Scholarship in teaching: an imperative for the 21st century.

At some medical schools broader definitions of scholarship have emerged along with corresponding changes in their academic reward systems. Such situations are not common, however. The definition of scholarship generally applied by medical schools is unnecessarily narrow and excludes areas of legitimate academic activity and productivity that are vital to the fulfillment of the school's educational mission. The authors maintain that creative teaching with effectiveness that is rigorously substantiated, educational leadership with results that are demonstrable and broadly felt, and educational methods that advance learners' knowledge are consistent with the traditional definition of scholarship. Faculty whose educational activities fulfill the criteria above are scholars and must be recognized by promotion. The authors specifically address scholarship in education, focusing on teaching and other learning-related activities rather than on educational research, which may be assessed and rewarded using the same forms of evidence as basic science or clinical research. They build on Boyer's work, which provides a vocabulary for discussing the assumptions and values that underlie the roles of faculty as academicians. Next, they apply Glassick et al.'s criteria for judging scholarly work to faculty members' educational activities to establish a basis for recognition and reward consistent with those given for other forms of scholarship. Finally, the authors outline the organizational infrastructure needed to support scholars in education.

Educating future physicians for Ontario: phase II.

In 1990, a collaborative project was launched to determine what the people of Ontario expect of their physicians and how the programs that prepare future physicians should be changed in response. The project, called Educating Future Physicians for Ontario (EFPO), brought together the five Ontario medical schools, the Council of Ontario Faculties of Medicine (COFM); a nonprofit, charitable organization, Associated Medical Services (AMS); and the Ontario Ministry of Health. The first phase ran for five years and was described in the November 1998 issue of Academic Medicine. After an external review, the project was continued for a second phase (EFPO II) for four more years until December 1998; that second phase is the topic of this article. EFPO II (1) focused more on residents' education; (2) emphasized four of the EFPO I-created physician roles in project activities; (3) maintained the province-wide, inter-institutional medical education framework of phase I, but fostered greater involvement of the seven sites (five medical schools and two regional health centers) in project activities; (4) stressed five project components (e.g., needs assessment and community partnerships) and worked for collaboration among components at all sites; (5) enhanced the original EFPO I Fellowship Program by adding residents and community fellows to the existing fellowships and by initiating leadership development activities, all of which bode well for the future leadership of medical education in Ontario. Students and residents played a vital role in EPFO II. Most of EFPO II's objectives were met, but the overall view of external reviewers was that the project was less successful than EFPO I. For example, the impact on clinical education, especially residency education, was less than anticipated. On the other hand, the project helped encourage the wide adoption of the eight physician roles that originated in EFPO I and advanced faculty development and assessment activities based on these roles. A third phase of EFPO concerning continuing medical education was planned, but support was not available. However, one of the funders will continue to support the successful fellowship and leadership program and the provincial education network for the next three years. Overall, the two phases of EFPO substantially modified medical education in Ontario to make it more responsive to evolving social needs.

Educating future physicians for Ontario.

In 1987, Ontario's physicians conducted a strike, ultimately not successful, over the issue of "extra billing." The fact that the Ontario public did not support this action reflected a major gap between the profession's view of itself and the public's view of the profession. In 1990, the province's five medical schools launched a collaborative project to determine more specifically what the people of Ontario expect of their physicians, and how the programs that prepare future physicians should be changed in response. The authors report on the first five years of that ongoing project. Consumer groups were asked to state their views concerning the current roles of physicians, future trends that would affect these roles, changes in roles they wished to see, and suggestions for changes in medical education. Methods used included focus groups, key informant interviews, an extensive literature review, and surveys, including a survey of health professionals. Concurrently, inter-university working groups prepared tools and strategies for strengthening faculty development, assessing student performance, and preparing future leadership for Ontario's medical education system. Eight specific physician roles were identified: medical expert, communicator, collaborator, health advocate, learner, manager ("gatekeeper"), scholar, and "physician as person." Educational strategies to help medical students learn to assume these eight roles were then incorporated into the curricula of the five participating medical schools. The authors conclude that the project shows that it is feasible to learn specifically what society expects of its physicians, to integrate this knowledge into the process of medical education reform, and to implement major curriculum changes through a collaborative, multi-institutional consortium within a single geopolitical jurisdiction.

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province's evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project's five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.

Dual diagnosis.

Although the problem of patients with dual diagnoses is not new, it has only been in the last few years that their unique and complex problems have begun to be addressed. This recognition coincides with society's concern regarding the magnitude of substance abuse problems in general. Currently, treatment consists of integrating concepts from substance abuse and mental health fields. This integration may improve the therapeutic outcome for these patients. As more experience is gained in this specialty, it is hoped that new treatment concepts will evolve that will more powerfully address the interactive aspect of substance abuse and psychiatric disorders.

A modified honours grading system and the selection of postgraduate trainees.

The selection of medical graduates for postgraduate training has often been considered to be unreliable and arbitrary because of the quality of information made available by medical schools to program directors. Many faculties of medicine have changed from reporting graduate performance in percentage grades to using an honours/pass/fail grading system to ensure that clearly established criteria for competence have been met and to encourage excellence and minimize competition. Unfortunately, the honours/pass/fail grading system has not been able to give a clear statement of relative class standing to assist in postgraduate selection. This paper describes a modified honours grading system, which takes into account a student's grade, the relative weighting of a course and the number of honours grades awarded per course. The proposed system was found to rank students in a way similar to that of the traditional percentage grading system, with no significant loss in internal consistency. The modified honours grading system permits faculties that use honours/pass/fail grades to report student performance and class standing, thereby assisting program directors in the selection of medical students for postgraduate training.

