Medicine, law, ethics: teaching versus learning

Background: Ethical care is concerned with aspects of work that may influence nurses’ ethical behavior. Intensive care units might expose nurses to moral judgment while caring. This qualitative study aimed to explain the nurses’ experience of moral judgment in intensive care units. Methods: The present qualitative study was conducted using the conventional content analysis method. The participants of the study included 23 nurses working in the intensive care units (ICU, CCU, NICU) of four hospitals affiliated with Sabzevar University of Medical Sciences who were selected using purposive sampling. The data were collected through semi-structured interviews. The questions asked in the interviews included, "Would you please describe one working day of yours caring in the intensive care units?" and "While caring, did you have to hesitate to make a decision ethically? If yes, would you describe that situation?" The Data were analyzed using the qualitative content analysis method proposed by Graneheim and Lundman. Results: Data collection and analysis led to the identification of 1 theme, 6 categories, and 23 subcategories. The identified theme was "intensified tension and conflict following ethical patient care in the intensive care units" and the categories were "repeated exposure to stress in ethical patient care in the intensive care units", "ethical care originated from the nurses’ beliefs", "moral judgment in care affected by the patient’s clinical condition", "moral judgment as a consequence of clinical judgment", "ethical care based on organizational and legal conditions in the moral environment", and "requirements of ethical care". Conclusion: The nurses in the intensive care units deal with ethical issues and are under a lot of stress. The results of this study can help nursing authorities pay more attention to developing ethical knowledge and ethical considerations in hospitals and provide organizational support to identify the moral tensions of nurses in intensive care units.

Back to table of contents Next article Taking IssueFull AccessManaged Care or Ethical Care: What's in a Name?H. Steven Moffic, M.D., H. Steven MofficSearch for more papers by this author, M.D., Psychiatry and Behavioral Medicine Department, Medical College of Wisconsin, MilwaukeePublished Online:1 Aug 2003https://doi.org/10.1176/appi.ps.54.8.1063AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Just hearing the term "managed care" is often enough to raise the hairs and pulses of most clinicians. At the 2002 "Behavioral Healthcare & Informatics Tomorrow" conference, Charles G. Ray, M.Ed., who is president and chief executive officer of the National Council for Community Behavioral Health, said that he no longer uses the term. To Mr. Ray and others, the term "managed care" just has too many negative associations with questionable management practices.What should replace the term? It seems that we need a term that does not ignore the problems managed care was supposed to address and one that will be widely accepted among payers, clinicians, the public, and even politicians.In the past, James Sabin, M.D., who is editor of the Managed Care column in Psychiatric Services, has advocated for the term "ethical managed care" as an alternative. However, that has not caught on, possibly because it includes the term "managed care" or because it is too long.Why not drop the word "managed" from Dr. Sabin's recommendation and use "ethical care"? Presumably no one would be offended by this term, and it would not ignore the cost issues influencing managed care. The preamble to the American Psychiatric Association's Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states, "a physician must recognize responsibility not only to patients, but also to society."This principle acknowledges the importance of costs but keeps the patient primary. When we use the word "ethical," we recognize the fact that as professionals we have widely accepted principles that can be referred to and used as national standards.If we can replace the term "managed care," then maybe we can also replace its derivative, "behavioral" health care. Behavioral generally refers only to observable, and possibly measurable, characteristics of a patient. This term seems to fit the focus of managed care—that functioning, not internal suffering, is the most important issue for insurance coverage. Our ethics as health care professionals require us to attempt to alleviate psychological suffering whenever possible. Therefore, when we need to refer to our own specialty, "ethical psychiatric care," or more broadly, "ethical mental health care," would be preferable to "behavioral health care." After all, isn't it our minds that really make us human? FiguresReferencesCited byDetailsCited byNone Volume 54Issue 8 August 2003Pages 1063-1063 Metrics PDF download History Published online 1 August 2003 Published in print 1 August 2003

In accident patient care, there is a substantial overlap between the scope of duties of hospital social services and tasks fulfilled by the German statutory accident insurances' visiting staff that regularly takes care of accident patients. Therefore, a project on the integration of hospital social services into the organizational structures of the German statutory accident insurance was initiated which aimed at optimising communication and realising synergy effects. A formative evaluation of the project was conducted that provided process- and outcome-related data for a comprehensive evaluation of the strengths and potentials of the project. Report forms containing patient-related information were completed by hospital social services. Forms were evaluated in terms of their utility for case management by accident insurance administrators using a checklist. Project implementation and procedures were documented and evaluated using semi-structured interviews with social services staff and accident insurance employees. Through the model, a comprehensive care for accident patients could be reached. In one third of all cases reviewed, rehabilitation management could be improved by including hospital social services. Moreover, in one third of all cases, care-related activities initiated by accident insurance funds could be reduced by involving local hospital social services. The report form used by hospital social services was evaluated as a useful tool in the context of patient care and rehabilitation management. The model was evaluated by interview participants as a highly targeted approach in accident patients' care management. Implications of the study for improving health care are discussed.

Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans.

Opportunities for pharmacy practice reform exist at state and national levels. The Virginia Commonwealth University (VCU) School of Pharmacy created a working group to assess these opportunities with a mission to advance pharmacy practice in Virginia. To assess the perceptions of chronic and acute care pharmacy practice and confidence in providing patient care and medication therapy management (MTM) activities and characterize current work activities of pharmacists in Virginia. A cross-sectional, online survey was used. VCU School of Pharmacy pharmacist preceptors, students, and faculty members were eligible. The questionnaire contained items that assessed perceptions of chronic and acute care pharmacy practice and confidence in patient care and MTM activities. Demographic and practice site characteristics were also collected. A total of 974 preceptors, 515 students, and 78 faculty members were invited to participate, and 335 preceptors, 155 students, and 41 faculty members had usable responses, yielding response rates of 34%, 30%, and 53%, respectively. Preceptors, students, and faculty members favorably viewed direct patient care roles in the chronic and acute care settings. Pharmacists were very confident or confident in performing many patient care and MTM activities. They were least confident in considering genetic characteristics when adjusting medications and creating business plans for new services. Many pharmacists in chronic and acute care settings provided some type of patient care service, but few were regularly providing services. Inadequate time, staffing, and reimbursement, and lack of perceived value from patients and providers were most frequently cited as barriers to service provision. VCU preceptors, students, and faculty members overwhelmingly believe that pharmacists should provide direct patient care and MTM activities. To transform pharmacy practice, it will be important to define the pharmacist's role, responsibilities, and expected outcomes and to consider time, staffing, and compensation as well as to engage patients and providers.

Practicing Medicine and Studying Law”: How Medical Schools Used to Have the Same Problems We Do and What We Can Learn from Their Efforts to Solve Them

New York University School of Medicine

Back to table of contents Previous article Next article Book ReviewsFull AccessTreatment of Suicidal Patients in Managed CareAndrew Edmund Slaby, M.D., Ph.D.Andrew Edmund SlabySearch for more papers by this author, M.D., Ph.D.Published Online:1 Jan 2002https://doi.org/10.1176/appi.ps.53.1.107AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Management of the suicidal patient brings to the fore problems with managed care more than that of patients with any other psychiatric condition. Failure to provide needed care in a timely manner can lead to unnecessary death and much pain for those who survive. Suicide ranks ninth among causes of death in the United States, and third for adolescents. Provision of psychopharmacotherapy and psychotherapy, in a protected environment if necessary, at the time of suicidal crisis allows the patient in pain to develop new ways of coping to reduce the immediate risk. In many instances it also serves to reduce the impact of future crises so that self-inflicted death is not perceived as an option.This interesting and timely volume addresses the difficulties clinicians encounter as a result of managed care restrictions, and it discusses strategies for working effectively within such restrictions. As the volume editor explains, caregivers often perceive managed care as an attack on the autonomy of their decision making, on the confidentiality of the treatment process, and on their anticipated reimbursement for services rendered.In contrast to the earlier fee-for-service culture, which some feared would stimulate the provision of unneeded care to generate greater hospital and caregiver revenue, the ethical concern today is over the financial gain employers and insurers can reap by limiting the care given to subscribers. Suicidal patients are at risk of being undertreated, being discharged too early, and not being provided care at the level required for their safety. A study cited by contributors to *this volume found that the suicide rate was 7 percent higher in a capitated system than in a fee-for-service system (1). Another study cited found that the premature assignment of patients to outpatient settings had a role in the more than twofold increase in the number of deaths by accidental poisonings and medication errors in the United States between 1983 and 1993 (2).This book, richly illustrated with examples, addresses the impact of managed care on crisis care and brief hospitalization of suicidal patients, with specific discussions of the unique concerns involved in treating the populations at greatest risk—adolescents, substance abusers, and the elderly. The risk that an attempt will lead to completed suicide is estimated to be seven times greater among persons with alcohol use disorders than among those without (3). The book's appendixes on risk evaluation and on navigating managed care should be read by all who provide care for suicidal patients.Strategies elaborated in this volume will help clinicians negotiate passage through the managed care landscape, which at first glance appears inimical and threatening to the values of clinicians. To provide effective care, caregivers must capitalize on the advantages of managed care, such as coordination of available alternatives, and minimize the disadvantages, such as potential undertreatment and the dilution of the clinician's responsibility. Limited access to care has paradoxically spawned creative programs that are intermediate between inpatient and outpatient care and has enhanced the need for clinicians who are skilled in the evaluation of suicide risk and in appropriate emergency triage.The fact that at the close of the 20th century more than 60 percent of Americans were enrolled in managed care (4) indicates both the need for a book like Treatment of Suicidal Patients in Managed Care and the need for clinicians with the skills it discusses.Dr. Slaby is clinical professor of psychiatry at New York University and New York Medical College.edited by James M. Ellison, M.D., M.P.H.; Washington, D.C., American Psychiatric Press, Inc., 2000, 218 pages, $39 softcover

