Experience of pain during mammographic screening by three different compression paddles.

INTRODUCTION: Experience of pain during screening mammography is shown to affect further attendance negatively. We aimed to explore the experience of pain during screening mammography using three different breast compression paddles. METHODS: Using a self-report questionnaire, we collected information on pain experienced during mammography from 938 women screened in Bodø at Nordland Hospital County in 2018, as a part of BreastScreen Norway. Pain was assessed by a numeric rating scale (NRS, 0-10). A fixed paddle, a flexible paddle or a fixed paddle standardizing pressure (study paddle) were used during screening. Compression force (kg) was recorded by the radiographers for each screening examination. Log-binomial regression was used to determine the relative risk (RR) of severe (≥7 on NRS) versus mild/moderate (<7 on NRS) experience of pain associated with type of compression paddle, adjusting for breast tenderness, shoulder(s) and/or neck pain prior to screening, compression force, age, body mass index and screening history. RESULTS: Mean score of self-reported experienced pain was 2.8 for the fixed, 2.3 for the flexible and 2.8 for the study paddle (p < 0.03 for fixed versus flexible and for flexible versus study paddle). Adjusted RR of severe pain was higher for the fixed (RRAdj 2.01, 95%CI 1.13-3.59) and the study paddle (RRAdj 2.52, 95%CI 1.44-4.42) compared to the flexible paddle. Breast tenderness was associated with a higher risk (RRAdj 1.93, 95%CI 1.04-3.58) of severe pain compared to no breast tenderness. CONCLUSION: Women screened with the flexible paddle reported lower experience of pain than those screened with the fixed or study paddle. IMPLICATION FOR PRACTICE: The flexible compression paddle might be the best choice regarding experience of pain in screening mammography. Breast tenderness should be considered by the radiographers in a practical screening setting.

Standardised or individualised X-ray tube angle for mediolateral oblique projection in digital mammography?

INTRODUCTION: We aimed to investigate whether there were any differences in positioning criteria related to the presentation of the pectoralis major muscle (pectoral muscle) for women of different heights using a standardized 60° X-ray tube angle for mammograms in mediolateral oblique (MLO) projection. METHODS: Data from MLO mammograms of right breasts of 45,193 women screened in BreastScreen Norway 2016-2019 were used. The positioning criteria were related to the pectoral muscle length (measure A and measure B), width and shape and considered adequate or inadequate depending on the degree of fulfilling the criteria. Data associated with the pectoral muscle were extracted from Volpara, an automated software for breast density assessment. Information on height was obtained from a self-reported questionnaire received by the women together with the invitation to attend the screening program. Women were divided into three groups based on the height percentiles (P) in the Norwegian growth curves: < 25th percentile (75th percentile (>P75th: >170 cm). Logistic regression was used to analyse the odds of adequate pectoral muscle length A and B, and shape, adjusting each model for screening technique and equipment model. Results were presented with odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Mean age of the screened women was 61.5 (SD = 4.8) years. The adequate measure for the pectoral muscle length A was obtained for 25.9% (11,724/45,193), length B for 76.3% (34,489/45,193), width for 75.0% (33,894/45,193) and shape for 97.6% (44,118/45,193) of the mammograms. Adjusted odds of an adequate pectoral muscle length A were lower for women of P75th (OR = 1.08, 95% CI 1.02-1.14) compared to women of P25-75. Odds of an adequate pectoral muscle shape were higher for women of P75th (OR = 0.92, 95% CI 0.87-0.97) compared to women of P25-75th. CONCLUSION: The 60° X-ray tube angle might suit most of the female population offered mammographic screening in Norway, but women of a relatively low height (163 cm or lower) might benefit from an X-ray tube angle less than 60-degrees. IMPLICATIONS FOR PRACTICE: Using 60° X-ray tube angle for the MLO mammograms in BreastScreen Norway fit the majority of the participating women. More research is needed to change the protocol associated with the tube angle for women shorter than 163 cm.

Mammographic features and screening outcome in a randomized controlled trial comparing digital breast tomosynthesis and digital mammography.

