Alterations of beta3-adrenoceptors expression and their myocardial functional effects in physiological model of chronic exercise-induced cardiac hypertrophy.

Physical training induces cardiovascular autonomic nervous system regulation adaptations, which could result from beta adrenergic receptor (AR) modifications. Among them, beta(3 )AR alterations have been recently reported but their functional effect remained to discuss. To explain the beta(3) AR gene expression in relation to function, we simultaneously studied the left ventricle (LV) beta(3) AR mRNA and protein levels and the myocardial functional effects of a beta(3) AR agonist following physical training. Forty rats were assigned to either a control (C; N = 20) or a trained (T; N = 20) group. The treadmill running protocol was performed for 8 weeks. Histological measurements on LV slices were quantified. The beta(3) AR mRNA abundance was studied with RT-PCR and beta(3) AR protein density with Western-Blot analysis. Myocardial functional effects of a beta(3) AR agonist, BRL37344 (10(-8) M), were studied in Langendorff-perfused hearts. Histological data confirmed the adapted patterns of the physiological cardiac hypertrophy observed in T (P < 0.01), with a significant increase in arteries density (P < 0.01) and an unchanged collagen concentration. The beta(3) AR protein density was increased in T (154 +/- 38% in T vs. 100 +/- 24% in C; P < 0.05), but no change was noted concerning the beta(3) AR mRNA level. After BRL37344 perfusion LVDP, +dP/dT and -dP/dT, in C (P < 0.01), and only +dP/dT in T (P < 0.05) were decreased. Moreover, all LV hemodynamic parameters were more altered after BRL37344 in C than in T (P < 0.01).Thus, in this physiological model of cardiac hypertrophy, an increase of beta(3) AR density without beta(3) AR mRNA alteration was observed. Classical negative myocardial lusitropic and inotropic effects induced by a specific agonist of beta(3) AR were diminished in trained rats.

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools.

BACKGROUND AND OBJECTIVES: The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre-clinical and clinical students shared the same perceptions. METHODS: A mail survey was conducted in Canada of all second-year students and senior clerks at one innovative medical school (problem-based learning (PBL), patient-centred, community-oriented) and three traditional medical schools. Students were asked to what extent they agreed or disagreed that the majority of their teachers behaved as humanistic physicians and teachers; 10 statements were used. Overall, 65% of the 1039 students returned the questionnaire. RESULTS: Over 25% of second-year students and 40% of senior clerks did not agree that their teachers behaved as humanistic caregivers with patients or were good role models in teaching the doctor-patient relationship. More than half of second-year students and senior clerks did not agree that their teachers valued human contact with them or were supportive of students who had difficulties. There were few differences in the way medical students at innovative and traditional schools perceived their teachers' humanistic qualities. At the pre-clinical level however, there were more students from the innovative school than from the traditional schools (around 60% vs. 40%, P < 0.005) who agreed that their teachers valued human contact with them and were supportive of students. CONCLUSION: Our results indicate that the PBL curriculum fosters better teacher-student relationships during the pre-clinical years. They also suggest that an unacceptably large number of medical students are taught by physicians who seem to lack compassion and caring in their interactions with patients. This study questions the adequacy of medical faculty as role models for the acquisition of caring competence by medical students.

A Delphi technique to identify and evaluate criteria for construction of PBL problems.

INTRODUCTION: In the process of PBL implementation, faculty members often ask what are the criteria for constructing problems and subsequently evaluating them. Although experts agree on a fundamental theoretical basis for developing problems, mostly prototypical, it is difficult to find specific criteria that could be used in constructing PBL problems. METHOD: A Delphi technique using six independent judges from the Rouen School of Medicine, France, answered this question. It took four rounds and five months. RESULTS: Nine criteria were identified and rank-ordered according to their relative importance: 1. stimulating thinking, analysis, and reasoning (openness 6.8 points); 2. assuring self-directed learning (autonomy 6.5); 3. using previous basic knowledge (richness 6.2); 4. proposing a realistic context (attractiveness 5.7); 5. leading to the discovery of learning objectives (coverage 5.0); 6. arousing curiosity (inquisitiveness 5.0); 7. choosing topics related to public health (relevance 5.0); 8. assuring contextual breadth (comprehensiveness 4.8); and 9. choosing an appropriate vocabulary (medical encoding 4.7). DISCUSSION: The identification represents a fresh outlook on the PBL process, from judges who had recent experience in constructing PBL problems. Related to Barrow's dimensions, these criteria could be seen as a more concrete and specific level of conceptualization. Paired with those found in the literature, they match six out nine already identified, although not prioritized criteria. CONCLUSION: Judges from a school just having implemented PBL, found that Reasoning and Autonomy are the most important criteria for constructing PBL problems.