Faculty members are expected to write high-quality multiple-choice questions (MCQs) in order to accurately assess dental students' achievement. However, most dental school faculty members are not trained to write MCQs. Extensive faculty development programs have been used to help educators write better test items. The aim of this pilot study was to determine if a short workshop would result in improved MCQ item-writing by dental school faculty at one U.S. dental school. A total of 24 dental school faculty members who had previously written MCQs were randomized into a no-intervention group and an intervention group in 2015. Six previously written MCQs were randomly selected from each of the faculty members and given an item quality score. The intervention group participated in a training session of one-hour duration that focused on reviewing standard item-writing guidelines to improve in-house MCQs. The no-intervention group did not receive any training but did receive encouragement and an explanation of why good MCQ writing was important. The faculty members were then asked to revise their previously written questions, and these were given an item quality score. The item quality scores for each faculty member were averaged, and the difference from pre-training to post-training scores was evaluated. The results showed a significant difference between pre-training and post-training MCQ difference scores for the intervention group (p=0.04). This pilot study provides evidence that the training session of short duration was effective in improving the quality of in-house MCQs.

Curriculum Management and Governance Structure ♦ The Curriculum Oversight Committee is the standing committee responsible for the overall curriculum. ♦ Four other curriculum committees (First Year, Second Year, Required Clerkship, Elective Clerkship), composed of course directors, clerkship directors, administrators, and students, provide year-specific discussion and advice on the curriculum (Figure 1).FIGURE 1:: Management of the Curriculum Office of Education ♦ The Curriculum Office within Academic Affairs has primary responsibility for overseeing and managing the curriculum. ♦ The Division of Medical Education and Evaluation within the Department of Medical Education and Biomedical Informatics (MEBI) supports the medical education program in a number of ways. MEBI was founded in 1967 as a division to help medical school faculty improve the teaching and learning process. The division achieved departmental status in 1989. ♦ The department's Division of Medical Education and Evaluation employs nine full-time faculty members and two part-time faculty; many clinician–educators have affiliate appointments in the department. MEBI faculty hold many leadership roles in the School of Medicine. These include representatives on every curriculum committee, Year 1 Curriculum Committee chair, School of Medicine Director of Evaluation, Teaching Scholars Program codirectors, OSCE program codirector, Medical Information for Decision Making course chair, and Institute for Simulation and Interprofessional Studies codirector. ♦ The department's mandate has broadened to provide instruction to faculty and students, conduct faculty development workshops, assist with and implement performance-based teaching and evaluation, and train medical education researchers and educators through the Teaching Scholars Program conduct research into teaching and learning in a variety of settings provide professional services for health sciences faculty, including course evaluation and test design and scoring develop innovations in biomedical and health informatics Financial Management of Educational Programs ♦ The diversity in the revenue base of the School of Medicine has helped the School respond to the current global financial crisis. ♦ The School's sources of revenue remain stable. However, the relative proportion of total revenue derived from each source is changing over time: Although state revenues and spending will continue to be constrained and the School of Medicine's state funds were cut in Fiscal Year 2010, the state revenue in support of a recent medical school class expansion will continue to be phased in until fully funded in 2013. The University and the School of Medicine completed a seven-year capital campaign in FY 2008. UW Medicine exceeded its capital campaign goal of $1 billion; the pledges of endowment and gifts supporting faculty, students, and programs will be realized over the next few years. The School is in a good position to continue to realize above-average growth in research programs that are integral to its educational programs. The hiring of faculty who are leaders in biomedical sciences and clinical practice and who are active in biomedical research is an important source of the School's success and high quality. The clinical programs recorded continued growth and positive financial performance in Fiscal Year 2009. Rapid systemwide process improvements to reduce costs, eliminate redundant services, and improve overall efficiency in conjunction with effective strategic planning increased key patient volumes and revenues. Revenues are transferred from the practice plans and hospitals to support the teaching, research, and patient care activities of the School of Medicine. ♦ Both the University and the School of Medicine provided bridge funding to support the academic programs. ♦ UW Medicine, the health system in which the School of Medicine is one of seven entities, is executing a comprehensive strategic plan to improve performance, implement new programs, consolidate programs to reduce costs and increase efficiency, and develop business plans around the larger strategic initiatives. The implementation of the strategic plan will achieve desired growth in the system and inform future decisions around resource allocation in the face of ongoing financial turmoil. Valuing Teaching ♦ The Colleges program, although technically not a teaching academy, has created an effective learning community of medical school teachers: Started in 2001, the Colleges' program consists of 37 faculty educators who function as a cohesive learning community, administrative unit, and cadre of teachers and mentors within the School of Medicine. The Colleges oversee a four-year integrated curriculum of clinical skills and professionalism; teach the Introduction of Clinical Medicine II course throughout the second year through weekly bedside teaching sessions with consistent, small student groups; and provide a consistent faculty mentor for all students throughout their medical school career. Faculty from diverse specialties are selected through a competitive process and devote a minimum of 0.25 FTE to the Colleges; selection criteria include clinical, teaching, and mentoring excellence. Faculty conduct and receive considerable faculty development in addition to direct involvement in curriculum development, teaching, and mentoring activities. ♦ The Teaching Scholars, a nine-month faculty development program, has developed a cadre of faculty educators who continue to work together