The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education.

The Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC) is a redesign of the principal clinical year to foster students' learning from close and continuous contact with cohorts of patients in the disciplines of internal medicine, neurology, obstetrics-gynecology, pediatrics, and psychiatry. With year-long mentoring, students follow their patients through major venues of care. Surgery and radiology also are taught longitudinally, grounded in the clinical experiences of a cohort of patients and in a brief immersion experience working directly with an attending surgeon. Students participate in weekly, case-based tutorials integrating instruction in the basic sciences with training to address the common and important issues in medicine, as identified by national organizations. In addition, they participate in a social science curriculum that focuses on self-reflection, communication skills, ethics, population sciences, and cultural competence. In the pilot year (July 2004 to July 2005), HMS-CIC students performed at least as well as traditional students in tests of content knowledge and skills, as measured by National Board of Medical Examiners (NBME) Subject Exams and the fourth-year Objective Structured Clinical Exam, and they scored higher on a year-end comprehensive clinical skills self-assessment examination, suggesting that they retained content knowledge better. From surveys, HMS-CIC students were much more likely to see patients before diagnosis and after discharge and to receive feedback and mentoring from experienced faculty than were their traditionally educated peers. HMS-CIC students expressed more satisfaction with their curriculum and felt better prepared to cope with the professional challenges of patient care, such as being truly caring, involving patients in decision making, and understanding how the social context affects their patients.     

Repaving the road to academic success: the IMeRGE approach to peer mentoring.

In recent years, academic health centers have made a considerable effort to encourage medical students and physicians-in-training to consider academic medicine as a career choice. For physicians, selecting a career in academic medicine may be the first hurdle, but the challenge of successfully maintaining an academic career is perhaps a more formidable task. Mentoring is a much-needed response to this challenge. But the success of traditional mentoring programs at academic institutions is often limited by, among other things, the availability of senior faculty who can serve as mentors. The authors describe the formation and organization of the Internal Medicine Research Group at Emory (IMeRGE), an innovative peer mentoring group within the Division of General Medicine at Emory University. This group, born partially out of the mentoring needs of our women and minority faculty, shared the primary goal of fostering a collaborative atmosphere among junior faculty, while simultaneously acquiring experience through advanced faculty development. The authors present our methods of garnering division support for designated time and financial resources, defining member responsibilities, developing a curriculum, providing peer support, and seeking advisors with expertise in the areas on which we wished to focus. In addition to the development of IMeRGE, the authors provide an overview of the pros and cons of traditional mentoring versus peer mentoring; discuss the challenges faced by IMeRGE and strategies for addressing these issues; and present the paradigm of IMeRGE as a template for alternative forms of academic mentorship.     

Faculty development in teaching skills: an intensive longitudinal model.

Although reflection contributes to the personal growth of clinician-educators and is important for effective teaching, few teaching skills programs report its use. The Johns Hopkins Faculty Development Program in Teaching Skills, first implemented in 1987 as a theoretically grounded, longitudinal model for faculty development of clinician-educators, comprises a set of conditions intended to promote reflective learning. This paper describes the program and reports evaluation results for 98 participants and a comparison group of 112 nonparticipants between 1988 and 1996. Participants met with facilitators weekly for nine months for 3.5 hours, in stable groups of four to six individuals. Educational methods used across seven content areas emphasized relationships and collaboration, and included information provision, experiential learning with reflection, and personal awareness sessions. A pre-post evaluation design with comparison group measured changes in self-assessed teaching and professional skills, teaching enjoyment, and learning effectiveness. A post-only evaluation design appraised overall program quality, educational methods, facilitation, learning environment, and perceived impact of participation. Program participants had significantly greater pre-post-change scores than nonparticipants for all 14 outcomes (p <.05). Multiple regression modeling indicated that program participation was associated with pre-post improvement in all outcomes except administration skills, controlling for all participant and nonparticipant baseline characteristics (p <.05). All measured programmatic characteristics were highly rated by participants. Experiential methods with reflection were rated significantly higher than information-provision and personal awareness sessions (p <.001). Evaluation results demonstrate a positive impact of this alternative approach to faculty development on clinician-educator perceptions of their attitudes and behaviors towards learners and colleagues.     

The POD: a new model for mentoring underrepresented minority faculty.

