Prerequisite for enhancing student learning outcomes in medical education.

Anyone achieving a grade of "A" has performed at a very good level. The label, "triple A", is sometimes used to distinguish those who are particularly outstanding. In this paper, teaching techniques that facilitate adults becoming triple A learners are discussed. A large volume of evidence has established that, in order to achieve this rating, student learning must be Active, Assessed and Aligned.

Dorsal anterior cingulate cortex resolves conflict from distracting stimuli by boosting attention toward relevant events.

In everyday life, we often focus greater attention on behaviorally relevant stimuli to limit the processing of distracting events. For example, when distracting voices intrude upon a conversation at a noisy social gathering, we concentrate more attention on the speaker of interest to better comprehend his or her speech. In the present study, we investigated whether dorsal/caudal regions of the anterior cingulate cortex (dACC), thought to make a major contribution to cognitive control, boost attentional resources toward behaviorally relevant stimuli as a means for limiting the processing of distracting events. Sixteen healthy participants performed a cued global/local selective attention task while brain activity was recorded with event-related functional magnetic resonance imaging. Consistent with our hypotheses, greater dACC activity during distracting events predicted reduced behavioral measures of interference from those same events. dACC activity also differed for cues to attend to global versus local features of upcoming visual objects, further indicating a role in directing attention toward task-relevant stimuli. Our findings indicate a role for dACC in focusing attention on behaviorally relevant stimuli, especially when the achievement of our behavioral goals is threatened by distracting events.

Effects of practice on executive control investigated with fMRI.

Various models of executive control predict that practice should modulate the recruitment of executive brain mechanisms. To investigate this issue, we asked 15 participants to perform a cued global/local attention task while brain activity was recorded with event-related functional magnetic resonance imaging (fMRI). Practice significantly reduced the recruitment of left inferior parietal regions that were engaged when participants oriented attention in response to global and local cue stimuli. In contrast, practice increased the recruitment of midline frontal regions that were engaged by interference between global and local forms during target processing. These findings support models of executive control in which practice increases the tendency for stimuli to automatically evoke task-relevant processes and responses.

The cost of palliative care for hepatocellular carcinoma in Hong Kong.

BACKGROUND: Hepatocellular carcinoma (HCC) is endemic in parts of Asia and Africa and most patients are not suitable for treatment with a curative approach. Little is known about the cost of palliative care for HCC. OBJECTIVE: To determine: (i) patient-specific costs of palliative care of HCC; and (ii) individual factors that drive patient-specific costs and to develop a model of cost per case under alternative circumstances. METHODS: 204 patients with inoperable HCC were prospectively tracked from first hospitalisation until death for health service utilisation. A societal perspective of cost was taken, including costs of formal and informal services incurred by payers, caregivers and patients. Observational data from a large Hong Kong cancer care programme were used. A regression analysis was performed using formal costs only, with the cost per observed day as the dependent variable. RESULTS: The median survival was 95 days and the mean observation period was 153 days. The mean value per person for formal healthcare cost was 30 983 Hong Kong dollars [$HK] ($US3872, 1998 values). The distribution of cost values were positively skewed. The regression analysis showed that age, days of observation and survival were negatively related to cost per observed day, and the Child-Pugh grading of severity of liver cirrhosis was positively related to cost per observed day. A sensitivity analysis based on the regression equation indicated that nonsurvivorship doubles the cost per case, increased severity as measured by the Child-Pugh Index adds about 50% to the cost, and chemotherapy increases cost 2-fold. CONCLUSIONS: The relatively modest average cost per patient with HCC in Hong Kong reflects the short median survival and subsequently the limited use of inpatient care and chemotherapy.

Moving with the sun.

A global 24-hour telemedicine conference entitled, "Moving with the Sun" was successfully completed on June 30 and July 1 1997 between participants from Hong Kong and China, as well as with sixteen major international medical centres around the globe. In addition to celebrating the return of Hong Kong to the People's Republic of China, the conference also signified the establishment of the Chinese University of Hong Kong, and Hong Kong as a bridge between Western countries and the PRC.