on educational projects, workshops, and curriculum development after they have completed the formal program. To date, 168 faculty from more than 20 clinical specialties, including nursing, physician assistants, pharmacy, and dentistry, have participated in the program. Many have been promoted and/or gone on to leadership positions at UW and elsewhere. ♦ The UW Medicine Faculty Appointments and Promotions Guide, which augments departmental criteria and the University Faculty Code, states that “to foster innovation and creativity, flexibility is encouraged in how contributions to scholarship, teaching, and service are evaluated and weighted.” The guide describes the scholarship of teaching as an important type of scholarship; teaching contributions listed as scholarship include curriculum development, materials for in-house use, educational software or video, educational information on the Internet, and new methods to evaluate the success of educational programs and the progress of trainees. ♦ Virtually all promotion packets now include a teaching portfolio that documents and highlights the faculty member's educational contributions. ♦ Evaluation of the scholarship of teaching is elicited through solicited evaluations from outside reviews at the time of promotion, including users of the information (faculty, trainees, students, and so on) and/or publication in peer-reviewed journals and presentation at scientific meetings. Curriculum Renewal Process ♦ The UW School of Medicine launched a comprehensive review of the medical school curriculum in 1998. The review was completed in 2001 and implementation of the resulting plan began in 2001-02. ♦ The guiding principles of the charge by the Dean specified that the review should include a balanced, thorough examination of course content examine teaching methods employed, emphasizing the introduction and use of contemporary information technology assure continuity and internal integrity within the curriculum, with strong themes introduced in first year and followed throughout the four years develop clear lines of responsibility and authority for the administration and management of the curriculum and its component parts develop a new approach to teach core clinical skills and professionalism ♦ The curriculum review process was organized into three phases: Phase I assessed the current curriculum, identifying strengths, weaknesses, and opportunities for enhancement; Phase II developed recommended changes to address areas of concern in Phase I; and Phase III developed specific implementation plans for the recommendations. Changes to the first and second years as a result of the curriculum review included addition of an evidence-based medicine and critical thinking first-year course that has evolved into Medical Information for Decision Making greater emphasis on small-group versus lecture-based teaching addition of the Colleges program, in which a cohort of dedicated clinical faculty teach bedside clinical skills to small groups of assigned students throughout the second year and continue to mentor those students throughout their medical school education Major additions to the third and fourth clinical years included: a required 4-week Neurology Clerkship, a required four-week surgical selective, and expansion of the Chronic Care/Rehabilitation Medicine Clerkship from two to four weeks, with focus on chronic care, rehabilitation medicine, geriatrics, pain management, and palliative care. The medical student research requirement was restructured into an Independent Investigative Inquiry, with expanded options for completing the requirement, including data gathering/hypothesis-driven inquiry; critical review of literature; experience-driven inquiry; and a special simulation-based experience. The curriculum management system was restructured to implement year-specific curriculum committees and a curriculum oversight committee. Learning Outcomes/Competencies ♦ The University of Washington School of Medicine learning objectives are available at: http://uwmedicine.washington.edu/Education/MD-Program/Current-Students/Curriculum/Pages/default.aspx. New Topics in the Curriculum Since 2000 ♦ Patient safety is included in the following courses: Medical Information for Decision-Making (first year), Capstone I-Transition to Clerkships (second year), Medicine Health and Society (second year), courses in the Institute for Simulation and Interprofessional Studies (ISIS) (courses available in all years) ♦ Quality improvement is included in the following courses: Medical Information for Decision Making (first year), Medicine, Health and Society (second year), Introduction to Clinical Medicine II (second year), ISIS (all years) ♦ Team-based learning is included in the following courses: Capstone I-Transition to Clerkships (second year), Problem-based Learning (second year), Chronic Care Clerkship (fourth year), Emergency Medicine Clerkship (fourth year), ISIS (all years) ♦ Simulations/training in new surgical techniques are included in the following: Capstone I-Transition to Clerkships (second year), Capstone II-Transition to Residency (fourth year). Started in 2005, ISIS was founded to improve the cost, patient safety, and quality of medicine by improving the education system for health professionals. ISIS trains students, residents, and fellows in psychomotor skills, interprofessional and communication, crisis management, and team building. Currently, ISIS is one of the few simulation centers nationally with a focus on collaborative research and is the nation's only simulation center that has begun to quantify utilization. Future plans focus on integrating education and research to deliver patient safety and quality outcomes and further integrating simulation into education. ISIS currently has 16 courses in which medical students can participate, including basics of airway management, emergency medicine procedures and resuscitation, thoracentesis, suturing and wound management for medical students, fundamentals of laparoscopic surgery, and others. Areas of Increased Emphasis Since 2002 ♦ Cultural competency (incorporated into many courses and programs, including Introduction to Clinical Medicine I and II, Healthcare for the Underserved, and through longitudinal pathway programs that students may undertake: Hispanic Health Pathway, Indian Health Pathway, Global Health Pathway, and Underserved Pathway). ♦ Evidence-based medicine (including the required first-year course Medical Information for Decision-Making). ♦ Bedside clinical-skills teaching, especially through the Colleges program in Introduction to Clinical Medicine II. ♦ Professionalism and ethics (incorporated into multiple courses, including Introduction to Clinical Medicine I and II; Cases in Clinical Ethics; and others). ♦ Medical humanities (incorporated into a number of courses, including Mind, Body and Pen: Writing and the Art of Becoming a Physician; Thinking Visually: How to Observe in Depth). ♦ Global health (incorporated into courses offered through the Department of Global Health, including Introduction to Global