Mentoring, long recognized as a catalyst for successful careers, is particularly important to the career development of underrepresented minority (URM) faculty. In academic medicine, mentor-protégé relationships are seriously threatened by increased clinical, research, and administrative demands and an emphasis on scholarship over citizenship. New mentoring models are needed, and they should be adaptable to a medical school's unique structure and mission. The Peer-Onsite-Distance (POD) model, developed in 2002 by the authors and introduced at the College of Medicine at the University of Arkansas for Medical Sciences, is a targeted, multilevel mentoring prototype that is built on a solid research foundation and tailored to the unique needs of URM medical school faculty. The mentee's individual needs for guidance related to career goals, resources, and the content and interaction skills that are known to be critical to successful academic careers are targeted for development. The multilevel approach provides a unique network of peer and faculty mentors who provide site-specific career guidance. Also in the network are leaders in their fields who can provide access to accurate information, cautions, predictions, and announcements of future resources or potential restrictions in academic medicine. Mentor commitments are clearly defined and time contributions are maximized. The POD model aims to promote retention and advance the careers of URM faculty by wrapping them in a protective cushion of interpersonal and intrapersonal support. The flexibility of the design allows for adaptation to any institution's unique structure and mission.     

Natural mentoring under the microscope: an investigation of mentoring relationships and latino adolescents' academic performance

The current study examined the role of natural mentoring relationships in the academic performance of urban, diverse, Latino high school students. Participants reported up to three mentors in their lives, and they were asked about their mentors' demographic characteristics and the characteristics of their mentoring relationships. The presence of a mentor was associated with fewer absences, higher educational expectations, and greater expectancies for success and sense of school belonging. Further, the number of reported mentors predicted fewer absences, higher educational expectations and a greater sense of school belonging. Mentors' educational level, frequency of contact, relationship duration, and total form of support provided by mentors were related to participants' academic outcomes. Mentor type also made a difference in youth's academic outcomes. Implications for future mentoring research and programs are discussed. © 2008 Wiley Periodicals, Inc.     

The Clinical Education Partnership Initiative: an innovative approach to global health education

Background

Despite evidence that international clinical electives can be educationally and professionally beneficial to both visiting and in-country trainees, these opportunities remain challenging for American residents to participate in abroad. Additionally, even when logistically possible, they are often poorly structured. The Universities of Washington (UW) and Nairobi (UoN) have enjoyed a long-standing research collaboration, which recently expanded into the UoN Medical Education Partnership Initiative (MEPI). Based on MEPI in Kenya, the Clinical Education Partnership Initiative (CEPI) is a new educational exchange program between UoN and UW. CEPI allows UW residents to partner with Kenyan trainees in clinical care and teaching activities at Naivasha District Hospital (NDH), one of UoN’s MEPI training sites in Kenya.

Methods

UW and UoN faculty collaborated to create a curriculum and structure for the program. A Chief Resident from the UW Department of Medicine coordinated the program at NDH. From August 2012 through April 2014, 32 UW participants from 5 medical specialties spent between 4 and 12 weeks working in NDH. In addition to clinical duties, all took part in formal and informal educational activities. Before and after their rotations, UW residents completed surveys evaluating clinical competencies and cross-cultural educational and research skills. Kenyan trainees also completed surveys after working with UW residents for three months.

Results

UW trainees reported a significant increase in exposure to various tropical and other diseases, an increased sense of self-reliance, particularly in a resource-limited setting, and an improved understanding of how social and cultural factors can affect health. Kenyan trainees reported both an increase in clinical skills and confidence, and an appreciation for learning a different approach to patient care and professionalism.

Conclusions

After participating in CEPI, both Kenyan and US trainees noted improvement in their clinical knowledge and skills and a broader understanding of what it means to be clinicians. Through structured partnerships between institutions, educational exchange that benefits both parties is possible.

