Case analysis and justification of physicians, collective actions

Since the last 100 years, physicians from many countries have been taking collective action. However, the media, civic groups, and the government have denounced them as inhuman and unethical. This study comprehensively analyzed the background and results of physicians’ collective actions that occurred in countries around the world, and reviewed the issues surrounding them. Among 314 cases in 70 countries discussed in the literature, 180 cases in 65 countries were analyzed. Of these 180 cases, 111 (61.7%) were successful, indicating that collective action has brought favorable results to physicians. Furthermore, 177 out of 301 requirements brought favorable results (58.8%). The main reason for collective actions was ‘improvement of working conditions’, which includes improving the medical and the reimbursement systems, adjusting working hours and wages, increasing manpower, supporting medical research, and improving other working environment and conditions. This study is significant because it provides statistical data on the causes and results of collective actions taken by physicians in countries around the world.

Similarity of the cut score in test sets with different item amounts using the modified Angoff, modified Ebel, and Hofstee standard-setting methods for the Korean Medical Licensing Examination / 보건의료교육평가

Purpose@#The Korea Medical Licensing Exam (KMLE) typically contains a large number of items. The purpose of this study was to investigate whether there is a difference in the cut score between evaluating all items of the exam and evaluating only some items when conducting standard-setting. @*Methods@#We divided the item sets that appeared on 3 recent KMLEs for the past 3 years into 4 subsets of each year of 25% each based on their item content categories, discrimination index, and difficulty index. The entire panel of 15 members assessed all the items (360 items, 100%) of the year 2017. In split-half set 1, each item set contained 184 (51%) items of year 2018 and each set from split-half set 2 contained 182 (51%) items of the year 2019 using the same method. We used the modified Angoff, modified Ebel, and Hofstee methods in the standard-setting process. @*Results@#Less than a 1% cut score difference was observed when the same method was used to stratify item subsets containing 25%, 51%, or 100% of the entire set. When rating fewer items, higher rater reliability was observed. @*Conclusion@#When the entire item set was divided into equivalent subsets, assessing the exam using a portion of the item set (90 out of 360 items) yielded similar cut scores to those derived using the entire item set. There was a higher correlation between panelists’ individual assessments and the overall assessments.

Similarity of the cut score in test sets with different item amounts using the modified Angoff, modified Ebel, and Hofstee standard-setting methods for the Korean Medical Licensing Examination / 보건의료교육평가

Purpose@#The Korea Medical Licensing Exam (KMLE) typically contains a large number of items. The purpose of this study was to investigate whether there is a difference in the cut score between evaluating all items of the exam and evaluating only some items when conducting standard-setting. @*Methods@#We divided the item sets that appeared on 3 recent KMLEs for the past 3 years into 4 subsets of each year of 25% each based on their item content categories, discrimination index, and difficulty index. The entire panel of 15 members assessed all the items (360 items, 100%) of the year 2017. In split-half set 1, each item set contained 184 (51%) items of year 2018 and each set from split-half set 2 contained 182 (51%) items of the year 2019 using the same method. We used the modified Angoff, modified Ebel, and Hofstee methods in the standard-setting process. @*Results@#Less than a 1% cut score difference was observed when the same method was used to stratify item subsets containing 25%, 51%, or 100% of the entire set. When rating fewer items, higher rater reliability was observed. @*Conclusion@#When the entire item set was divided into equivalent subsets, assessing the exam using a portion of the item set (90 out of 360 items) yielded similar cut scores to those derived using the entire item set. There was a higher correlation between panelists’ individual assessments and the overall assessments.

Introduction to the 2019 World Federation for Medical Education World Conference / 보건의료교육평가

No abstract available.

