anatomie en-deça de ces limites quantitatives sans mettre en danger la formation fondamentale nécessaire à tout médecin. Ils contredisent donc nettement certaines tendances considérant l'anatomie comme une discipline devenue négligeable dans un curriculum médical moderne.

     

Talking medicine: a course in medical humanism--what do third-year medical students think?

OBJECTIVE: The early 1990s sparked an interest in organized medicine to reclaim and re-evaluate how it promotes professionalism among physicians. The American Board of Internal Medicine (ABIM) launched Project Professionalism as a means to define and evaluate professionalism as a component of clinical competence. The course "Talking Medicine" was developed to create a series of small-group discussions on humanism and professionalism where students can reflect on the process of becoming a physician and share personally or ethically difficult and rewarding cases with each other. We asked students to define these concepts and use these definitions to spark small-group discussion. DESCRIPTION: "Talking Medicine" is predicated on the belief that humanism and professionalism come to students and others through understanding a number of core concepts and relationships complemented by self-reflection. "Talking Medicine" offers a consistent (every other week for ten weeks) opportunity to share experiences in small groups (six to eight students), facilitated by two preceptors, in a format driven by students' experiences. Although the focus is on students' experiences, readings are provided on basic topics and contexts in humanism and professionalism (e.g., end-of-life care, mistakes, spirituality in medicine, and boundaries between patients and doctors). Also, at the beginning of each internal medicine clerkship we asked students to define humanism and professionalism anonymously on sheets of paper to be handed to the preceptors. DISCUSSION: "Talking Medicine" began in summer 2000. We hope to expand it to other institutions. We surveyed students and found 94% felt "very" or "somewhat" comfortable in the course. Seventy-three percent of students reported that the course increased their "connectedness" to classmates, and 61% favored its occurring during all rotations. Fifty-nine percent reported that their interest in caring for patients improved, and 53% reported their interest in internal medicine as a field improved. Answers to open-ended questions highlighted the importance of "Talking Medicine" as a forum to connect with others-both students and faculty. Despite this course's focus during an internal medicine clerkship, students see a broader definition of professionalism than the ABIM; the student's definitions were similar in many ways to the Group of Educational Affairs definition of professionalism. Third-year medical students focus more on tolerance of difference (e.g., race, socioeconomic status, and varying health beliefs), and the importance of collegiality and collaboration in the new environment of patient care. Their vantage point early in training allows them to look critically at the profession they are joining and view its shortcomings and strengths. Future work is needed that focuses on how these definitions change as students' progress through fourth year, into residency, and finally continuing medical education. Nevertheless, we suggest that "Talking Medicine" may be most effective in helping classmates connect to and learn from each other, thereby setting a foundation for changes in how they interact with patients.     

What future for dissection in courses of human topographical anatomy in universities in the UK?

In the United Kingdom most medical schools have traditionally included dissection as a major component of their anatomy courses. There is a dearth of substantive literature which can be used to demonstrate the educational values of dissection, although many authors have expressed opinions. Current scrutiny of the role of dissection has been prompted by many influences acting on medical schools in the UK, including changes in the medical curriculum promoted by the General Medical Council, changes in the mechanisms of funding for universities and their courses, and the introduction of research assessments and appraisal of teaching. It is probable that in the UK dissection will continue to decline but that its reduced role will be prompted by the interactions of many complicated processes, only some of which will be educationally driven. © 1995 WiIey-Liss, Inc.     

Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors

In recent decades wide-ranging changes have occurred in medical school curricula. Time spent studying gross anatomy has declined amidst controversy as to how, what, and when teaching is best delivered. This reduced emphasis has led to concerns amongst clinicians that a new generation of doctors are leaving medical school with insufficient anatomical knowledge. Previous studies have established that medical students value their anatomy teaching during medical school. None have sought to establish views on the sufficiency of this teaching. We investigate the opinions of newly qualified doctors at a UK medical school and relate these opinions to career intentions and academic performance in the setting of a traditional dissection and prosection-based course. Overall nearly half of respondents believe they received insufficient anatomy teaching. A substantial proportion called for the integration of anatomy teaching throughout the medical school course. Trainees intent on pursuing a surgical career were more likely to believe anatomy teaching was insufficient than those pursuing a nonsurgical career; however, overall there was no statistical difference in relation to the mean for any individual career group. This study adds to the current debates in anatomical sciences education, indicating that overall, regardless of career intentions, new doctors perceive the need for greater emphasis on anatomical teaching.     