PURPOSE: To compare the distribution of mammographic features among women recalled for further assessment after screening with digital breast tomosynthesis (DBT) versus digital mammography (DM), and to assess associations between features and final outcome of the screening, including immunohistochemical subtypes of the tumour. METHODS: This randomized controlled trial was performed in Bergen, Norway, and included 28,749 women, of which 1015 were recalled due to mammographic findings. Mammographic features were classified according to a modified BI-RADS-scale. The distribution were compared using 95 % confidence intervals (CI). RESULTS: Asymmetry was the most common feature of all recalls, 24.3 % (108/444) for DBT and 38.9 % (222/571) for DM. Spiculated mass was most common for breast cancer after screening with DBT (36.8 %, 35/95, 95 %CI: 27.2-47.4) while calcifications (23.0 %, 20/87, 95 %CI: 14.6-33.2) was the most frequent after DM. Among women screened with DBT, 0.13 % (95 %CI: 0.08-0.21) had benign outcome after recall due to indistinct mass while the percentage was 0.28 % (95 %CI: 0.20-0.38) for DM. The distributions were 0.70 % (95 %CI: 0.57-0.85) versus 1.46 % (95 %CI: 1.27-1.67) for asymmetry and 0.24 % (95 %CI: 0.16-0.33) versus 0.54 % (95 %CI: 0.43-0.68) for obscured mass, among women screened with DBT versus DM, respectively. Spiculated mass was the most common feature among women diagnosed with non-luminal A-like cancer after DBT and after DM. CONCLUSIONS: Spiculated mass was the dominant feature for breast cancer among women screened with DBT while calcifications was the most frequent feature for DM. Further studies exploring the clinical relevance of mammographic features visible particularly on DBT are warranted.

Anxiety and Depression during COVID-19 Pandemic among Medical Students in Nepal.

Background Medical students' psychological response to societal lockdown during the COVID-19 pandemic has not been studied much. Objective To assess levels of anxiety and depression among medical students during initial stages of COVID-19 pandemic in Nepal and relate their distress to relevant variables. Method A cross-sectional study with online questionnaire was conducted among medical students at different colleges in Nepal. Hospital Anxiety and Depression Scale (HADS) detected 'anxiety' and 'depression'. The covariates were explored by logistic regression analyses. Result A total 416 medical students [mean age: 22.2 (2.1); males 57.7%, females 42.3%] participated. HADS-anxiety scores [mean: 7.1(4.3)] were significantly and positively correlated with HADS-depression [mean: 5.9 (4.1)] (r=0.695; p < 0.001). Point prevalence of total HADS caseness (HADS-T) was 26.7%. Specific HADS-defined caseness were: anxiety (HADS-A) 11.8%, depression (HADS-D) 5.5%, and comorbid anxiety and depression (HADS-cAD) 9.4%. All four types of caseness were significantly more prevalent among students with a history of mental problems (AOR=4.7, 3.2, 2.6, and 3.2 respectively). HADS-T was higher among those with a concurrent physical illness (AOR=2.4). HADS-T, HADS-A and HADS-D scores were higher among the age group > 22 years (AOR= 2.2, 2.5 and 4.4 respectively). HADS-cAD was almost threetimes higher among those with a possible COVID-19 exposure (AOR=2.8). Conclusion A significant number of medical students in Nepal suffered from high levels of anxiety and depression during the COVID-19 shut-down. The students in the higher (> 22 years) age group, those with past mental disorders, possible COVID-19 exposure, and concurrent physical illness showed elevated levels of anxiety and/or depression.

Impact factor of medical education journals and recently developed indices: Can any of them support academic promotion criteria?

Journal Impact Factor (JIF) has been used in assessing scientific journals. Other indices, h- and g-indices and Article Influence Score (AIS), have been developed to overcome some limitations of JIF. The aims of this study were, first, to critically assess the use of JIF and other parameters related to medical education research, and second, to discuss the capacity of these indices in assessing research productivity as well as their utility in academic promotion. The JIF of 16 medical education journals from 2000 to 2011 was examined together with the research evidence about JIF in assessing research outcomes of medical educators. The findings were discussed in light of the nonnumerical criteria often used in academic promotion. In conclusion, JIF was not designed for assessing individual or group research performance, and it seems unsuitable for such purposes. Although the g- and h-indices have demonstrated promising outcomes, further developments are needed for their use as academic promotion criteria. For top academic positions, additional criteria could include leadership, evidence of international impact, and contributions to the advancement of knowledge with regard to medical education.