History and Future of the Korean Medical Education System / 의학교육논단

Western medicine was first introduced to Korea by Christian missionaries and then by the Japanese in the late 19th century without its historical, philosophical, cultural, social, political, and economic values being communicated. Specifically, during the Japanese colonial era, only ideologically ‘degenerated’ medicine was taught to Koreans and the main orthodox stream of medicine was inaccessible. Hence, Korean medical education not only focuses on basic and clinical medicine, but also inherited hierarchical discrimination and structural violence. After Korea's liberation from Japan and the Korean war, the Korean medical education system was predominantly influenced by Americans and the Western medical education system was adopted by Korea beginning in the 1980s. During this time, ethical problems arose in Korean medical society and highlighted a need for medical humanities education to address them. For Korean medical students who are notably lacking humanistic and social culture, medical humanities education should be emphasized in the curriculum. In the Fourth Industrial Revolution, human physicians may only be distinguishable from robot physicians by ethical consciousness; consequentially, the Korean government should invest more of its public funds to develop and establish a medical humanities program in medical colleges. Such an improved medical education system in Korea is expected to foster talented physicians who are also respectable people.

Comparison of standard-setting methods for the Korean Radiological Technologist Licensing Examination: Angoff, Ebel, bookmark, and Hofstee / 보건의료교육평가

PURPOSE@#This study aimed to compare the possible standard-setting methods for the Korean Radiological Technologist Licensing Examination, which has a fixed cut score, and to suggest the most appropriate method.@*METHODS@#Six radiological technology professors set standards for 250 items on the Korean Radiological Technologist Licensing Examination administered in December 2016 using the Angoff, Ebel, bookmark, and Hofstee methods.@*RESULTS@#With a maximum percentile score of 100, the cut score for the examination was 71.27 using the Angoff method, 62.2 using the Ebel method, 64.49 using the bookmark method, and 62 using the Hofstee method. Based on the Hofstee method, an acceptable cut score for the examination would be between 52.83 and 70, but the cut score was 71.27 using the Angoff method.@*CONCLUSION@#The above results suggest that the best standard-setting method to determine the cut score would be a panel discussion with the modified Angoff or Ebel method, with verification of the rated results by the Hofstee method. Since no standard-setting method has yet been adopted for the Korean Radiological Technologist Licensing Examination, this study will be able to provide practical guidance for introducing a standard-setting process.

Comparison of standard-setting methods for the Korean Radiological Technologist Licensing Examination: Angoff, Ebel, bookmark, and Hofstee / 보건의료교육평가

PURPOSE: This study aimed to compare the possible standard-setting methods for the Korean Radiological Technologist Licensing Examination, which has a fixed cut score, and to suggest the most appropriate method. METHODS: Six radiological technology professors set standards for 250 items on the Korean Radiological Technologist Licensing Examination administered in December 2016 using the Angoff, Ebel, bookmark, and Hofstee methods. RESULTS: With a maximum percentile score of 100, the cut score for the examination was 71.27 using the Angoff method, 62.2 using the Ebel method, 64.49 using the bookmark method, and 62 using the Hofstee method. Based on the Hofstee method, an acceptable cut score for the examination would be between 52.83 and 70, but the cut score was 71.27 using the Angoff method. CONCLUSION: The above results suggest that the best standard-setting method to determine the cut score would be a panel discussion with the modified Angoff or Ebel method, with verification of the rated results by the Hofstee method. Since no standard-setting method has yet been adopted for the Korean Radiological Technologist Licensing Examination, this study will be able to provide practical guidance for introducing a standard-setting process.

Dr. Myung-Sun Kim (1897–1982): An Eternal Teacher of Yonsei University

No abstract available.

