Social marketing: application to medical education.

Medical education is often a frustrating endeavor, particularly when it attempts to change practice behavior. Traditional lecture-based educational methods are limited in their ability to sustain concentration and interest and to promote learner adherence to best-practice guidelines. Marketing techniques have been very effective in changing consumer behavior and physician behavior. However, the techniques of social marketing-goal identification, audience segmentation, and market research-have not been harnessed and applied to medical education. Social marketing can be applied to medical education in the effort to go beyond inoculation of learners with information and actually change behaviors. The tremendous potential of social marketing for medical education should be pilot-tested and systematically evaluated.

Changing career patterns of deans of medicine, 1940-1992.

This study examined the occupational experiences of deans of medicine during five decades, 1940-1992, to explore whether changes in their prior career paths could explain the increasing turnover of deans that occurred during this period. The results indicate that deans are now more likely to have had previous administrative experience, as either chairs or lower-level administrators, than they were in earlier decades; in most cases, this administrative experience has occurred in the same institutions in which they were appointed to the deanship ("inside hires"). However, the greater number of deans with prior administrative experience cannot explain the increasing turnover of deans because administrative experience was associated with longer tenures. The kinds of positions the deans took upon leaving office did not change during the study period, particularly among those who had short tenures of four years or less. During the five decades, inside hires leaving during their first five years in office most often moved into faculty, chair, or lower-level administrative positions. Outside hires leaving during their first five years most often went on to higher-level administrative positions. The study results do not support the hypothesis that the shorter tenures of deans in recent decades are related to their previous professional experiences or to increasing opportunities for deans to move to better positions. In conclusion, the authors emphasize that organizational and environmental factors rather than deans' individual characteristics must have played the dominant role in the increasing turnover of deans of medicine in recent years.

Comments on the AAMC policy statement recommending strategies for increasing the production of generalist physicians.

The United States has a physician specialty imbalance, primarily a shortage of generalists (defined as family physicians, general internists, and general pediatricians) relative to other specialists. In recent years, the rising costs of health care, the expansion of managed care, and problems of access to care have accentuated the critical role that generalists must play in a cost-effective, accessible health care system. Despite numerous public and private initiatives designed to address the supply of generalist physicians, the ratio of generalists to specialists has been decreasing. Although the factors contributing to the shrinking proportion of generalists are many and are often outside the control of educators, there is evidence that medical schools can play a major role in influencing specialty choice. Recognizing the need to address the specialty imbalance in this country, the Association of American Medical Colleges (AAMC) appointed the Generalist Physician Task Force to develop a statement suggesting actions that the AAMC and its constituents could take to foster a greater representation of generalist physicians in the United States. The task force produced an Executive Summary, published as an AAMC policy statement in early 1993, that contained recommended strategies for medical schools, graduate medical education, and the practice environment. The authors of the present article critique these recommendations, provide a background and rationale for each of them, and give suggestions about how some of the recommendations might be implemented. While they are in general agreement with the AAMC policy statement, they feel the recommended strategies fall short of the need. They maintain that the AAMC statement represents an admirable but cautious approach to a daunting problem, and that the time is past when cautious approaches will suffice. The authors conclude with the hope that bolder initiatives will emerge from the new AAMC Office of Generalist Physician Programs.

Turnover of deans of medicine during the last five decades.

This report uses published information on the tenures of the 862 U.S. medical school deans who served from 1940-41 through 1990-91 to ascertain whether the turnover of deans has increased historically. The data confirm the wide-spread impression that there has been increasing instability of medical school leadership in recent decades. The proportion of deans who survive to a specific tenure in office has diminished, and the proportion of schools with new deans has increased, although with marked yearly fluctuations. Furthermore, the frequency of deans' turnover has not been evenly distributed among medical schools. Some schools have had large numbers of short-tenured deans, while other schools have had only a few deans over the five decades studied. The authors speculate that the rise in the turnover of deans may be related to the criteria used for their selection and/or because American academic medical centers have grown in size and are increasing in organizational complexity. The authors urge that future research that explores the causes of recent deans' turnover should incorporate modern management and statistical techniques and consider organizational variables as well as the personal and professional characteristics of deans.

Faculty rewards for the generalist clinician-teacher.

Historically, medicine has regarded itself as a profession of great breadth, encompassing the total range of human activity: biological, behavioral, social and organizational. In the last several decades, however, it has become increasingly reductionist, fragmented, and specialized. Recent developments, as exemplified by the return of the generalist clinician-educator to the academic community, portend a reversal of this trend. Manifestations of a change in the orientation of medicine and medical education toward bolism and bumanism include a movement toward improved compensation for "cognitive" services, development of new promotion tracks for clinician-teachers, and increased support and recognition of applied clinical research. Generalist faculty are in a position to benefit from these trends, but obstacles remain; vigilism and activism are required to maintain momentum.

Charting the winds of change: evaluating innovative medical curricula.