Factors associated with non-urgent utilization of Accident and Emergency services: a case-control study in Hong Kong.

Accident and Emergency Departments (A&E) have been a popular source of primary care, and studies have shown that up to two thirds of patients attending A&E have problems that could be managed by general practitioners (GPs). Although many studies have found that patients of lower socio-economic class with less social support have a higher utilization rate of A&E, some recent studies have revealed contrary evidence. In this study 2410 patients were randomly selected from four A&E at different times. The gold standard in differentiating true emergency cases and GP cases was based on a retrospective record review conducted independently by a panel of emergency physicians. Two emergency physicians reviewed each case independently, and if their independent ratings were in agreement, this became the gold standard. Patients classified as GP cases were given a telephone interview, and a sample was selected and matched with cases from general out patient clinics (GOPC) in the public sector by morbidity. Reasons for not attending a private GP included closure of clinic, deterioration of symptoms, GPs' inability to diagnose properly, and patients' wish to continue medical treatment in the same hospital. Reasons why non-urgent patients did not choose to attend the nearby public GOPC included affordability, closure of the GOPC, patients' wish to continue treatment at the same hospital, GOPC too far away, no improvement shown after visits to GOPC doctors, and GOPC doctors' inability to make proper diagnoses. The reasons for high level of utilization of A&E services are complex and reflect problems of delivery of GP services. There is an urgent need for GPs to set up a network system to provide out of hours services, and also for a better interfacing between primary and secondary care, and between public and private sectors, so that patients can be referred back to GPs. Interim clinical services provided to those non-urgent cases by nursing practitioners or by GPs working in A&E could also facilitate discharge of patients to primary care facilities.

Strategic planning in medical education: enhancing the learning environment for students in clinical settings.

BACKGROUND: The 1999 Cambridge Conference was held in Northern Queensland, Australia, on the theme of clinical teaching and learning. It provided an opportunity for groups of academic medical educators to consider some of the challenges posed by recent changes to health care delivery and medical education across a number of countries. PURPOSE: This paper describes the issues raised by the practical challenges posed by the current environment and how they might be addressed in ways that could promote more effective learning in clinical settings. METHOD: A SWOT analysis is a tool that can help in forward planning by identifying the strengths, weaknesses, opportunities and threats presented by any situation. Our SWOT analysis was used to generate a list of items, from which we chose those most feasible and most likely to promote positive change. RESULTS: Twenty different issues were identified, with four of them chosen by consensus for further elaboration. The discussion gave rise to four main recommended strategies: ensuring that clinical teachers thoroughly understand the purpose and process of learning in clinical settings; equipping learners with 'survival skills'; making the best use of learning resources within different clinical environments and making judicious use of information technology to enhance learning efficiency. CONCLUSIONS: The four strategies were selected not only because of their inherent importance, but also because of their feasibility. Modest changes can motivate students to feel part of a clinical team and a 'community of practice' and enhance their capacity for self-regulated practice.

In-training assessment - its potential in enhancing clinical teaching.

CONTEXT: In-training assessment (ITA) has established its place alongside formative and summative assessment at both the undergraduate and postgraduate level. In this paper the authors aimed to identify those characteristics of ITA that could enhance clinical teaching. METHODS: A literature review and discussions by an expert working group at the Ninth Cambridge Conference identified the aspects of ITA that could enhance clinical teaching. RESULTS: The features of ITA identified included defining the specific benefits to the learner, teacher and institution, and highlighting the patient as the context for ITA and clinical teaching. The 'mapping' of a learner's progress towards the clinical teaching objectives by using multiple assessments over time, by multiple observers in both a systematic and opportunistic way correlates with the incremental nature of reaching clinical competence. CONCLUSIONS: The importance of ITA based on both direct and indirect evidence of what the learner actually does in the real clinical setting is emphasized. Particular attention is given to addressing concerns in the more controversial areas of assessor training, ratings and documentation for ITA. Areas for future research are also identified.