Health, Multidisciplinary Perspectives in Global Health, Global Health Challenges, and others). ♦ Successful transitions between training stages (incorporated into Capstone I-Transition to Clerkships and Capstone II-Transition to Residency). ♦ Chronic care, including increased attention to end-of-life care (incorporated into the expanded Chronic Care Clerkship that offers rehabilitation medicine, palliative care, pain management, and geriatrics core options; Respectful Death: Exploring Interdisciplinary End-of-Life Care; and other courses). Changes in Pedagogy ♦ Increased emphasis on small-group learning; success is measured through student course evaluations and faculty course evaluations. ♦ New emphasis on alternative learning technologies—Podcasts, Mediasite, common learning resources across regional sites; success is measured through student and faculty course evaluations. ♦ Increased emphasis on bedside teaching of basic skills; success is measured through annual surveys, exit interviews, student performance, attitude surveys, and other methods. ♦ Provision of transitional instruction between classroom and clerkships and medical school and residency; success is measured by surveys at the completion of transition experiences/courses. ♦ Increased emphasis on vertical integration of medical skills; success is measured by regular discussions between College Faculty with clerkship directors. ♦ Increased emphasis on professionalism; success is measured by end-of-year student surveys, student course evaluations, and exit interviews. ♦ Increased emphasis on mentoring and incorporating mentoring into the educational process through the Colleges; success is measured by student surveys and exit interviews. ♦ Increased emphasis on student and faculty learning communities through the Colleges program; success is measured by student surveys, exit interviews, and faculty surveys. ♦ Increased focus on interprofessional collaboration and teamwork; success is measured through multiple ISIS evaluation mechanisms. Changes in Assessment ♦ Clarification of and emphasis on evaluation of professionalism/professional behavior in education and practice. ♦ Limited utilization of web-based testing in basic science and clinical courses. ♦ Use of NBME subject examinations in clerkships. ♦ Increased centralization and standardization of student evaluation of courses and clerkships across all teaching sites. Clinical Experiences ♦ As the regional allopathic medical school for more than one quarter of the land mass of the United States, the UW School of Medicine relies on approximately 200 clinical training sites throughout the five-state WWAMI region (Washington, Wyoming, Alaska, Montana, and Idaho) for ensuring that the students have exposure to an appropriate mix of clinical teaching settings. ♦ The main teaching hospitals and clinics in Seattle are the University of Washington Medical Center, Harborview Medical Center, UW Physicians Neighborhood Clinics, Seattle Children's Hospital, and the VA Puget Sound Health Care System; Northwest Hospital and Regional Medical Center joined UW Medicine in 2010. ♦ These sites are supplemented in the WWAMI region with major, well-established hospital teaching sites in Boise, Idaho, Anchorage, Alaska, Billings and Missoula, Montana, and Spokane, Washington, and smaller hospitals and clinics in towns and cities across the WWAMI region. ♦ The clinical instruction is rated very highly by medical students and is regarded as the greatest strength of the curriculum; the individual clerkships receive exceptional overall ratings, in particular for teaching and patient care interactions. ♦ Because students complete their clerkships across five states with multiple clinical instructors, collecting and providing grades and feedback on clinical performance can take long periods of time; new electronic resources are strongly mitigating this time lag. ♦ The logistics of travel to and housing and services at clinical sites throughout the five-state region can be challenging, especially for students with families; the school and individual clerkships attempt to reduce this challenge as much as possible by providing housing at distant sites. ♦ Residents do not teach students in all regional clinical sites; this introduces both challenges and opportunities. Residents are a good source of constant teaching for students and introduce different levels and types of instruction; where residents are not available for teaching, students have a unique opportunity to work directly and closely with attending physicians, particularly in small rural sites. Regional Campuses ♦ The University of Washington School of Medicine's WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) program utilizes six regional campuses, in addition to the main campus in Seattle, for the first year of medical school: Montana State University—Bozeman, Montana University of Alaska at Anchorage—Anchorage, Alaska University of Idaho—Moscow, Idaho University of Wyoming—Laramie, Wyoming Washington State University—Pullman, Washington Washington State University Riverpoint Campus—Spokane, Washington (started in 2008, adding 20 medical students per class to the School of Medicine) Highlights of the Program/School The Colleges program provides students with a combination of strong, standardized bedside clinical-skills training in the second year in small-group settings, sustained mentoring from a College faculty member throughout students' education, and community and connectedness in the context of a large medical school. As the medical school for the five WWAMI states, the UW School of Medicine's regional program is truly unique; the strong partnership that has developed among universities across these states, including legislatures, academic and community physicians, and health care professionals, is a model of collaboration, resource sharing, and cost efficiency. The School of Medicine focuses on and has relative success in addressing the need for primary care and health care for underserved regions while maintaining a strong research program. In its efforts to increase and enhance primary care and health care for the underserved, the School has developed unique programs, such as the Targeted Rural Underserved Track (TRUST), the WWAMI Rural Integrated Training Experience (WRITE), and the Rural/Underserved Opportunities Program (R/UOP) programs, in which students spend from weeks and months to entire years in rural and underserved communities learning medicine. The Department of Global Health, founded in 2007 as a joint department within the schools of Medicine and Public Health, builds and expands on long-standing strengths in infectious diseases. Students have multiple options for courses and international experiences. Additional educational opportunities are provided through the Institute for Health Metrics and Evaluation, established in 2007. It is a research center that measures the world's pressing health issues and provides scientific evaluations of health system and program performance for guiding health policy and accelerating global health progress.