[New pedagogic approaches adapted to the teaching of pharmacology, the activities centered on the student]. / Nouvelles approches pédagogiques adaptées à l'enseignement de la pharmacologie, des activités centrées sur l'étudiant.

The traditional way of teaching of pharmacology is discussed in three parts. First two trends are presented that impact on the evolution of medical education. The first trend orients teaching toward instructional formats that solicit, and often require full student involvement. This is justified by the second trend: the organization of knowledge into long-term memory is built around semantic networks linked to the clinical context, thus facilitating recall in clinical practice. In the second part a method is presented which illustrates these principles: problem-based learning (PBL). The tutor's is role and roles where the onus is on the students are specified. The last part explores how PBL could be a more relevant method for teaching pharmacology, provided that three prerequisite assumptions are respected.

[Medical education at the dawn of the 21st century: a challenge for the French Units of Education and Investigation]. / La formation médicale à l'aube du xxie siècle: un défi aux Unités de Formation et de Recherche (UFR) françaises.

In the incoming 21st century, traditional medical schools are facing major challenges, if medical education wants to sustain educating physicians capable of answering continuous increasing health care needs of populations they should serve. Institutions should be willing to accept the necessity to modify instructional processes to favor student autonomy and to manage knowledge explosion. A new approach should guide schools in determining undergraduate program content and objectives, in favoring a learning process centered on student and oriented towards community needs, as well as in investing into faculty development in pedagogy. This approach triggers medical schools to establish with their students a new social contract intended to educate them as responsible and autonomous future medical citizens.

Clinical teachers as humanistic caregivers and educators: perceptions of senior clerks and second-year residents.

BACKGROUND: The acquisition and nurturing of humanistic skills and attitudes constitute an important aim of medical education. In order to assess how conducive the physician-learning environment is to the acquisition of these skills, the authors determined the extent to which clinical teachers are perceived by their trainees as humanistic with patients and students, and they explored whether undergraduate and graduate students share the same perceptions. METHODS: A mail survey was conducted in 1994/95 of all senior clerks and second-year residents at Laval University, University of Montreal and University of Sherbrooke medical schools. Of 774 trainees, 259 senior clerks and 238 second-year residents returned the questionnaire, for an overall response rate of 64%. Students' perceptions of their teachers were measured on a 6-point Likert scale applied to statements about teachers' attitudes toward the patient (5 items) and toward the student (5 items). RESULTS: On average, only 46% of the senior clerks agreed that their teachers displayed the humanistic characteristics of interest. They were especially critical of their teachers' apparent lack of sensitivity, with as many as 3 out of 4 declaring that their teachers seemed to be unconcerned about how patients adapt psychologically to their illnesses (75% of clerks) and that their teachers did not try to understand students' difficulties (78%) or to support students who have difficulties (77%). Compared with the clerks, the second-year residents were significantly less critical, those with negative perceptions varying from 27% to 58%, 40% on average. Except for this difference, their pattern of responses from one item to another was similar. INTERPRETATION: This study suggests the existence of a substantial gap between what medical trainees are expected to learn and what they actually experience over the course of their training. Because such a gap could represent a significant barrier to the acquisition of important skills, more and urgent research is needed to understand better the factors influencing students' perceptions.

Sustaining curricular change at Sherbrooke through external, formative program evaluations.

