Faculty development, teacher training and teacher accreditation in medical education: twenty years from now.

To address the issue of faculty development in the year 2020, an attempt is made to predict the structure of the future medical school and the profile of a future medical teacher. By projecting from the technological, sociological and structural processes that affect medical education, it can be envisaged that there will be several types of medical teachers, namely specialists, who will be resource people for the students, evaluators of student performance, and a minority of 'process teachers'. The role of the process teachers will be to tutor, facilitate learning, coach and guide the students in the only domain which cannot be self-learned by technological devices, namely: moral issues, interpersonal communication and crisis management. Each type of teacher requires a different training programme. All programmes, however, should be comprehensive, longitudinal or multiphasic, and lead the faculty member from orientation in both the institution and the educational field to a leadership position by successive approximations. It is further expected that societal demands will impose teacher accreditation and, perhaps, licensing. This, however, will remain in the medical profession's hands, and may bring about a resolution of the 'role-profession conflict', and a more favourable self-perception of faculty members as teachers. Finally, an optimistic conclusion is drawn for the future of medical education.

Should the vaccine injury compensation program be expanded to cover adults?

In 1996, the National Vaccine Advisory Committee (NVAC) asked for a review of the pros and cons of including adult influenza and pneumococcal vaccines in the Vaccine Injury Compensation Program (VICP). The authors, as staff to the subcommittees charged with undertaking this assessment, looked at the following questions: (a) Would inclusion in VICP of these two vaccines, used primarily for adults, increase adult vaccination levels? (b) Is this Federal involvement warranted based on the liability burden for these vaccines? (c) Does the risk of adverse events following vaccinations warrant inclusion of these vaccines? (d) Is there a consensus among stakeholders favoring their inclusion? To address these questions, the authors reviewed information on adult vaccines, including data on l lawsuits filed and reports of injuries, and sought input from interested groups. They found no evidence that the use of influenza and pneumococcal vaccines would increase if they were included in VICP. They found a low liability burden for these vaccines, that serious adverse events were rare, and that no consensus existed among stakeholders. After considering the staff report, NVAC chose, in 1996, not to advise the Department of Health and Human Services to include adult vaccines in VICP.

Measuring impact of nursing intervention on cancer patients' ability to control symptoms.

Cancer patients' ability to control symptoms and to maintain reasonable quality of life is limited due to lack of knowledge, guidance, and instructions from health care providers, who usually refrain from transferring responsibility for the treatment to the patient. The present study describes a measured effect of a structured nursing intervention in which nurses were trained to apply the self-care model to 48 ambulatory cancer patients under chemo- or radiotherapy or both. The intervention included 10 structured home visits to each patient during 3 months, in which the nurse assessed symptoms and advised, guided, supported, and educated the patient in the relevant areas. The symptoms were quantitatively assessed using the Symptom Control Assessment (SCA) instrument, which was developed and validated specifically for this study. The SCA relates to 16 signs, symptoms, and complaints that encompass both the universal and the deviation-from-health needs, in addition to anxiety, body image, and sexuality. The instrument allows either the patient or the nurse to rate the severity of the complaint, the patient's independence in controlling it, the patient's perception of the familial and external help extended to him or her, and the knowledge of the symptom and its control possessed by the patient. Also, the SCA allows comparing the patient's ratings with the professional view of the visiting nurse. The SCA was proven to be a highly reliable and valid instrument. The results indicate that the intensity of the complaints decreased in the experimental group during the 3-month period while they increased in the matched control group, creating a considerable difference between the two groups on multivariate analysis of covariance (MANCOVA). On t-tests, significant improvement was found in 15 out of the 16 symptoms, including pain. The greatest reduction was found in the "psychosocial symptoms," namely anxiety, sociability, body image, and sexuality. Similarly, the patients' independence, knowledge, and perception of familial help increased in the experimental group and declined in the control group. Perhaps the most meaningful change was a significant increase in the ability of the experimental patients to assume responsibility for their own treatment as it is reflected by the increase of the independence ratings for all 16 symptoms. This is in sharp contrast to the decrease in 15 of the 16 symptoms among control patients. The results suggest that the self-care approach is effective also in improving the quality of life for unstable cancer patients by reduction of suffering and increase in controlling capabilities.

Acute encephalopathy followed by permanent brain injury or death associated with further attenuated measles vaccines: a review of claims submitted to the National Vaccine Injury Compensation Program.