Carpal Tunnel Syndrome in Patients Undergoing Long-Term Hemodialysis Therapy: Clinical Characteristics and Results of Surgical Treatment

PURPOSE: Carpal tunnel syndrome (CTS) has become increasingly recognized as a complication of long-term hemodialysis. This study evaluated the clinical characteristics and compared the results of carpal tunnel release for CTS patients with or without hemodialysis. METHODS: We retrospectively reviewed the clinical characteristics and surgical outcomes of 49 chronic hemodialysis patients with 83 CTS hands. Also, 100 patients were selected for the control group. Patient characteristics, accompanying systemic conditions, operative outcomes were compared. RESULTS: In hemodialysis group, the mean age and hemodialysis duration were 59.5+/-10.5 years and 4.1+/-2.5 years, respectively. Of the 83 hands with CTS, 45 (54.2%) had arteriovenous fistulas, while 38 (45.7%) did not (p=0.02). Most (81.6%) of the patients reported symptom improvement after surgical treatment, and the remaining patients (18.4%) reported persistent and recurrent symptoms. Rates of remaining symptoms and reoperations were significantly higher in the CTS patients with hemodialysis group. CONCLUSION: Majority of CTS patients with hemodialysis have much improved after transverse carpal ligament release. However, they showed higher recurrence than idiopathic CTS patients. In recurrent patients, use of the extended carpal tunnel release is effective in symptom relief.

Comparative Study of Electromyography and Hand Elevation Test in Carpal Tunnel Syndrome

PURPOSE: Since the hand elevation test was first introduced by Ahn in 2001, it has been one of most performing provocative test for diagnosing carpal tunnel syndrome. Although many studies have been published on the hand elevation test, there are no study that can explain why false-negative results of hand elevation test appears in carpal tunnel syndrome patients diagnosed by electromyography (EMG) findings. Therefore we searched out whether hand elevation test is related with EMG severity. MATERIALS AND METHODS: We made a retrospective study of 654 bilateral carpal tunnel syndrome patients. Among them 134 were studied which had different hand elevation test results on each hands. The paired samples t-test was used to compare the EMG severity of each group. The relationships between hand elevation test and EMG severity were examined using Pearson-product correlations. Comparing whether the frequency of false negative hand elevation were different between both hands, and whether the severity of EMG depends on which side of hand is, was evaluated with Mann-Whitney U-test. RESULTS: Severity of EMG in positive group was moderate to severe on average, whereas mild to moderate on negative group, with significant difference statistically (p<0.001). Correlation between the hand elevation test results and EMG severity also showed significance statistically (p<0.001). CONCLUSION: Mild severity of EMG was found out to be the factor affecting the false results. However, EMG severity and hand elevation test shows a meaningful correlation, supporting the value of hand elevation test.

Stabilizing Morbidity and Predicting the Aesthetic Results of Radial Forearm Free Flap Donor Sites

BACKGROUND: The radial forearm flap is a versatile, widely used flap. However, the possibility of donor site complications has led to concern over its use. Some surgeons prefer using other flaps whose donor sites can be closed primarily with less morbidity, including avoiding unpleasant scarring. However, in our experience, donor site stability of the radial forearm flap can be reliably achieved by using well-implemented specific procedures. Here, we present a collection of donor site cases of the radial forearm flap and investigate factors that affect the aesthetic results as the basis for a reference for selecting a radial forearm flap. METHODS: In this retrospective study, we reviewed 171 cases in which a radial forearm flap was used for free tissue transfer after resecting head and neck cancer. We focused on donor site morbidity rates. Each operation involved a detailed procedure designed to minimize donor site morbidity. Moreover, statistical investigations were conducted for 22 cases to determine factors affecting the scar appearance. RESULTS: Only one case developed total skin graft necrosis as a major complication. Scar-related aesthetic results were acceptable, and the body-mass index, body weight, diabetes, and cardiac problems were significant factors related to the appearance of scars. CONCLUSIONS: Performing the radial forearm flap using a well-implemented detailed technique helps achieve acceptable donor site morbidity results. The aesthetic results were more promising for patients without excess body weight, diabetes, or cardiac problems. Therefore, anxiety about donor site morbidity should not be a reason to avoid selecting the radial forearm flap in suitable patients.