A survey of undergraduate teaching in anaesthesia.

Currently, no well accepted and clearly defined 'core' curriculum for undergraduate anaesthesia, teaching exists. To address this deficiency, we surveyed 73 university departments of anaesthesia and intensive care. Sixty-five replied from South-east Asia (12), Australasia (13), the UK and Ireland (28) and Canada (12). A questionnaire containing 37 items ranging from departmental structure to curriculum content was used. We found significant regional differences. Overall, most departments taught pharmacology of anaesthetic drugs (83%), pre-operative assessment (92%) and care of the unconscious patient (77%). Ninety-seven per cent taught airway management and intubation and 80% taught intravenous cannulation. Basic life support was taught by 92% and advanced life support by 71%. Fewer than half taught advanced trauma life support principles (44%). Critical care teaching was less well defined, but a consensus of schools taught respiratory failure and ventilation, management of circulatory shock and principles of sepsis and multi-organ system failure. Practical clinical skills were taught mainly using patients and simulators, 46% had a skills laboratory and six employed a resuscitation officer. However, it should be noted that we did not assess the quality and outcome of teaching.

Measuring the inappropriate utilization of accident and emergency services?

Accident and Emergency (A&E) departments are increasingly popular venues for primary care, causing a serious threat to healthcare quality. This paper reports the development of a comprehensive research method for identifying primary care patients attending A&E. Patients were randomly selected from the four A&E departments across different time periods and different regions in Hong Kong. The definition of GP cases was based on a retrospective record review conducted by a panel of emergency physicians using the standard laid down by the Hong Kong College of Family Physicians. The patients sampled were similar in sex and age distribution to A&E attendees for the whole territory. The level of GP cases was found to be 57 per cent, with a significantly higher proportion of patients in the younger age group. The high level of use reflects the lack of a well co-ordinated development of primary care services and interfacing with secondary care.

Planning criteria for multicentre, multilingual telemedicine conferences.

The international telemedicine conference Chinese TeleMed 96 was held in November 1996. This three-way teleconference included delegates in London (where the international telemedicine conference TeleMed 96 was taking place) and medical staff from one Beijing hospital and one Hong Kong medical faculty. In total, over 1000 health-care personnel across eight time-zones participated. The event demonstrated that the quality of teleconferencing technology was suitable for medical teaching, for providing medical consultations to remote locations and for stimulating medical exchanges. In general, planning a telemedicine conference requires a longer lead time, a wider representation of expertise in the organizing committee and more financial resources than conventional conferences. It is recommended that the aim and format of a telemedicine conference be determined at least one year before the target date. Criteria for improving the preparation of such conferences have been identified and a set of guidelines for future conference organizers has been drawn up.

Teaching evidence-based medicine.

The practice of evidence-based medicine is inherently pedagogical by its nature, requiring one to use tools that are basic lifelong learning skills. To facilitate the teaching of these skills, it is important to emphasise how the average Hong Kong practitioner's difficulty in keeping abreast of the rapidly growing body of medical literature can be efficiently resolved by using evidence-based medicine protocols. Four evidence-based medicine workshops were recently offered in Hong Kong. These workshops were organised and taught in a manner similar to one that had been found to be effective in other settings. Issues related to both the strengths and shortcomings of using this strategy in the local context are discussed. Implications for organising future workshops of this kind are also identified.

System approach for a multicenter, multilingual international telemedicine conference.

Chinese Telemed 96, a three way international telemedicine conference was successfully held in November 1996. Over 1,000 physicians, allied health professional and medical students participated in this conference in Beijing, Hong Kong and London. This program demonstrated that the quality of telecommunication technology was suitable for the Chinese University of Hong Kong, Faculty of Medicine to use it in facilitating medical consultations and sharing expertise among widely dispersed colleagues. The consensus of Hong Kong participants was that the audiovideo and telecommunication technology used in this conference were adequate. In order to improve overall quality, however, a better co-ordination of the technical support across sites is required. Other felt that the conference suffers from the shortage of highly trained technical staff required to support the communication system. However, following the total evaluation of this conference, it is concluded that while technical support, site and location are important factors in a good telemedicine conference, a well run telemedicine conference is more dependent on a sound planning process and its execution.