Undertreated Hypertension and its Implications for Public Health in Nepal: Nationwide Population-Based Survey.

BACKGROUND: Hypertension (HTN), a major risk factor for cardiovascular diseases (CVDs), is a substantial global public health problem. Occasional studies indicate a high prevalence of HTN in the Nepalese population, but no nationwide population-based data exist so far. We opportunistically used a survey of major disorders of the brain in Nepal to measure blood pressure (BP) in participants selected randomly from the adult general population. OBJECTIVE: To establish the prevalence of elevated BP (eBP), and factors associated with it, regardless of any antihypertensive therapy being taken. We took this to be indicative of unmet health-care need. METHOD: This was a cross-sectional study, conducted by unannounced household visits, employing multistage random cluster sampling. To achieve representativeness, 15 districts out of 75 in the country were investigated: one district from each of the three physiographic divisions in each of the five development regions of Nepal. One adult aged 18-65 years was selected from each household and interviewed by structured questionnaire. BP was recorded in a standardised manner by digital device (Microlife 3BM1-3®). RESULT: From 2,109 eligible households, 2,100 adults (99.6%) participated. The prevalence of eBP (>140/90 mmHg on ≥2 readings) was found to be 15.1%. Multivariate logistic regression showed significant and independent associations with demographic variables (higher age, male gender), with life-style factors (daily alcohol consumption, BMI ≥25), and with living at high altitude (≥2000 m). CONCLUSION: In the context of the survey we could not collect data on antihypertensive therapy being taken but, clearly, whatever this might have been, it was failing to meet treatment needs. Almost one in six adults met criteria for hypertension, carrying risk implications for CVDs and their substantial public-health consequences. Two remediable associated factors were identified, although in a cross-sectional survey we could not prove causation.

Can we rely on simulated patients' satisfaction with their consultation for assessing medical students' communication skills? A cross-sectional study.

BACKGROUND: In medical education, teaching methods offering intensive practice without high utilization of faculty resources are needed. We investigated whether simulated patients' (SPs') satisfaction with a consultation could predict professional observers' assessment of young doctors' communication skills. METHODS: This was a comparative cross-sectional study of 62 videotaped consultations in a general practice setting with young doctors who were finishing their internship. The SPs played a female patient who had observed blood when using the toilet, which had prompted a fear of cancer. Immediately afterwards, the SP rated her level of satisfaction with the consultation, and the scores were dichotomized into satisfaction or dissatisfaction. Professional observers viewed the videotapes and assessed the doctors' communication skills using the Arizona Communication Interview Rating Scale (ACIR). Their ratings of communication skills were dichotomized into acceptable versus unacceptable levels of competence. RESULTS: The SPs' satisfaction showed a predictive power of 0.74 for the observers' assessment of the young doctors and whether they reached an acceptable level of communication skills. The SPs' dissatisfaction had a predictive power of 0.71 for the observers' assessment of an unacceptable communication level. The two assessment methods differed in 26% of the consultations. When SPs felt relief about their cancer concern after the consultation, they assessed the doctors' skills as satisfactory independent of the observers' assessment. CONCLUSIONS: Accordance between the dichotomized SPs' satisfaction score and communication skills assessed by observers (using the ACIR) was in the acceptable range. These findings suggest that SPs' satisfaction scores may provide a reliable source for assessing communication skills in educational programs for medical trainees (students and young doctors). Awareness of the patient's concerns seems to be of vital importance to patient satisfaction.

Reliability and Validity of a Nepali-language Version of the Hospital Anxiety and Depression Scale (HADS).

BACKGROUND: In several languages and settings, the Hospital Anxiety and Depression Scale (HADS) has demonstrated reliable and valid screening properties in psychiatry. OBJECTIVE: To develop a Nepali version of HADS with acceptable reliability and construct validity for use among hospital patients and in the general population. METHOD: The original English version was translated into Nepali using a forward-backward translation protocol. Psychometric properties were tested by factor analysis and Cronbach's alpha. The translated scale was administered to three groups of adult in-patients in a university hospital in three trials, and to a sample of adults from the community in a fourth trial. Some of the 14 items were reworded reiteratively to achieve viable semantic and statistical solutions. RESULTS: The two-factor solution with anxiety and depression subscales eventually explained 40.3% of the total variance. Cronbach's alpha was 0.76 for anxiety (HADS-A) and 0.68 for depression (HADS-D). All seven HADS-A items showed at least acceptable item-to-factor correlations (range 0.44-0.74), and full construct validity was achieved for this subscale. Item-to-factor correlations for six HADS-D items were also at least acceptable (range 0.42-0.70); one item (D4) had persistently low correlations throughout all trials, although construct validity was still satisfactory. CONCLUSION: Reiterated rewording of items guided by statistical testing resulted in a Nepali version of HADS with satisfactory psychometric properties.