OBJECTIVE: To determine if there is evidence for a causal relationship between acute encephalopathy followed by permanent brain injury or death associated with the administration of further attenuated measles vaccines (Attenuvax or Lirugen, Hoechst Marion Roussel, Kansas City, MO), mumps vaccine (Mumpsvax, Merck and Co, Inc, West Point, PA), or rubella vaccines (Meruvax or Meruvax II, Merck and Co, Inc, West Point, PA), combined measles and rubella vaccine (M-R-Vax or M-R-Vax II, Merck and Co, Inc, West Point, PA), or combined measles, mumps, and rubella vaccine (M-M-R or M-M-R II, Merck and Co, Inc, West Point, PA), the lead author reviewed claims submitted to the National Vaccine Injury Compensation Program. METHODS: The medical records of children who met the inclusion criteria of receiving the first dose of these vaccines between 1970 and 1993 and who developed such an encephalopathy with no determined cause within 15 days were identified and analyzed. RESULTS: A total of 48 children, ages 10 to 49 months, met the inclusion criteria after receiving measles vaccine, alone or in combination. Eight children died, and the remainder had mental regression and retardation, chronic seizures, motor and sensory deficits, and movement disorders. The onset of neurologic signs or symptoms occurred with a nonrandom, statistically significant distribution of cases on days 8 and 9. No cases were identified after the administration of monovalent mumps or rubella vaccine. CONCLUSIONS: This clustering suggests that a causal relationship between measles vaccine and encephalopathy may exist as a rare complication of measles immunization.

The development of students' perceptions of effective teaching: the ideal, best and poorest clinical teacher in nursing.

This article attempts to study students' perceptions of effective clinical teacher in nursing. To do this, 123 students from three schools with different curricula identified the important characteristics of a clinical teacher, using a modified NCTEI instrument. Then each respondent assessed to what extent her or his best and poorest clinical teachers possess these characteristics. The profile of an effective clinical teacher which emerged places the highest weight on the nursing competencies of the teacher and downplays both interpersonal relationships and personality traits. Differences between 2nd and 3rd year students were found in the placement of teaching skills and evaluation characteristics. No differences were disclosed among the compared schools. Conflicting research findings are analyzed. The results strongly suggest that the image of the ideal clinical teacher is not rooted in an existing teacher figure. The possible implications of the findings on the role model function of the clinical teacher are discussed.

Chronic arthropathy and musculoskeletal symptoms associated with rubella vaccines. A review of 124 claims submitted to the National Vaccine Injury Compensation Program.

OBJECTIVE: To report the outcome of 124 claims of chronic arthropathy associated with rubella vaccine submitted to the National Vaccine Injury Compensation Program. METHODS: Medical records and testimony were reviewed separately by physicians and Special Masters to determine the clinical diagnosis and eligibility for compensation under the Program. RESULTS: Among the 124 subjects with chronic arthropathy, the onset occurred between 1 week and 6 weeks after the rubella vaccination in 72, and < 1 week or > 6 weeks after the vaccination in 52. Various conditions developed in the 2 onset groups (1-6 weeks postvaccination, < 1 week or > 6 weeks postvaccination), including, respectively, unspecified arthritis (n = 29, n = 1), specified arthritis (n = 11, n = 19), arthralgia (n = 24, n = 7), fibromyalgia (n = 4, n = 11), and multiple symptoms with minimal arthralgia or myalgia (n = 4, n = 14). Concordance of medical recommendations by Program physicians and Special Masters' decisions in 56 completed claims was 91%, with awards mainly to patients with chronic unspecified arthritis and arthralgia. CONCLUSION: The Program and the US Court of Federal Claims have accepted a causal relationship between currently used rubella vaccine in the US and some chronic arthropathy with an onset between 1 week and 6 weeks after vaccine administration.

Spiritual healing for infertility, pregnancy, labour, and delivery.

Spiritual healing has been reported anecdotally to be of benefit for most of the ills of mankind. Research in the past few decades amply confirms this assertion. This paper discusses the applications of healing for infertility, pregnancy, labour and delivery. Though healers in the UK are forbidden by law to give healing around the time of birth without the supervision of a midwife or other medical personnel healers are increasingly working alongside conventional carers in doctors' surgeries and hospitals. There is a definite place for healers to participate in bringing life into the world. Healers and grateful parents report that labour and delivery are eased when healing is given and that babies born after receiving healing seem more alert and 'connected' to those around them.

Reporting vaccine-associated paralytic poliomyelitis: concordance between the CDC and the National Vaccine Injury Compensation Program.

This paper compares cases of paralytic poliomyelitis reported to the systems operated by the National Vaccine Injury Compensation Program and the Centers for Disease Control and Prevention (CDC) for reporting of adverse events associated with vaccination. Of the 118 cases of vaccine-associated paralytic poliomyelitis determined by either system, 18 were reported initially only to the compensation program, 50 only to the CDC, and 50 to both. The annual incidence of vaccine-associated paralytic poliomyelitis determined from data from both systems varied from 6 to 13 cases (mean = 9.1) a year, with an increase of 1.4 cases a year when initial reports only to the compensation program are included. Thus, the compensation program provides important supplemental incidence data.