The increased interest, in North America and around the world, in problem-based and community-oriented medical curricula has sparked interest in the evaluation of these innovative programs. In January 1989, the Josiah Macy Jr. Foundation sponsored a conference to consider designs for evaluation studies and the potential distinctive outcomes of the innovative curricula that might be foci of these studies. After defining an "innovative curriculum," the participants identified seven characteristics of "important evaluation studies," particularly endorsing studies that compare curricula as whole entities. The participants then identified 26 areas where differences between graduates of innovative and traditional curricula might be expected, and five equally important areas where differences are not expected. Distinctive outcomes of innovative curricula were anticipated in areas such as interpersonal skills, continuing learning, and professional satisfaction. Overall, these recommendations are offered to stimulate creative evaluations of the growing number of innovative programs in medical education.

Event-related covariances during a bimanual visuomotor task. II. Preparation and feedback.

Event-related covariance (ERC) patterns were computed from pre-stimulus and feedback intervals of a bimanual, visuomotor judgment task performed by 7 right-handed men. Late contingent negative variation (CNV) ERC patterns that preceded subsequently accurate right- or left-hand responses differed from patterns that preceded subsequently inaccurate responses. Recordings from electrodes placed at left frontal, midline antero-central, and appropriately contralateral central and parietal sites were prominent in ERC patterns of subsequently accurate performances. This suggests that a distributed cortical 'preparatory network,' composed of distinct cognitive, integrative motor, somesthetic, and motor components, is essential for accurate visuomotor performance. ERC patterns related to feedback about accurate and inaccurate responses were similar to each other in the interval immediately after feedback onset, but began to differ in an interval spanning an early P300 peak. The difference became even greater in an interval spanning a late P300 peak. For both early and late P300 peaks, ERC patterns following feedback about inaccurate performance involved more frontal sites than did those following feedback about accurate performance. Together with the stimulus- and response-locked results presented in part I, results of this study on the preparatory and feedback periods suggest that ERCs show salient features of the rapidly shifting, functional cortical networks that are responsible for simple cognitive tasks. ERCs thus provide a new perspective on information processing in the human brain in relation to behavior--a perspective that supplements conventional EEG and ERP procedures.

Event-related covariances during a bimanual visuomotor task. I. Methods and analysis of stimulus- and response-locked data.

A new method that measures between-channel, event-related covariances (ERCs) from scalp-recorded brain signals has been developed. The method was applied to recordings of 26 EEG channels from 7 right-handed men performing a bimanual visuomotor judgment task that required fine motor control. Covariance and time-delay measures were derived from pairs of filtered, laplacian-derived, averaged wave forms, which were enhanced by rejection of outlying trials, in intervals spanning event-related potential components. Stimulus- and response-locked ERC patterns were consistent with functional neuroanatomical models of visual stimulus processing and response execution. In early post-stimulus intervals, ERC patterns differed according to the physical properties of the stimulus; in later intervals, the patterns differed according to the subjective interpretation of the stimulus. The response-locked ERC patterns suggested 4 major cortical generators for the voluntary fine motor control required by the task: motor, somesthetic, premotor and/or supplementary motor, and prefrontal. This new method may thus be an advancement toward characterizing, both spatially and temporally, functional cortical networks in the human brain responsible for perception and action.

Human neuroelectric patterns predict performance accuracy.

In seven right-handed adults, the brain electrical patterns before accurate performance differed from the patterns before inaccurate performance. Activity overlying the left frontal cortex and the motor and parietal cortices contralateral to the performing hand preceded accurate left- or right-hand performance. Additional strong activity overlying midline motor and premotor cortices preceded left-hand performance. These measurements suggest that brief, spatially distributed neural activity patterns, or "preparatory sets," in distinct cognitive, somesthetic-motor, and integrative motor areas of the human brain may be essential precursors of accurate visuomotor performance.

The effect of treatment setting and patient characteristics on pain in terminal cancer patients: a report from the National Hospice Study.

Debilitating pain is the symptom most often associated with cancer by the general public. The National Hospice Study (NHS) evaluated pain control among terminal cancer patients served in hospital based (HB) and home based (HC) hospices, and in conventional care settings (CC) such as outpatient clinics and oncology units. Pain was reported by the patient when able to respond and by the patients' primary care person (PCP) during repeated interviews until death. Patient and PCP pain reports were correlated at 0.43. PCPs reported that around 16% of patients were pain free in the last weeks of life while 18% were in persistent pain. Statistically adjusting for differences in the CC, HB, and HC samples, HB patients were less likely to report having persistent pain than either CC or HC patients, although there were no differences in the proportion of patients who were pain free. Age was negatively correlated with the level of pain. As expected, brain and bone metastases were related to pain in opposite directions, with more pain among those with bone involvement and less among those with brain involvement. Conclusions about whether HB hospices really are superior at pain control must be made cautiously in view of the relationship between age and pain and the greater age of hospice patients in our study.