Measuring Neuroticism in Nepali: Reliability and Validity of the Neuroticism Subscale of the Eysenck Personality Questionnaire.

BACKGROUND: The Neuroticism subscale of the Eysenck Personality Questionnaire Revised Short Form (12 items) (EPQRS-N) has proven to be a reliable and valid measure in multiple languages. OBJECTIVE: To develop a single-factor Nepali-language version of the EPQRS-N for use in the adult population of Nepal. METHOD: The original English version of EPQRS-N was translated into Nepali using a forward-backward translation protocol. The first set of translated items was modified after testing by factor analysis with principal component extraction in an outpatient sample. Items with low factor correlations or poor semantic consistencies were reworded to fit the gist of the original items in a Nepali cultural context; the revised version was then tested in a representative random sample from the general population. Again, the same statistical procedures were applied. RESULTS: The first trial gave three factors. Based on the factor distribution of the items or their semantic quality, five were reworded. In the second trial, a two-factor solution emerged; the second factor had only one item with high correlation, which also had modest correlation with the first factor. Accordingly, a forced one-factor solution was chosen. This gave an internal consistency (Cronbach's alpha) of 0.80, with item-to-factor correlations from 0.40 to 0.73, and item-to-sum correlations from 0.31 to 0.61. CONCLUSION: The final Nepali version of EPQRS-N achieved satisfactory internal consistency. The item distribution coincided with the original English version, providing acceptable construct validity. It is psychometrically adequate for use in capturing the personality trait of neuroticism, and has broad applicability to the adult population of Nepal because of the diversity of the participant samples in which it was developed.

Women treated with breast conserving surgery do better than those with mastectomy independent of detection mode, prognostic and predictive tumor characteristics.

BACKGROUND: Primary breast conserving treatment (BCT) is well known to have similar long-term survival as mastectomy in breast cancer patients. However, recent studies are suggesting better survival among women treated with BCT compared with mastectomy. More knowledge is needed to understand how disease specific survival is influenced by detection mode, prognostic and predictive tumor characteristics. We aimed to investigate this issue among women targeted by the Norwegian Breast Cancer Screening Program. METHOD: Information about 9547 women aged 50-69 years diagnosed with primary invasive breast cancer without distant metastasis, who underwent either BCT or mastectomy, 2005-2011, were included in the study. Kaplan-Meier plots were used to estimate six years survival, while Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer death associated with surgical treatment. Information about molecular subtype, detection mode, age at diagnosis, tumor size, lymph node involvement, and histologic grade, in addition to radiation treatment, chemotherapy and endocrine therapy were included in adjusted analyses. RESULTS: BCT was performed among 61.9% of the women included in the study. Women treated with BCT had prognostic and predictive favorable tumor characteristics compared to women treated with mastectomy. Adjusted analyses revealed a 1.7 (95% CI: 1.3-2.4) higher risk of breast cancer death among women who underwent mastectomy compared with BCT. CONCLUSION: Women treated with BCT have significantly better breast cancer-specific survival and a lower risk of dying from breast cancer compared to women treated with mastectomy, independent of detection mode, prognostic and predictive tumor characteristic.

R-R interval variations influence the degree of mitral regurgitation in dogs with myxomatous mitral valve disease.