The Federally Supported Health Centers Assistance Act of 1992: an experiment in malpractice coverage.

Based on a claims experience that was extremely low and malpractice insurance rates that remained at "commercial" rates, the Congress concluded in 1992 that coverage of malpractice actions against these grantees and their health care practitioners would be more cost-effective under the Federal Tort Claims Act. This, in turn, would allow the grantees to apply the savings to providing health services to their beneficiaries. The lawmakers thereupon enacted a 3-year experiment in coverage of malpractice actions involving certain Public Health Service grantees. This article describes the background, structure, and administration of this statutory experiment.

Training immigrant doctors: issues and responses.

An unprecedented wave of immigration of doctors to Israel, mainly from the former Soviet Union, posed for Israeli health leaders the problem of bringing them to a common and accepted Western level of performance. Stemming from the deep commitment which Israel has towards the immigrants, the state offers them a training opportunity to enhance their chances of being licensed and finding jobs in their profession. A 6-month programme was launched by Ben-Gurion University, later adopted by other medical schools and supported by the Government of Israel. The programme was designed to provide effective responses to the specific problems of the immigrant population, which are: lack of knowledge of local language, both everyday and professional; overspecialization in too narrow specialties; possession of clinical specialties which do not exist in the new country; insufficient updating in medical sciences and technology; unawareness of economic implications of health care; difficulty in originating new solutions to clinical problems, and lack of skill in answering objective test items. The programme is characterized by a protective environment, problem-oriented learning, small-group activities and emphasis on learning languages. The clinical problems are designed to emphasize the general practitioner's point of view of both common and emergency situations. The programme has achieved its goals, as judged by the success rate of its graduates in the National Licensing Examination as compared with the success of immigrant doctors who chose not to participate in the training.(ABSTRACT TRUNCATED AT 250 WORDS)

Problem-based clinical confrontation modules planned and conducted by students.

A course has been described which attempts to introduce clinical relevancy to the basic science knowledge. It has been demonstrated how senior students' feedback about curricular shortcomings can be redirected to their constructive participation in the educational process. The described Clinical Confrontation course develops problem-solving skills and self-learning habits in the learners while they are processing and rearranging prior knowledge. At the same time, both the scientific base of medicine and the internal logic of the disciplines are preserved.

Teacher training and faculty development in medical education.

Many components of the described teacher-training program are implemented elsewhere (2, 4, 6, 8, 16); however, two features of the BGU program, when combined, make it unique. One is the timewise hierarchical structure, which enables gradual acquisition of instructional skills, progressing from generic to specific (9) and from curricular generalities to particulars of a course and of a lesson. The teacher him/herself determines the pacing. Opportunities to implement already acquired skills precede the development of additional ones. Moreover, the program acknowledges individual differences, and thus offers a variety of themes and training methods to fit personal needs and expectations. The second feature is the emphasis placed throughout the program on the motivational aspects. Indeed, the term "training" becomes alien to the program. Its very essence is to create personal involvement of every trainee on both emotional and practical levels. The individual is guided to become a member in a multidisciplinary team, working together towards an understandable and worthwhile cause. The involvement of the teachers is encouraged and welcomed. When this feeling is combined with the realization that education is a discipline in its own right, a feeling of belonging to both the institution and to the teaching profession arises. Such feelings might well be a prerequisite for any educational innovation (7). The high proportion of educational leaders who emerged from the program illustrates these two features. Personal growth and institutional development are intertwined. The BGU training program has been rigorously evaluated and has proven to be effective. However, continuous assessment must be instituted and maintained. Such formative evaluation may also meet the requirement of an ongoing on-the-job reinforcement (17). Nevertheless, BGU cannot yet afford further expansion of the program--this will have to wait for the graduation of the fourth-phase trainees.

Moral reasoning as a criterion for admission to medical school.

To determine whether admission interviews could differentiate applicants on their personal qualities (such as integrity, empathy and commitment) 456 applicants from two medical schools were tested on the Defining Issues Test (DIT), which measures the amount of principled or post-conventional moral reasoning. No difference was found between the DIT scores of the accepted and the rejected applicants of the school in which the admission criteria are the traditional scholastic ones. On the other hand, a great difference was shown in the school which admits students for their personal characteristics as assessed by interviews. Yet only moderate correlation was shown between the DIT and the interview scores. Since moral reasoning is a key concept in medical professional behaviour and is correlated with clinical performance, the findings deserve special attention. A possible use of the DIT in the student selection process is discussed.