Bioinformatics for medical students: a 5-year experience using OMIM® in medical student education

PurposeGiven advances in genomic medicine, medical students need increased confidence in clinical genetics skills to address multiple genetic conditions. After success of first-year medical school instruction in the Online Mendelian Inheritance in Man (OMIM®) database, we report the impact on gaining confidence in broad clinical genetics skills in 5 subsequent years.MethodsWe collected 5 years of successive pre- and postintervention survey based self-assessments on medical student use of genetic medicine information resources and confidence in genetic medicine skills. To assess retention of confidence in these skills, we administered a follow-up survey to students after 1–2 years of clinical rotations.ResultsWe found a consistent, statistically significant increase in students’ confidence in clinical genetics skills after the first-year OMIM educational session, with confidence retention above baseline up to 2 years after the educational exposure. Skills include ability to generate a differential diagnosis for genetic conditions, share information with patients and families, and find accurate information on genetic conditions. The majority agreed that increased use of OMIM will better prepare students to achieve these skills.ConclusionIntegration of the OMIM database in first-year education is an effective instructional tool that may provide a lasting increase in confidence in clinical genetics skills.     

Subsyndromal depression: an impact on quality of life?

OBJECTIVE: The objective of this study was to demonstrate the association between quality of life and subsyndromal depression in a primary care clinic in a Brazilian sample. METHODS: This was a cross-sectional study. The cases were divided into three groups according to the severity of depressive symptoms: 1) subjects with major depressive disorder; 2) subjects with subsyndromal depression; 3) subjects without depressive symptoms--controls. The participants completed the World Health Organization Instrument to Assess Quality of Life (WHOQOL-BREF), the Quality of Life--Depression (QLDS), the Centers for Epidemiologic Studies--Depression instrument (CES-D), and the Composite International Diagnostic Interview (CIDI). RESULTS: The sample consisted of 438 primary care users (35.2% of them had subsyndromal depression). The subjects with major depression presented the worst impairment of quality of life, which was measured by the WHOQOL-BREF and the QLDS. The patients with subsyndromal depression had a smaller impact on their quality of life and the subjects without depression presented an even lower impact. The hierarchical linear regression involving demographic variables and the severity of depressive symptoms showed that the severity of depression was the variable with higher correlation with quality of life dimensions, presenting increased variation in the domains (from 9% to 24%). CONCLUSIONS: The results suggest that subsyndromal depression causes impairment of the quality of life in primary care patients of a Brazilian sample.     

Are medical students being taught anatomy in a way that best prepares them to be a physician?

Reasoning in a clinical context is an attribute of medical expertise. Clinical reasoning in medical school can be encouraged by teaching basic science with a clinical emphasis. The aim of this study was to investigate whether anatomy is being taught in a way that facilitates the development of clinical reasoning. Two multiple‐choice tests on thoracic anatomy were developed using a modified Delphi approach with groups of four clinical consultants and four teachers, respectively, expressing their opinions about knowledge relevant to thoracic anatomy. Validity was assessed by administering the tests to clinical consultants, anatomy teachers, and pre‐course medical students. Post‐course medical students took both tests to explore the focus of the course, i.e., whether it facilitated clinical reasoning. The pre‐course students scored significantly lower than the teachers and post‐course students on both tests and lower than the consultants on the consultants’ test (P < 0.001 for all comparisons). The teachers significantly outperformed the consultants (P = 0.03 on the consultants’ test, P < 0.001 on the teachers’ test) and the medical students (P < 0.001 on both tests). The post‐course students scored significantly lower on the consultants’ test (P = 0.001) and significantly higher on the teachers’ test (P = 0.02) than the consultants. This study demonstrates poor performances by medical students on a test containing clinically relevant anatomy, implying that the teaching they have received has not encouraged clinical reasoning. Clin. Anat. 28:568–575, 2015. © 2015 Wiley Periodicals, Inc.     