Suppression of Peripheral Sympathetic Activity Underlies Protease-Activated Receptor 2-Mediated Hypotension

Protease-activated receptor (PAR)-2 is expressed in endothelial cells and vascular smooth muscle cells. It plays a crucial role in regulating blood pressure via the modulation of peripheral vascular tone. Although some reports have suggested involvement of a neurogenic mechanism in PAR-2-induced hypotension, the accurate mechanism remains to be elucidated. To examine this possibility, we investigated the effect of PAR-2 activation on smooth muscle contraction evoked by electrical field stimulation (EFS) in the superior mesenteric artery. In the present study, PAR-2 agonists suppressed neurogenic contractions evoked by EFS in endothelium-denuded superior mesenteric arterial strips but did not affect contraction elicited by the external application of noradrenaline (NA). However, thrombin, a potent PAR-1 agonist, had no effect on EFS-evoked contraction. Additionally, omega-conotoxin GVIA (CgTx), a selective N-type Ca2+ channel (I(Ca-N)) blocker, significantly inhibited EFS-evoked contraction, and this blockade almost completely occluded the suppression of EFS-evoked contraction by PAR-2 agonists. Finally, PAR-2 agonists suppressed the EFS-evoked overflow of NA in endothelium-denuded rat superior mesenteric arterial strips and this suppression was nearly completely occluded by omega-CgTx. These results suggest that activation of PAR-2 may suppress peripheral sympathetic outflow by modulating activity of I(Ca-N) which are located in peripheral sympathetic nerve terminals, which results in PAR-2-induced hypotension.

Transient Receptor Potential C4/5 Like Channel Is Involved in Stretch-Induced Spontaneous Uterine Contraction of Pregnant Rat

Spontaneous myometrial contraction (SMC) in pregnant uterus is greatly related with gestational age and growing in frequency and amplitude toward the end of gestation to initiate labor. But, an accurate mechanism has not been elucidated. In human and rat uterus, all TRPCs except TRPC2 are expressed in pregnant myometrium and among them, TRPC4 are predominant throughout gestation, suggesting a possible role in regulation of SMC. Therefore, we investigated whether the TRP channel may be involved SMC evoked by mechanical stretch in pregnant myometrial strips of rat using isometric tension measurement and patch-clamp technique. In the present results, hypoosmotic cell swelling activated a potent outward rectifying current in G protein-dependent manner in rat pregnant myocyte. The current was significantly potentiated by 1microM lanthanides (a potent TRPC4/5 stimulator) and suppressed by 10microM 2-APB (TRPC4-7 inhibitor). In addition, in isometric tension experiment, SMC which was evoked by passive stretch was greatly potentiated by lanthanide (1microM) and suppressed by 2-APB (10microM), suggesting a possible involvement of TRPC4/5 channel in regulation of SMC in pregnant myometrium. These results provide a possible cellular mechanism for regulation of SMC during pregnancy and provide basic information for developing a new agent for treatment of premature labor.

Physicians' perspectives on social competency education in academic medicine / 한국의학교육

PURPOSE: This study aims to explore the improvement of medical curriculums by examining the relationship between attributes of the Korean physicians and their needs for specialized departments and professionals for enhancing Korean physicians' social competence. METHODS: The uniqueness of this study is in its conduction a survey about the Korean physicians' needs of specialized departments and professionals for physicians' social competence or not, unlikely that previous studies focused on reviews. Subjects of this study are 288 physicians among the members of the Korean Society of Medical Education and The Korea Intern Resident Association. The hierarchical regression analyses are conducted. RESULTS: The authors present the results. First, the needs of specialized departments decline if physicians have ever majored on basic medical and learned professionalism ethics. Second, the older physicians are, the much more learned professionalism ethics and the needs of leadership competence physicians have, the necessities of specialized professionals are reduced. Finally, the physicians' needs of patient-oriented communication and sympathy of human in society as well as professionalism ethics increase recognitions of the importance of specialized professionals. CONCLUSION: These results show that strengthening systemic and educators' individual capacity for successful social competence curriculums is important.