Tuberculosis among elderly Chinese in residential homes: tuberculin reactivity and estimated prevalence.

Objectives of this study were to determine the prevalence of positive tuberculin reactivity and associated factors among elderly nursing home residents in a population with a relatively high tuberculosis notification rate, to estimate the prevalence of active tuberculosis, and to assess tuberculin reactivity as a screening tool. A stratified, disproportional, randomized cluster sample of residents was selected and the Mantoux test (using 0.1 ml of 5 tuberculin units of purified protein derivative of tuberculin) carried out. All subjects with a positive test had a chest X-ray followed by sputum smear and culture if the X-ray was abnormal. Sputum examination was also carried out in a random sample of controls, matched for age and gender, drawn from subjects with a negative Mantoux test. Information regarding medical history, tobacco smoking habits, symptoms related to tuberculosis, and communal eating habits were gathered. Also anthropometric data were collected. Sixteen nursing homes in the catchment area of a major district hospital in Hong Kong comprising 587 residents (136 men, 451 women, mean age 80 +/- 8 years) participated in this study. The weighted prevalence of tuberculin reactivity was 43.8%. It was higher in men, among those who took their meals in a common area, in the younger age group, and in those with no previous history of hospitalization. No association was found between prevalence and duration of residence, smoking, skinfold thickness, past medical history, or any relevant symptoms. Following radiological and sputum examination, the estimated prevalence of active tuberculosis ranged from 1.2 to 2.6%. The sensitivity of the tuberculin test was 86, the specificity 30%. The prevalence of active tuberculosis in nursing homes in Hong Kong is high, but it is unclear whether cross-infection or poor health of the residents is the major contributing factor. Tuberculin skin testing does not appear to be a useful screening method in this population.

Knee muscle strength in elite male gymnasts.

This study was launched to establish the profile of knee dynamic concentric strength in elite male gymnasts after it was found that three of the 10-member Canadian men's gymnastics team had incurred anterior cruciate ligament (ACL) rupture. The dynamic concentric force characteristics of the quadriceps and hamstring muscles of 84 male gymnasts were studied at the Canadian National Championships using a Kin-Com isokinetic dynamometer. These tests were performed at 90 degrees/sec and 230 degrees/sec and revealed that the hamstrings to quadriceps peak torque ratio was not only unusually low (0.5) when compared with data collected in previous research, but that this ratio was consistent across all ages, from 12 to 27 years. The torque ratios were also reported at 30 degrees, 45 degrees, and 60 degrees and it was found that the ratios decreased as the joint angle increased and again was consistent across the four age groups. It was also found that the hamstrings to quadriceps peak torque ratio did not increase (hamstrings becoming stronger relative to quadriceps) as velocity of movement increased as has been reported in other studies. It was hypothesized that the large shear forces that are generated about the knee in gymnastics (extrinsically from backward landing and intrinsically from the quadriceps eccentrically contracting), combined with the relatively weak hamstrings, could be one cause for the increasing incidence of ACL injuries in that sport. The results of this study indicate that it would be prudent for clinicians involved with gymnasts to test for knee strength imbalance and to prescribe exercises to correct it when necessary.

Acute care hospital morbidity in the Blood Indian Band, 1984-87.