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: Is there an association?

Objective

Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students’ overall student performance on a multi-station clinical skills assessment (CSA) examination.

Methods

This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student–SP encounters.

Results

PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students’ PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing.

Conclusions

Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing.

Practice implications

Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.     

The impact of acute stress on cognitive functioning: a matter of cognitive demands?

Introduction: There is a controversy in the literature whether stress and related cortisol responses are beneficial or impairing for cognitive functioning. Conflicting results might be due to individual differences in stress reactivity and cognitive load of the applied tasks.

Methods: N?=?48 participants underwent the Socially Evaluated Cold Pressor Test and were confronted with the Frankfurter Aufmerksamkeits-Inventar-2 (FAIR-2) which is a low-load attention task and two subscales of the Intelligenz-Struktur-Test 2000 R (I-S-T 2000R) as a high-load reasoning task before and after the stressor. Participants were post hoc divided into high (stress induced cortisol increase of ≥1.5?nmol/l) vs. low-cortisol responders.

Results: Cortisol responders showed an increased attentional performance in the post-stress condition (η²?>?.14). However, there were neither stress or responder main effects nor an interaction effect on reasoning abilities.

Conclusions: Results of the present study show that stress related changes in cognitive performance are due to individual differences in cortisol response and the cognitive load of the performed task. Future studies will show if these results are also valid for alternative cognitive tasks and if they can be replicated in female participants.     

Specialist training in medical microbiology across Europe in 2021—an update on the actual training situation based on a survey

BackgroundThe importance of defining and establishing professional standards for Clinical Microbiology (CM) in Europe has long been highlighted, starting with the development of a European curriculum. The first European Curriculum in Medical Microbiology (MM) was adopted by the European Union of Medical Specialists (UEMS) council in 2017.ObjectivesThis paper assesses how training programmes in CM in Europe align with the European curriculum, just under 5 years after its introduction, and reviews what methods of assessment are in use to assess the CM trainees' progress during training programmes.SourcesUsing an internet-based platform, a questionnaire was circulated to the full, associate and observer members of the UEMS MM section. Information collected related to the structure, content and delivery of CM training in the participating countries, as well as methods of assessment used to evaluate training progress.ContentTwenty-one countries responded, from a total of 30 countries invited to participate. All had a structured CM training programme, with a curriculum, dedicated trainers and a record of training activities. Fifteen countries require trainees to pass an exit examination, and over 60% of countries participate in continuous workplace-based assessment. Of the participating countries, 57% meet the European Training Requirements recommendation that duration of specialist training is 60 months. Regarding core competencies, all trainees gain experience in laboratory skills and infection prevention and control, but the emphasis on clinical management and antimicrobial stewardship is more varied across countries.ImplicationsThe UEMS MM curriculum has been largely adopted by 21 countries within less than 5 years of ratification, which speaks optimistically to a future of standardized quality training across Europe. The introduction of a pilot European Examination in Clinical Microbiology in 2021 is the start of a pan-European assessment of the success of the implementation of this curriculum and the first step in quality assurance for CM training in Europe.     

The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care?

OBJECTIVES: To examine race differences in knowledge of the Tuskegee study and the relationship between knowledge of the Tuskegee study and medical system mistrust. METHODS: We conducted a telephone survey of 277 African-American and 101 white adults 18-93 years of age in Baltimore, MD. Participants responded to questions regarding mistrust of medical care, including a series of questions regarding the Tuskegee Study of Untreated Syphilis in the Negro Male (Tuskegee study). RESULTS: Findings show no differences by race in knowledge of or about the Tuskegee study and that knowledge of the study was not a predictor of trust of medical care. However, we find significant race differences in medical care mistrust. CONCLUSIONS: Our results cast doubt on the proposition that the widely documented race difference in mistrust of medical care results from the Tuskegee study. Rather, race differences in mistrust likely stem from broader historical and personal experiences.     