     

The HVJ-envelope as an innovative vector system for cardiovascular disease

Recently promising results of gene therapy clinical trials have been reported for treatment of peripheral vascular and cardiovascular diseases using various angiogenic growth factors and other therapeutic genes. Viral vector and non-viral vector systems were employed in preclinical studies and clinical trials. Adenoviral vector and naked plasmid have been used most in the clinical studies. HVJ (hemagglutinating virus of Japan or Sendai virus)-liposome vector, a hybrid non-viral vector system with fusion of inactivated HVJ virus particle and liposome, has developed and demonstrated high transfection efficiency in preclinical studies of many different disease models, including a wide range of cardiovascular disease models. However, some limitations exist in the HVJ-liposome technology, especially in the scalability of its production. Recently an innovative vector technology, HVJ envelope (HVJ-E) has been developed as a non-viral vector, consisting of HVJ envelope without its viral genome, which is eliminated by a combination of inactivation and purification steps. HVJ-E is able to enclose various molecule entities, including DNA, oligonucleotides, proteins, as single or multiple therapeutic remedies. The therapeutic molecule-included HVJ-E vector can transfect various cell types in animals and humans with high efficiency. In this review, vector technology for cardiovascular disease and the biology of HVJ-E vector technology is discussed.     

Laboratory identification of factor inhibitors: an update

Coagulation factor inhibitors comprise antibodies that bind to and then neutralise specific pro-coagulant plasma proteins. Coagulation factor inhibitors can develop against any coagulation factor, although the most common are against factor VIII (FVIII). These can develop in individuals with inherited haemophilia A (HA) as an immune response to factor replacement therapy, or as auto-antibodies leading to the condition of acquired HA. Clinical suspicion for inhibitors may arise when individuals present with bleeding symptoms without any prior bleeding diathesis, or when a patient with known mild haemophilia presents with a bleeding diathesis more extreme to their usual presentation, or when there is failure of factor replacement therapy to arrest bleeding in a known haemophiliac. The laboratory identification of factor inhibitors requires a careful and systematic approach that excludes other possible causes of prolonged screening tests, most commonly the activated partial thromboplastin time (APTT), and sometimes prothrombin time (PT). Coagulation factor inhibitor studies, including the Bethesda assay, are then undertaken to measure inhibitor titre, which guides treatment. This paper overviews the laboratory investigation of factor inhibitors, and also briefly reviews recent cross-laboratory inhibitor studies and the most recent evidence related to differential inhibitor formation according to type of therapy.     

Self and peer assessment in tutorials: application of a relative-ranking model.

PURPOSE: While self assessment continues to be touted as being of paramount importance for continuing professional competence, problem-based learning curricula, and adult learning theory, techniques for ensuring valid judgments have proven elusive. This study tested the applicability of an innovative relative-ranking procedure to problem-based learning tutorials. METHOD: A total of 36 students in the McMaster University Faculty of Health Sciences' MD program were provided relative-ranking forms listing seven domains of competence along with their definitions. The student, two of the student's peers, and the student's tutor were asked to complete the ranking exercise after their second, fourth, and sixth tutorials. RESULTS: Combining each level of the time and rater variables generated 66 correlation coefficients, none of which was significantly different from zero. Re-performing the analysis on only the extreme domains did not improve this result. CONCLUSION: The relative-ranking instrument developed did not prove to be a reliable measure of tutorial performance. Ratings were inconsistent from one week to the next as well as across raters within a week.     

Carbon monoxide: innovative anti-inflammatory properties of an age-old gas molecule

Observations of the effects of carbon monoxide (CO) on mammalian systems have been known for thousands of years. To be sure, CO is deadly under certain conditions and concentrations, but perhaps as the data presented here will make clear, it also possesses other diverse functional and immunomodulatory properties. This review, together with the other reviews in this issue, will detail that over the past three decades, fundamental functional role(s) for this gas molecule are beginning to emerge. This review outlines that at low concentrations, exogenously administered CO is a molecule involved in the regulation of the inflammatory response in a variety of disease models. CO has been shown to modulate such cellular functions as cytokine production, cell proliferation and apoptosis, protecting the lungs and hearts of rodents from such stressors as endotoxin, ischemia/reperfusion injury, cardiac xenograft rejection, and asthma. Although the mechanism by which this simple diatomic gas provides this protection remains obscure, the conclusions are the same: CO at low concentrations, concentrations that are well below those that would otherwise create toxic effects, is proving beneficial in models of acute injury. CO, akin to nitric oxide, is proving to be an extraordinary signaling molecule generated by the cell that is vital in the regulation of cellular homeostasis.