The film-reporting session as a qualifying examination in diagnostic radiology.

To assess the value of a film-reporting session as a qualifying examination in radiology, 11 residents were allowed 1 hour to interpret and dictate reports on 20 test cases. Reports were marked by four examiners; two used a standardized marking scheme and two a simple pass or fail assessment. The marking schemes were compared and the scores were related to the level of training and performance on the American College of Radiology (ACR) practice examination. With pass or fail marking, there was 55% agreement between markers and poor correlation with the candidates' training level. There was 100% marker agreement using the standardized scheme and better correlation with the level of training. There was poor correlation with the ACR scores. Preliminary results suggest that a film-reporting session with standardized marking is feasible and may be a useful addition to current evaluation methods in diagnostic radiology.

Anxiety and physical illness in the elderly.

The prevalence of anxiety disorders increases with advancing age. Unfortunately, the diagnosis of anxiety in elderly patients is often reached only after everything else has been ruled out. Elderly patients with clinical anxiety often present with physical complaints that mask the underlying anxiety disorder. Recognition and management of anxiety disorders in the elderly must be prompt to interrupt the cycle of anxiety-depression, physical illness, and other stresses.

What is ... normative versus criterion-referenced assessment.

Any reform of the current medical curriculum requires a reappraisal of the principles and practices of the evaluation system. The norm-referenced test which at this time is the primary method of evaluation was initially designed to rank order students for the purpose of selection. Difficulties arise when it is used, as it currently is for the assessment of competence. The norm-referenced test is often insensitive to instruction and, while it provides information regarding the relative strengths and weaknesses of students in comparison to their peers, it does not provide an estimate of the absolute level of performance achieved. In addition to promoting competition among students, the norm-referenced test is less suitable for programme evaluation. As it is the principal responsibility of a medical school to produce competent physicians and not to rank order them, it is more reasonable to compare student achievement to an external standard of performance or criterion. Criterion-referenced testing, then, is more suitable for the assessment of competence and, within this setting, percentage competency scores can be utilised when there is a need for the rank ordering of student achievement for the purposes of selection. It is recommended that criterion-referenced testing be the primary method of evaluation, as it best meets the objectives of the medical school by emphasising the achievement of clearly established external standards and, thereby, ensuring a high quality of performance.

Sexual relationships of patients with kleptomania.

Kleptomania, a disorder of impulse control in which the patients feel a compelling urge to steal objects of no value to them, has long been considered a disorder related in some fashion to sexual impulses. Recent advances in the clinical understanding of human sexual functioning have not been accompanied by an effort to refine our thinking about its relationship to kleptomania. Research is hampered by the relative rarity of the disorder and the propensity of patients to avoid seeking professional help. Consequently, the available literature is restricted to case studies or small series that fail to differentiate between kleptomania and other forms of shoplifting. This paper describes the six patients I have seen with the primary diagnosis of kleptomania; all had dysfunctional sexual relationships. The sole male patient was a homosexual, and compulsively promiscuous. Sexual counseling and/or therapy may provide an additional method for treating this difficult disorder.

The value of preoperative screening investigations in otherwise healthy individuals.

To assess the value of routine screening preoperative investigations in an otherwise healthy surgical population, the charts of 2570 patients undergoing cholecystectomy in two university teaching hospitals were reviewed. Of these, 1010 patients who were believed to be free of active disease other than cholelithiasis were selected for further study. Preoperative screening investigations were assessed in terms of frequency of use and abnormalities detected. The predictive values of these tests were analyzed and compared with information obtained from the history and physical examination. The frequency with which action was taken because of abnormal test results was also determined. Of the 5003 preoperative screening tests performed, abnormal results were obtained in 225. Of these, 104 were of potential importance. Action resulting from these abnormalities occurred in 17 cases. In only four patients could a conceivable benefit have arisen from a preoperative screening test. When compared with the results of the history and physical examination, routine preoperative investigations provided little further information that altered management in otherwise healthy surgical patients undergoing cholecystectomy.

Management of specific anxiety disorders in the elderly.

Advanced age is not, per se, an indication for a different treatment approach, although certain modifications in the treatment plan are required. Recognition and management of anxiety disorders in the elderly must be prompt to interrupt the vicious cycle of anxiety-depression, physical illness, and other stresses.

Psychological factors involved in impotence. A review of the literature.

Recent developments in the treatment of impotence and studies on the results of psychological methods for its treatment seem to indicate that the number of individuals who suffer from impotence of purely psychogenic origin is less than was reported in literature of the last decade. It is undoubtedly true, however, that psychological factors play an important role in the pathogenesis of this disorder. This review looks at psychological factors involved in impotence from three perspectives. Beginning with a historical review, those theoretical bases which formed the premise for psychological therapies are described. Second, diagnostic issues are explored in some detail. Finally, the variety of treatment modalities which have been used, with varying degrees of success, is described. It appears that whatever psychological treatment method is used, the patients who have the best prognosis are those in whom the disorder has lasted for less than two years, who have a strong motivation for psychotherapy, persisting sexual desire, and who are without significant psychopathology.