To determine whether insurance status (managed care vs traditional commercial and Medicare) influences resource consumption (as measured by length of stay [LOS]) in the intensive care unit (ICU). Retrospective analysis of the 1992 Massachusetts state hospital discharge database, using prospectively developed and validated risk-stratification models. All nonfederal hospitals in Massachusetts. Of all adult hospitalizations where an ICU stay was incurred (n=104270), we selected those covered by 1 of 4 payer groups (n=88050): (1) commercial fee-for-service (patients aged <65 years); (2) commercial managed care (patients aged <65 years); (3) traditional Medicare (patients aged >/=65 years); and (4) Medicare-sponsored managed care (patients aged >/=65 years). Mean ICU LOS. The ICU LOS regression models were constructed using split-halves validation to adjust for differences in age, sex, severity of illness, diagnosis, discharge status, and payer. Separate models were constructed for those younger than 65 years and those aged 65 years or older. Robustness of the models was explored using goodness of fit and correlation. The effect of payer on hospital mortality was also explored using logistic regression. Observed minus predicted mean ICU LOS and mortality rates were correlated with managed care penetration at the hospital level. The ICU LOS models performed well (R2=0.84 and R2L [likelihood ratio statistic]=0.92 for the development set, and R2=0.83 and R2L=0.89 for the validation set). Significant covariables affecting LOS included age, severity of principal illness, comorbidity, reason for admission, and discharge status (P<.001 for each). Among the cohort younger than 65 years (n=27805), although unadjusted mean ICU LOS was shorter (2.9 vs 3.43 days; P<.05) for those covered by managed care organizations, payer status had no independent effect on ICU LOS (P=.48). Among those older than 65 years, there was neither a difference in unadjusted ICU LOS (3.94 vs 3.88 days; P>/=.05) nor an independent effect of payer on ICU LOS (P=.35). Unadjusted mortality was lower among managed care patients (3.9% vs 5.1% in patients aged <65 years [P<.05] and 8.7% vs 12.1% in patients aged > or = 65 years [P<.05]). Age, severity of principal diagnosis, comorbidity, and reason for admission significantly influenced mortality (P<.001). After controlling for these factors with the mortality model (R2L=0.92 and 0.89, C statistic [12 df]=8.45 and 17.58, and P=.75 and .13 [where a large P reflects good agreement] for the development and validation sets, respectively), payer continued to have a small but significant effect on mortality (odds ratios ranging from 1.67 at 0.1% probability of death to 1.11 at 30% probability of death.) Managed care penetration among the commercially insured varied across hospitals (n=82) from 0% to 68%. There was no correlation between managed care penetration and either ICU LOS (R2=0.04; P=.09) or mortality (R2=0.0; P=.88). Though patients covered under managed care consume fewer ICU resources, this appears to be primarily attributable to a difference in patient-related factors. Thus, as managed care case mix changes in the future to include sicker and older patients, the initial advantages of reduced resource consumption may diminish.