Sleeping in? The impact of age and depressive sub-type on hypersomnia

BACKGROUND: While early morning wakening is held to be a classic feature of melancholia, we investigate the clinical observation that young patients with melancholia and bipolar depression tend to be more likely to report hypersomnia. METHODS: We examine age-related rates of those two sleep disturbance patterns in a consecutive set of out-patients with differing depressive sub-types assessed over a 20-year period. RESULTS: Hypersomnia was more likely to be reported than early morning wakening across all age bands by those with non-melancholic depression. Hypersomnia was also more likely than early morning wakening in younger patients with melancholia and bipolar disorder but, with age, early morning wakening became the dominant pattern. LIMITATIONS: The study was retrospective, undertaken in a sample attending a tertiary referral unit and artefactual determinants of the associations were not pursued. CONCLUSIONS: We speculate that hypersomnia may be a non-specific homeostatic coping response to stress and thus to the non-melancholic depressive disorders, but that this pattern is overruled by an early morning wakening pattern in the more biological depressive sub-types as the individual ages, perhaps reflecting a noradrenergic contribution.     

The significance of E266K polymorphism in the NOD1 gene on Helicobacter Pylori infection: an effective force on pathogenesis?

The severity of Helicobacter pylori-related diseases varies greatly among infected individuals and seems to be influenced by both host and bacterial factors. Infection with a cytotoxin-associated gene pathogenicity island (Cag PAI)-positive H. Pylori strain causes a higher grade of gastric mucosal inflammation than an infection caused by a negative strain. Furthermore, such an infection is associated with severe atrophic gastritis and gastric adenocarcinoma. NOD1 protein is a cytosolic pattern recognition receptor that responds to peptidoglycan delivered by H. Pylori cag pathogenicity island. The aim of this study is to investigate whether the presence of the NOD1 G796A polymorphism has any influence on the clinical outcomes of Cag PAI-positive H. Pylori. Both Helicobacter pylori and CagA-positive 150 patients were considered eligible for the study. In this selected group, NOD1 G796A was detected by using polymerase chain reaction/restriction fragment length polymorphism. Activity and severity of gastritis, atrophy, intestinal metaplasia and Helicobacter pylori density were assessed in body and antral biopsies. Also post-therapy controls for predicting Helicobacter pylori persistence were done. The correlations of these parameters were determined by SPSS 15 packet program for statistical analysis. Of the 150 CagA-positive patients, 57 had (38%) heterozygote (GA), and 29 had (19.3%) homozygote (AA) mutant variants of NOD1. The other 64 patients had (42.7%) wild-type DNA(GG). NOD1 796A allele carriers had higher risk for antral atrophy (OR = 13.35, 95% CI = 5.12–34.82) and antral intestinal metaplasia (OR = 2.71, 95% CI = 1.26–5.80). Carriage of the single nucleotide polymorphism of NOD1 G796A proved to be a significant risk factor for the Helicobacter pylori therapy failure (OR = 4.62, 95% CI = 1.67–12.79). Our results suggest that carriage of the NOD1 G796A mutation increases the susceptibility of gastric epithelial cells for intestinal metaplasia and atrophy when infected by CagA-positive Helicobacter pylori strains. Additionally, it increases the ratio of eradication failure.     

Are pharmacy-based minor ailment schemes a substitute for other service providers?: A systematic review

Background

Pharmacy-based minor ailment schemes (PMASs) have been introduced throughout the UK to reduce the burden of minor ailments on high-cost settings, including general practice and emergency departments.

Aim

This study aimed to explore the effect of PMASs on patient health- and cost-related outcomes; and their impact on general practices.

Design and setting

Community pharmacy-based systematic review.