Ionic Mechanisms of Desflurane on Prolongation of Action Potential Duration in Rat Ventricular Myocytes

PURPOSE: Despite the fact that desflurane prolongs the QTC interval in humans, little is known about the mechanisms that underlie these actions. We investigated the effects of desflurane on action potential (AP) duration and underlying electrophysiological mechanisms in rat ventricular myocytes. MATERIALS AND METHODS: Rat ventricular myocytes were enzymatically isolated and studied at room temperature. AP was measured using a current clamp technique. The effects of 6% (0.78 mM) and 12% (1.23 mM) desflurane on transient outward K+ current (I(to)), sustained outward current (I(sus)), inward rectifier K+ current (I(KI)), and L-type Ca2+ current were determined using a whole cell voltage clamp. RESULTS: Desflurane prolonged AP duration, while the amplitude and resting membrane potential remained unchanged. Desflurane at 0.78 mM and 1.23 mM significantly reduced the peak I(to) by 20+/-8% and 32+/-7%, respectively, at +60 mV. Desflurane (1.23 mM) shifted the steady-state inactivation curve in a hyperpolarizing direction and accelerated inactivation of the current. While desflurane (1.23 mM) had no effects on I(sus) and I(KI), it reduced the L-type Ca2+ current by 40+/-6% (p<0.05). CONCLUSION: Clinically relevant concentrations of desflurane appear to prolong AP duration by suppressing Ito in rat ventricular myocytes.

Efficiency of the Boston Questionnaire in Carpal Tunnel Syndrome: Comparing Scores with Provocation Tests and Electrophysiological Studies

PURPOSE: We aimed to make a comparison of Boston Questionnaire scores with provocation tests and findings of electrophysiological studies in patients with a carpal tunnel syndrome. MATERIALS AND METHODS: The Boston Questionnaire was applied preoperatively for 248 hands in 142 patients with an idiopathic carpal tunnel syndrome. Boston Questionnaire scores were compared with provocation tests (Phalen's test, Tinel's sign, compression test and hand elevation test) and electrophysiological findings. RESULTS: Correlation study between the Boston Questionnaire scores and electrophysiological findings showed that the electrophysiological findings correlated more with symptom severity score (Spearman coefficient, 0.545; p<0.01) than with functional status score (Spearman coefficient, 0.307; p<0.01). Symptom severity score and functional status scores of the Boston Questionnaire correlated more linearly with the hand elevation test than with other provocation tests. CONCLUSION: This study demonstrates a high correlation of Boston Questionnaire scores with the electrophysiological findings and the hand elevation test.

Carpal Tunnel Syndrome by Ganglion: A Case Report

PURPOSE: Carpal tunnel syndrome is the most common peripheral compressive neuropathy. Most cases are idiopathic, but rarely carpal tunnel syndrome can be associated with a ganglionic mass. We report our recently encountered experience of surgical treatment of carpal tunnel syndrome caused by a simple ganglionic mass. METHODS: A 53-year-old man presented with chief complaints of numbness and hypoesthesia of his left palm, thumb, index finger, long finger, and ring finger of one and half month duration. Physical examination revealed positive Tinnel's sign without previous trauma, infection or any other events. Electromyography showed entrapment neuropathy of the median nerve. Magnetic resonance imaging(MRI) showed an approximately 2.0cm-sized mass below the transverse carpal ligament. Upon surgical excision, a 1 x 1.5cm2 mass attached to the perineurium of the median nerve and synovial sheath of the flexor digitorum superficialis and redness and hypertrophy of the median nerve were discovered. With surgical intervention, we completely removed the ganglionic mass and performed surgical release of the transverse carpal ligament. RESULTS: The pathology report confirmed the mass to be a ganglion. The patient exhibited post-operative improvement of his symptoms and did not show any complications. CONCLUSION: We present a review of our experience with this rare case of carpal tunnel syndrome caused by a ganglionic mass and give a detailed follow-up on the patient treated by surgical exploration with carpal tunnel release.