Mitral regurgitation (MR) due to myxomatous mitral valve disease (MMVD) is a frequent finding in Cavalier King Charles Spaniels (CKCSs). Sinus arrhythmia and atrial premature complexes leading to R-R interval variations occur in dogs. The aim of the study was to evaluate whether the duration of the R-R interval immediately influences the degree of MR assessed by echocardiography in dogs. Clinical examination including echocardiography was performed in 103 privately-owned dogs: 16 control Beagles, 70 CKCSs with different degree of MR and 17 dogs of different breeds with clinical signs of congestive heart failure due to MMVD. The severity of MR was evaluated in apical four-chamber view using colour Doppler flow mapping (maximum % of the left atrium area) and colour Doppler M-mode (duration in ms). The influence of the ratio between present and preceding R-R interval on MR severity was evaluated in 10 consecutive R-R intervals using a linear mixed model for repeated measurements. MR severity was increased when a short R-R interval was followed by a long R-R interval in CKCSs with different degrees of MR (P<0.005 when adjusted for multiple testing). The relationship was not significant in control dogs with minimal MR and in dogs with severe MR and clinical signs of heart failure. In conclusion, MR severity increases in long R-R intervals when these follow a short R-R interval in CKCSs with different degrees of MR due to asymptomatic MMVD. Thus, R-R interval variations may affect the echocardiographic grading of MR in CKCSs.

Prevalence of all relevant eating disorders in patients waiting for bariatric surgery: a comparison between patients with and without eating disorders.

OBJECTIVE: To study the prevalence of all relevant eating disorders in 157 obese patients waiting for bariatric surgery. Another aim was to explore for possible differences between gender, and those with and without ED. The dependent variables were: socio-demographic characteristics, BMI, obesity onset, and obesity-related somatic diseases. METHODS: ED was assessed using the self-report questionnaire, "Eating Disorders in Obesity" (EDO). The patients answered a questionnaire that targeted socio-demographic and health information. RESULTS: Subgroups were based on the patients responses to items on the EDO: 1 patient (0.6%) with Bulimia Nervosa (BN), 6 (3.8%) with Eating Disorder Not Otherwise Specified (EDNOS), 21 (13.4%) with Binge Eating Disorder (BED), and 23 (14.6%) with Binge Eating (BE). The patients in the EDNOS group were those who lacked one criterion of the BN diagnosis. The patients in the BE group lacked one criterion of the BED diagnosis. Twenty-eight (17.8%) fulfilled the DSM-IV-TR criteria for ED. When patients with BE were added, 51 patients (32.5%) were identified with ED or sub-threshold ED. In the explorative part of the study, no gender differences in socio-demographic variables, BMI, obesity onset, and obesity-related somatic diseases emerged. With the exception of age, no differences were found in these variables between those with and without ED. CONCLUSION: Employing all relevant eating disorders and binge eating symptoms (BE) for this population identified patients with pathological eating behaviors, which are not detected in previous studies measuring only BED and BE.

High-dose methotrexate in childhood all.

An event-free survival is currently achieved in 70-80% of children diagnosed with acute lymphocytic leukemia (ALL). A decline in the long-term sequalae from therapy is a challenge at present. Due to the high incidence of central nervous system (CNS) relapse in ALL patients, cranial irradiation was introduced as a prophylactic measure in the beginning of the 1970s. Cranial irradiation, however, may cause secondary malignancies in the CNS. In recent years neurotoxicities have been demonstrated to follow cranial irradiation in a large proportion of ALL patients. Because of these deleterious effects, most ALL protocols are limited to the combination intrathecal and intravenous methotrexate as the standard for CNS prophylaxis. In the 1970s, an intermediate dose was administered, while from the 1980s a high dose of methotrexate was combined with intrathecal methotrexate. The regular methotrexate dose of later years has been in the range of 5-8 g/m2. The intravenous methotrexate dose has actually varied from 2 to 33.6 g/m2. The highest dose, 33.6 g/m2, has been without intrathecal instillation. In a study from Norway, high-dose methotrexate (6-8 g/m2) was used, and only two (2.2%) of 89 ALL cases showed CNS relapse, both of reversible kind. In the United Kingdom, a randomized controlled study was started in 1990. Results published so far are based on a segment of cases characterized by standard risk and white blood cell count below 50 x 10(9); a 4% reduction in CNS relapse was found for high-dose methotrexate in comparison to those treated only with long-term intrathecal methotrexate. The use of methotrexate unalterably warrants some precautions. Rescue therapy with folinic acid is usually started 36 h after initiating the methotrexate infusion. Steps are also taken to secure adequate intake of fluids and alkalinization of the urine. Provided irradiation is avoided, neurotoxicities rarely occur. For regular high-dose methotrexate adverse effects mostly involve mucositis and myelosuppresion.