Method

Standard systematic review methods were used, including searches of electronic databases, and grey literature from 2001 to 2011, imposing no restrictions on language or study design. Reporting was conducted in the form recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist.

Results

Thirty-one evaluations were included from 3308 titles identified. Reconsultation rates in general practice, following an index consultation with a PMAS, ranged from 2.4% to 23.4%. The proportion of patients reporting complete resolution of symptoms after an index PMAS consultation ranged from 68% to 94%. No study included a full economic evaluation. The mean cost per PMAS consultation ranged from £1.44 to £15.90. The total number of consultations and prescribing for minor ailments at general practices often declined following the introduction of PMAS.

Conclusion

Low reconsultation and high symptom-resolution rates suggest that minor ailments are being dealt with appropriately by PMASs. PMAS consultations are less expensive than consultations with GPs. The extent to which these schemes shift demand for management of minor ailments away from high-cost settings has not been fully determined. This evidence suggests that PMASs provide a suitable alternative to general practice consultations. Evidence from economic evaluations is needed to inform the future delivery of PMASs.     

“Who writes what?” Using written comments in team-based assessment to better understand medical student performance: a mixed-methods study

Background

Observation of the performance of medical students in the clinical environment is a key part of assessment and learning. To date, few authors have examined written comments provided to students and considered what aspects of observed performance they represent. The aim of this study was to examine the quantity and quality of written comments provided to medical students by different assessors using a team-based model of assessment, and to determine the aspects of medical student performance on which different assessors provide comments.

Methods

Medical students on a 7-week General Surgery & Anesthesiology clerkship received written comments on ‘Areas of Excellence’ and ‘Areas for Improvement’ from physicians, residents, nurses, patients, peers and administrators. Mixed-methods were used to analyze the quality and quantity of comments provided and to generate a conceptual framework of observed student performance.

Results

1,068 assessors and 127 peers provided 2,988 written comments for 127 students, a median of 188 words per student divided into 26 “Areas of Excellence” and 5 “Areas for Improvement”. Physicians provided the most comments (918), followed by patients (692) and peers (586); administrators provided the fewest (91). The conceptual framework generated contained four major domains: ‘Student as Physician-in-Training’, ‘Student as Learner’, ‘Student as Team Member’, and ‘Student as Person.’

Conclusions

A wide range of observed medical student performance is recorded in written comments provided by members of the surgical healthcare team. Different groups of assessors provide comments on different aspects of student performance, suggesting that comments provided from a single viewpoint may potentially under-represent or overlook some areas of student performance. We hope that the framework presented here can serve as a basis to better understand what medical students do every day, and how they are perceived by those with whom they work.

     

The use of oncolytic vaccinia viruses in the treatment of cancer: a new role for an old ally?

The use of genetically engineered, tumor-targeting viruses as oncolytic agents has recently emerged as a promising new area for the development of novel cancer therapies. The first viruses to enter the clinic, such as ONYX-015 (an oncolytic adenovirus), provided evidence both for the safety and for the anti-tumor potential of this approach. The results of these early trials have also allowed investigators to examine the limitations of these viruses and to develop potentially far more effective approaches. In this review the development of such next generation viruses, in particular the potential use of strains of vaccinia virus, will be discussed. Vaccinia has an enormous history of use in humans and possesses many of the features felt to be beneficial for the creation of a successful virotherapy agent. It causes no known disease in humans, yet is capable of infecting almost all cell types with a subsequent rapid and lytic infection, which subsequently induces a vigorous local CTL immune response at the site of infection. Vaccinia also displays natural tumor tropism, and several approaches have been used to further limit viral replication to tumor cells and to optimize the immune response induced at the site of the tumor. Finally, the large cloning capacity of vaccinia allows for the addition of multiple foreign genes into the viral genome. This has been exploited to increase the bystander effect of the virus by immune modulation or by expression of pro-drug converting enzymes as well as to incorporate safety controls and reporters for in vivo molecular imaging. Initial clinical trials with these viruses further highlights their potential as the next generation of oncolytic agents and as highly effective future cancer therapies.