In this case study, the authors discuss external, formative program evaluation as a means to monitor and sustain ongoing curricular change and to prepare for periodic accreditation reviews. The Faculty of Medicine at Sherbrooke (in Quebec, Canada), following a major curricular reform begun in the mid-1980s, held three external, formative program evaluations in 1988, 1991, and 1994, using expert judgment and "connoisseur" models of evaluation. The authors present the goals of the evaluations (e.g., to evaluate the implementation of intended curricular changes) and the 17-step process used (e.g., "involve as many faculty and students as possible before and during the visit"), and describe the preparation for the evaluations, the selection of the external evaluators (e.g., a chief medical officer from the World Health Organization, a high-profile basic sciences teacher, the chairman of the previous accreditation team, and others), and on-site activities and reporting. Recommendations from the evaluators and the subsequent actions taken (and in a few cases, not taken) by the school are presented and discussed in terms of program planning, curricular content, basic sciences, problem-based learning and tutors' training, assessment of students, resource constraints, clerkships, community orientation, students' self-directedness, and medical humanism. The three evaluations helped guide and support the major curricular undertakings and encouraged continued changed and refinements. They also had a significant effect on the curriculum itself, on the faculty, and on the socioeducational climate of the school.

Developing and evaluating the student assessment system in the preclinical problem-based curriculum at Sherbrooke.

BACKGROUND: Students' learning was used as an outcome measure in the first phases of the major curriculum reform started in 1987 by the Université de Sherbrooke Faculty of Medicine, which shifted from a traditional to a student-centered, problem-based learning (PBL) and community-oriented program. The system for evaluating preclinical students' learning is intended to reinforce the integration of basic and clinical sciences. METHOD: To discover whether the evaluation system was fulfilling its intended goals, the authors used data from the classes of 1991-1993 to assess the reliability and validity of three evaluation instruments. The three instruments were (1) written examinations composed of multiple-choice questions (MCQs), short-answer questions (SAQs), and problem-analysis questions (PAQs); (2) PBL tutor rating forms that evaluate students' reasoning skills, communication and group-interaction skills, and autonomy and humanism; and (3) clinical skills evaluations, including objective structured clinical examinations (OSCEs). The weights allocated to the instruments reflected how the faculty valued each evaluation dimension in each of the three phases of the preclinical curriculum. RESULTS: Reliability indexes improved throughout the system implementation. The written examinations proved to have content validity according to the PBL learning objectives. As evaluated by students, the PAQs were found to be at a taxonomic level that assessed ability to analyze information a third of the time in the first year of implementation of the PBL curriculum and 17% in the second year. Variations and correlations of students' mean performances across instructional units and between the evaluation instruments led to the development of a student longitudinal performance profile to be used before yearly promotion decisions are proposed. The profile was introduced in the fifth year of PBL implementation. CONCLUSION: The system allows students to learn higher-taxonomic-level content and fulfills the institution's social responsibility of judging program outcomes and promoting qualified students, although evaluation by PBL tutors is still psychometrically questionable and the measurement of students' reasoning and ability to analyze problems is still an unfinished evaluation task.

A student-centred, problem-based curriculum: 5 years' experience.

In 1987, the University of Sherbrooke's school of medicine implemented a student-centred, problem-based learning (PBL) curriculum. The experience of the first 5 years is reviewed; program goals, the schedule of learning activities, the instructional format and assessment of student learning are described. The new program is more demanding of teachers and requires better faculty training in pedagogy. No new financial resources have been available. The preclinical reform has led to revision of the clerkship, where sessions on clinical reasoning are now based on the PBL philosophy. Student reactions to the program are reported. The Sherbrooke experience has demonstrated that it is both possible and feasible to shift from a traditional to a problem-based curriculum.

From traditional to problem-based learning: a case report of complete curriculum reform.

The Sherbrooke School of Medicine, Quebec, has restructured its entire curriculum to make problem-based learning (PBL) the main instructional format. This complete reform is explained both in terms of process and content. The curriculum problems were clearly identified and overcome by a major structural shift-over following the stages of a strategic planning of change. Implementation over a period of 7 years is described according to a four-stage framework: need for change; selection of the PBL solution; planning for implementation; and the full-scale adoption of the PBL method. The programme is described in relation to the congruence of goals, learning and evaluation activities. Initial impact on student learning and evaluation, attracting better quality students, academic staff roles, and on financing the operation are discussed. Changing the undergraduate programme has become an institutional project directed by the Office of the Dean.