Introduction:Though, Medical Council of India had recommended introducing horizontal and vertical integration, an integrated approach to teaching medical subjects has not become popular in Medical Colleges in India.Objective: To develop, implement, and evaluate an Integrated Learning Program for the third-year professional students at a medical school in India.Method: The integrated learning programme (ILP) was conducted for the first time in 2016 for a batch of 181 third year professional students of a Medical School in Western India. It was an integrated module employing correlation and vertical integration. It incorporated Interactive Lectures, Videos, Self-study, Clinical Visits and Home Visits. Student assessment was formative using pre and post MCQ test and case presentation through checklists to assess clinical skills and home visit skills. Evaluation of the programme was based on feedback from the students and faculty members and report prepared by the students. Results: The mean score of students in the knowledge domain assessed through Multiple Choice Questions (MCQs)for ILP on Iron Deficiency Anemia conducted at the end of the ILP was statistically significantly (P=0.022). The feedback from faculty members and students was positive, highlighting benefits of ILP as; integrated learning of the basic sciences, their application to clinical cases and active student learning. Few challenges were also identified like higher input required from faculty members. Most of the faculty members and students recommended that the integrated programme should be continued and extended to other parts of the curriculum.Conclusion: The study findings conclude that an integrated learning programme is beneficial and is likely to improve quality of health care provided to the patients. It is feasible within a conventional medical curriculum of an Indian Medical School.