Acute care hospital morbidity of the Blood Indian Band was compared with that of all Albertans between April 1, 1984 and March 31, 1987. The Blood Indians had over 2.5 times as many hospital separations and 2.2 times as many patient days as the Albertans. The highest separation rare ratios by ICD-9-CM chapter for both Blood males and females were for endocrine, metabolic and nutritional disorders. Blood females had higher rate ratios for hospitalizations for all chapters except neoplasms and Blood males had higher rate ratios for all except congenital anomalies and neoplasms. For individual conditions, Blood males had the highest separation rate ratios for alcohol dependence syndrome, gastritis/duodenitis and diabetes mellitus. Bronchitis/emphysema and diabetes mellitus had the highest rate ratios for Blood females. The results are consistent with those reported in other studies of North American Indians. Their health status is more consistent with a developing country than that expected in Canada and does not appear to be improving.

Acute median nerve dysfunction from wheelchair propulsion: the development of a model and study of the effect of hand protection.

Carpal tunnel syndrome is prevalent among individuals who are wheelchair dependent. Maximal electrophysiologic median nerve dysfunction has been isolated to the proximal part of the carpal tunnel--the site of hand-wheel interface during wheeling. The objective of this study was to determine if measurable median nerve dysfunction (conduction slowing or block) results from a single session of vigorous wheeling and, if so, if protection for the hand with a glove (padded over the region of the carpal tunnel) could minimize the dysfunction. Thirty-five subjects (16 wheelchair dependent; 19 able-bodied) propelled a roller-mounted wheelchair at maximal rate of 2,000 hand strikes. A protective glove was worn on 1 hand only. Immediately before and after the wheeling, hand surface temperatures and bilateral median motor and sensory conductions were performed, and across-carpal tunnel conduction velocity and conduction block were calculated. Another group of 11 able-bodied subjects underwent similar electrodiagnostic testing before and after one half hour of vigorous stationary cycling (no hand trauma). Results were analyzed using a three-way analysis of covariance for repeated measures and demonstrated that (1) significant increases (5.2% to 8.5%) in across carpal tunnel conduction block occurred as a result of wheelchair propulsion but not cycling; (2) the wheeling-induced conduction block was not altered by using a protective glove. This study has demonstrated a model for measuring acute median nerve dysfunction resultant from wheeling but raises doubts regarding the protective effect of glove use on median nerve function.

Validity of convenient indicators of obesity.

A validation study of convenient indicators of obesity was undertaken in 540 male and female subjects, aged 7-14 yr. Four adiposity measures that have commonly accepted obesity classification points [relative weight, relative body mass index (BMI), sum of five skinfolds, and triceps skinfold] were derived from measures of height, weight, and five skinfold thickness measurements. Body density measures were converted to percentage of body fat using Lohman's (1986) age- and gender-specific regression equations. Using greater than or equal to 20% body fat for males and greater than or equal to 25% for females as the standard for obesity, the diagnostic utilities (sensitivity, specificity, overall accuracy, and positive and negative predictive values) of the four obesity indicators at their commonly used obesity cutoff points were determined. Preliminary analyses demonstrate that use of these indicators should not be considered independent of the gender of the subject or without reference to the purpose for classifying subjects as obese. Secondary analyses, in which the obesity cutoff point in each indicator was altered to obtain a minimum specificity level of 95%, demonstrated that a sum of skinfolds was better at identifying true obesity than all other indicators in both males and females. There is potential for inappropriate labeling with all convenient indicators of obesity, and thus they should be used with caution.

Comparison of convenient indicators of obesity.

A comparative study of obesity measurements was undertaken with 533 male and female subjects, aged 11.8-15.9. Six adiposity measures (three skinfold indices, three height-weight indices) were derived from measures of height, weight, and eight skinfold thickness measurements. A principal components analysis of these adiposity measures resulted in a unifactorial solution accounting for 85.6% of the total variance. A cross-tabulation analysis with the derived factor scores and a criterion visual inspection rating supported the interpretation that the underlying construct of the factor was adiposity, and that a factor score of greater than 1.5 SD above the mean was a suitable standard for labeling obesity. Utilizing this dichotomy of factor scores as a standard, the differential diagnostic capabilities of four adiposity scales commonly used in identifying obesity was undertaken. Pursuit of this methodology, with the use of additional measures and larger sample sizes, is recommended to ensure the validation of an obesity measure.