Preparing faculty to teach in a problem-based learning curriculum: the Sherbrooke experience.

Over the last 6 years Sherbrooke Medical School has undertaken a major reform of its undergraduate curriculum. A new student-centred, community-oriented curriculum was implemented in September 1987. Problem-based learning (PBL) is now the main educational method. To adequately prepare teachers for the curriculum a series of faculty development programs in pedagogy were offered: first, a 2-day introductory workshop to initiate teachers into educational principles and their application in the new program; second, a 1-year basic training program in medical pedagogy; third, a 1-day workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring. Over 60% of all full-time teachers attended the introductory program and 80% the tutor training program. The 1-year basic training program was completed by 33% of the faculty members. The implementation of these programs, coupled with a high participation rate, resulted in a more student-centred educational philosophy and a greater interest in medical education. This had a significant impact when the new curriculum was instituted. Lessons learned from the experience are discussed.

Training psychiatrists and family doctors in evaluating interpersonal skills.

Ten psychiatrists and 15 family doctors were asked to score videotapes of patient-doctor encounters before and after each of two training periods. One period focused on the theory of assessment of doctors' interpersonal skills, while the other was purely practical. Results indicate that after one training session in either theory or practice, both groups of doctors achieved a significantly higher interrater reliability. The second session, which crossed over theory and practice of assessment, did not increase the improvement in interrater agreement achieved by the first training period. Although both groups of doctors showed a significant increase in interrater agreement, psychiatrists exhibited greater reliability scores than family doctors before the experiment as well as after the second training session. These results were discussed in terms of their implicatioins for future research on the doctor-patient relationship.

Basic Training Program in Medical Pedagogy: a 1-year program for medical faculty.

In 1979 université de Montréal developed the Basic Training Program in Medical Pedagogy; the program has since been offered at two other Canadian medical schools. The learning activities are spread over an academic year so that the teachers are able to continue their clinical or research duties. The program, which follows a model of systematic instruction, comprises 17 self-instructional modules on basic educational topics adapted to medical teaching. The topics are related to four components of an integrated system: student needs and learning objectives, instructional methods, student evaluation and program evaluation. The instructional format is aimed at three levels--understanding, analysis and application--to which assignments and assessments are related. In addition to the modules, the program offers 15 half-day sessions for small groups (five participants and one instructor) to discuss aspects of the program, especially home assignments and the application of personal educational projects. A minimum of 100 hours of personal time is requested. The program's main goal is that students be placed at the centre of the educational process. Of 215 participants since 1979, 171 (80%) have completed the program and reported high satisfaction. Issues related to any faculty development program are discussed.

Double-contrast arthrotomography of the shoulder: correlation of radiological and surgical findings in complete rotator cuff tears.

Double-contrast arthrotomography of the shoulder appears extremely valuable; we have verified its accuracy in measurements of complete rotator cuff tears. The first 31 patients so investigated and explored surgically have been retrospectively evaluated. Accurate measurements were found in 85% of the coronal diameters and in 69% of the sagittal ones.

[Evaluation of Neer's hemi-arthroplasty in the treatment of humeral fractures]. / Evaluation de l'hémi-arthroplastie de Neer dans le traitement des fractures de l'humérus.

Eighteen patients with fractures of the proximal humerus with at least four fragments, with or without dislocation (group IV, V and VI of Neer's classification), were treated by hemiprosthetic replacement. The average age was 59 years. The follow-up was from 1 to 7 years. Patients were assessed on two occasions by two evaluators using Neer's protocol. The glenohumeral and the scapulothoracic movements, using the other shoulder as control, were measured radiologically at 0 degrees, 45 degrees and maximal abduction. Pain, function and range of motion were recorded. No complication was encountered. By radiologic assessment, it was possible to classify results in three groups. In all of the unsatisfactory results, the centre of motion of the prosthesis was displaced proximally. Satisfactory and excellent results were obtained in 66%. The best results are obtained if patients are operated on early; repair of the rotator cuff is important. The centre of rotation of the prosthesis must be in precise biomechanical relation to the glenoid fossa; such a relation is of prognostic value.