An Introduction to the New Web Site of the Journal of the Korean Medical Association

The Journal of the Korean Medical Association (JKMA) established a new web site in July, 2010 available at http://jkma.org/. Here, we introduce the basic structure and concept of the new web site. The new web site provides current medical information from Korea to KMA members as well as global readers. The history of Korean medicine will also be organized in an easily accessible. Starting from this basic platform, JKMA will improve and expand other online functions in the near future. We hope every member of the Korean Medical Association enjoys browsing the content of JKMA through the new site and using the information they find in their clinical practice.

Entrapment Neuropathy of Median and Ulnar Nerve Due to Soft Tissue Chondroma: A Case Report

PURPOSE: Soft tissue chondroma is a rare benign tumor, found mainly on the palm and sole and grows slowly. Typically, mature hyaline cartilage is the dominant pathological feature. There are reports that assert soft tissue chondromas to be a cause of median nerve entrapment syndrome. However, this is the first case report showing soft tissue chondroma to be a cause of simultaneous median and ulnar neuropathy. METHODS: A 62 year-old woman presented with chief complaints of numbness and hypoesthesia of her right palm for 4 to 5 years, and a palpable mass on her right palm that had been increasing in size slowly for 3 years. Physical examination revealed a firm, mobile, non-tender and about 3 x 3 cm2 sized mass in the center of the right palm. Electromyography showed entrapment neuropathy of the median and ulnar nerve. Ultrasonography showed an approximately 5.7 cm2 mass below the flexor tendon of ring finger. Upon surgical excision, a 3 x 3 cm2 mass attached to the flexor digitorum profundus of ring finger and redness and hypertrophy of both the median and ulnar nerve were discovered. Mass excision was performed gently and the specimen was referred for histopathologic study. Mass excision resulted in median and ulnar nerve release. RESULTS: The pathology report confirmed the mass to be a soft tissue chondroma with mature hyaline cartilage. The patient exhibited post-operative improvement of her symptoms and did not show any complications. CONCLUSION: This is the first case report showing soft tissue chondroma to be a cause of simultaneous median and ulnar neuropathy.

A Case Report of Nerve Entrapment Syndrome with Lymphedema

PURPOSE: One of the most common cause of upper extremity lymphedema is breast cancer surgery. We experienced the nerve entrapment syndrome which was associated with postmastectomy lymphedema. To the best of our knowledge, this is the first case report of lymphedema induced nerve entrapment syndrome on upper extremity in Korea. METHODS: A 54-year-old woman presented with a tingling sensation on her right hand, which had been present for 1 year. On her history, she had a postmastectomy lymphedema on her right upper extremity for 20 years. Initial electromyography (EMG) showed that the ampulitude of the median, ulnar, and dorsal ulnar cutaneous nerve were decreased, and conduction block was also seen in median nerve across the wrist. In needle EMG, incomplete interference patterns were observed in the muscles innervated by median and ulnar nerves. In conclusion, electrophysiologic study and clinical findings suggested right median and ulnar neuropathy below the elbow. Therefore, we performed surgical procedures, which were release of carpal tunnel, Guyon's canal, and cubital tunnel. RESULTS: The postoperative course was uneventful until the first two years. The tingling sensation and claw hand deformity were improved, however, the motor function decreased progressively. In 7 years after the operation, patient could not flex her wrist and thumb sufficiently. EMG which was performed recently showed that ulnar motor response was of low ampulitude. Moreover, median, ulnar, dorsal ulnar cutaneous, lateral antecubital cutaneous and median antebrachial cutaneous sensory response were unobtainable. Abnormal spontaneous activities were observed in upper arm muscles. In conclusion, multiple neuropathies were eventually developed at above elbow level. CONCLUSION: On treating nerve entrapments associated with lymphedema, medical professionals should be fully aware of the possibility of unpredictable results after the surgery, because of the pathophysiologic traits of chronic lymphedema.