Stress reactivity to and recovery from a standardised exercise bout: a study of 31 runners practising relaxation techniques.

OBJECTIVE: To compare the efficacy in runners of two relaxation techniques with regard to exercise reactivity and recovery after exercise. METHODS: Thirty one adult male runners were studied prospectively for six months in three groups practising either meditation (n = 11) or autogenic training (n = 11) or serving as controls (n = 10). Before and after the six months relaxation intervention, indicators of reactivity to exercise and metabolism after exercise (blood lactate concentration, heart rate (HR), and oxygen consumption (VO2)), were tested immediately after and 10 minutes after exercise. Resting HR was also assessed weekly at home during the trial. State anxiety was measured before and after the intervention. RESULTS: After the relaxation training, blood lactate concentration after exercise was significantly (p<0.01) decreased in the meditation group compared with the control group. No difference was observed in lactate responses between the autogenic training group and the control group. There were no significant differences among the groups with regard to HR, VO2, or levels of anxiety. CONCLUSION: Meditation training may reduce the lactate response to a standardised exercise bout.

The PBL group: self-reflections and feedback for improved learning and growth.

The aims of the PBL group are briefly stated: the facilitation of learning, the fostering of self-directed and lifelong learners, and the developments of social skills that may enhance professional relations. These goals may only be reached by systematic and proficient work with the group processes in PBL; and this work has relevance in all the phases of the life of a group: in the initial formation and in the later renegotiations of interactive patterns. In working with the dynamics of a group, the importance of self-evaluation, reflection and feedback between students is emphasized. Inventories are suggested as a means to improve the feedback between students, and also changes in group interactions. The paper calls for a renewed interest in group dynamics in PBL.

The relation of continuing attachment to adjustment in conjugal bereavement.

The role of continuing attachment in adjustment to conjugal loss was examined. At 6 months postloss, 70 midlife bereaved participants were interviewed to assess different forms of continuing attachment. They also engaged in a monologue role-play with their deceased spouse, providing a behavioral measure of grief-related distress. In addition, they completed general and grief-specific symptom inventories at 6 months and again at 14 and 25 months postloss. The results indicated that use of the deceased's possessions to gain comfort was positively correlated with concurrent distress in the role-play and predictive to less of a decrease in grief-specific symptoms over time in a growth curve analysis. In contrast, attachment through fond memories was related to less distress in the role-play. The results, therefore, suggest that whether continuing attachment is adaptive or not depends on its form.

[Adults treated as children for acute lymphocytic leukemia--methotrexate, late effects and quality of life]. / Voksne behandlet for akutt lymfatisk leukemi som barn--metotreksat, seneffekter og livskvalitet.

From 1975 to 1980, 153 Norwegian children were diagnosed with acute lymphocytic leukaemia. In 1995, all 98 survivors were studied and compared to matched family controls. 132 children were treated with the national protocol. Of these, 93 (70.5%) were survivors at the time of the study. The remaining five survivors were treated with different treatment schemes. The national protocol included methotrexate infusions combined with intrathecal methotrexate as prophylactics against neuroleukaemia, instead of the irradiation. Neither doxorubicin nor cyclophosphamide were included. In this study, a questionnaire was used that covered demographic data, quality of life, and medical information the response rates were 96% (94 persons) for survivors and 92% (90 persons) for family controls. Information was also obtained for the remaining four survivors. No significant differences were found between survivors and controls with regard to quality of life and demographics, with one exception, Somatisation on the GHQ-28. Hospital records of all patients were checked for possible late effects. One case of serious sequela (hemiparesis during therapy) was found, probably related to methotrexate therapy. Seven other serious, possible sequelae were recorded, but probably not related to methotrexate. There were no cases of secondary malignant neoplasm.

[Group learning in medical education]. / Gruppebasert undervisning i medisinstudiet.

The implementation of group learning in medical education puts special demands on the participants, but also offers pedagogical benefits, which may be conductive to the efficient learning of facts, skills and attitudes. The group makes it possible to verify or modify the learned material, which is an important part of preparing for a career as a doctor. Students develop a dependence on others when solving problems in groups, whereas as clinicians they are often alone when confronted with problems demanding quick decisions. In this article we discuss some of the pedagogical principles involved in group learning and make suggestions on how to apply them to learning based on problem solving and other forms of group learning in the medical curriculum.