Redefining Scholarship in Academic Radiology

Purpose: This article presents the results of a study aimed at devising comprehensive, standard and objective criteria for measuring faculty members' workload. Material and method: The indicators for measuring faculty members' workload were collected through a comprehensive review of the literature, a survey of the available documents and methods for measuring workload in the country, and interviews with health authorities and faculty members. In all,81 indicators were identified which fell under 5 categories: instruction; research; consultancy and academic services; administrative and managerial services; and personal and professional development. A questionnaire using these 81 indicators was designed and randomly mailed to 120 faculty members of Iran University of Medical Sciences and Health Services working in six faculties. They were asked to rate each question using a seven scale response, from complete disagreement to complete agreement. 98 faculty members responded, that is, 15% of all the faculty members of the university. All the indicators were ranked according to the scores received in the questionnaires. Results: 81 indicators were identified and weighted. The faculty members suggested Assistant Professor of Teaching that 25 more indicators needed to be added to the list. The category of instruction, with 32 indicators, was regarded as the most important category. Teaching a new course, preparation time for class and number of students in the class, were considered to be as important as the other instructional indicators. The weighting given to each indicator was influenced by the specialty of the rater. Faculty members believe the workload data should be reported by themselves preferably at the end of every academic year or semester. Discussion and conclusion: The criteria and the guidelines suggested in this study might be useful for evaluation, accreditation, ranking, promotion, tenure decisions, policy making and improving the quality of education in medical universities. Each department or faculty needs to have their own specific indicators weighted by their faculty members. This provides consistency and stability in workload data collection. The indicators for professional development also need to be considered in measuring faculty workload. Keywords workload, faculty member, medical

Senator Specter, Honorable Members of the Committee, it is my high privilege to speak on behalf of a subject near and dear to my heart. I have been involved in the care of patients with cancer and in cancer clinical trials for the past 34 years. I chair the Southwest Oncology Group, the largest National Cancer Institute-supported cancer clinical research organization. In 1996, this Group enrolled 6,359 patients to therapeutic cancer clinical trials from all 50 states (Fig. 1), and completed the randomization of 18,867 normal, healthy men into the intergroup Prostate Cancer Prevention Trial. Cancer clinical trials are always designed to improve the outcomes of cancer patients. However, only 2%-3% of all eligible cancer patients in this country are treated on these cutting-edge trials. It is clear that this number must increase dramatically in order for us to be able to translate the monumental advances emanating from the basic cancer research laboratories into effective diagnosis, prevention and treatment strategies for patients with and at high risk for cancer. This low accrual is related to multiple factors: First, managed care has had a negative impact related to its refusal to reimburse for the clinical care aspects of patients on cancer clinical trials. During my presentation to the President's Cancer Panel in San Antonio in September, I shared three thoughts as to what the Panel should be asking as they pursue the question of "Managed Care's Role in the War on Cancer": &bul; "Should managed care bear a portion of the costs of clinical research as a form of R & D?" &bul; "What State or Federal legislation is needed to assure that managed care patients have access to cancer clinical research?" &bul; "Will there be any future for cancer clinical research when the managed care tidal wave finally reaches Chicago and New York?" The NCI-Department of Defense and the NCI-Department of Veterans Affairs Interagency Agreements are superb models of what needs to be done for the rest of managed care. Secondly, the Southwest Oncology Group is outstripping its financial support at its current rate of accrual. Even if the managed care problem was resolved, there must be more money to support clinical research to translate this plethora of science to patients with cancer. I am also Director of the San Antonio Cancer Institute, a National Cancer Institute-designated Comprehensive Cancer Center. A recent astonishingly productive Breast Cancer Program Project Grant received a priority score one point below the pay line. While this grant will undoubtedly be funded by exception, it is representative of a nationwide problem of insufficient funds to support truly outstanding research. The following quote is from another Cancer Center Director, who is also a Cooperative Group Chair: "We never know where the next breakthrough will come from. Every time we discover a new gene, we also have a new marker for early diagnosis, a new predictor of response to therapy, a new target for chemoprevention, as well as for cancer treatment. Every discovery in a Cancer Center provides fuel for the Cooperative Group program, and requires affirmation in large clinical trials. Thus, the universe of cancer research is a continuum, (where) improved funding for any of it, impacts all of it, and improved funding for all of it will hasten the pace of discovery throughout." (Richard L. Schilsky, M.D.) Finally, I would like to paraphrase a futurist that I recently heard: &bul; "The present is obsolete." &bul; "The future has already been discovered" in the laboratories of molecular biologists throughout this country! We must search among those discoveries for the keys to cancer cures. &bul; "We are confronted with insurmountable opportunities!" &bul; "These new tools will change the rules of the game!" &bul; "We should not manage change, we should love change and make change our best friend," as all those involved in cancer research and the Congress must do every day. (Don Burrus) Thank you for your attention.