Why Clinicians Hold the Key to Fixing Health Care’s Complexity Problem

The future of health professions education: Emerging trends in the United States.

Impact of Health Literacy on Eye Health Disparities

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.

This toolkit brings together those with first-hand experience of designing, delivering, evaluating and participating in a Longitudinal Integrated Clerkship (LIC) within a UK Higher Education Institution and those working closely on programmes focussing on Health Education England (HEE)'s and NHS England's national priorities. In August 2022, a collaborative workshop was held for students and tutors participating in a London-based LIC in 2021–2022, faculty with prior experience in running LICs, and HEE representatives. The aim of the workshop was to co-produce a toolkit to guide undergraduate institutions, who may wish to introduce an LIC within their medical school curriculum that aligns to these national priorities. Although this toolkit primarily focuses on a UK audience, we anticipate that other health systems facing a need for similar educational reform may also find use for this toolkit. The NHS Long Term Plan,1 the HEE Future Doctor Report2 and The Enhance Programme3 have outlined key national priorities for the future of health and social care (Figure 1), including how we can train our workforce to deliver these aims. These priorities include embedding generalist skills in early career doctors, so they can better provide person-centred care in the context of complex multi-morbidity, while considering the impact of deep-rooted health inequity and social determinants of health. They can better provide person-centred care in the context of complex multi-morbidity, while considering the impact of deep-rooted health inequity and social determinants of health. This toolkit has been written for medical schools but may also be beneficial for other undergraduate and postgraduate health educators, who are considering setting up longitudinal educational programmes to meet their local and national health and workforce priorities. This document may also enable health and social care providers and third sector organisations, who are partnering up to support educational programmes, to better understand how longitudinal courses may benefit their health priorities. Currently, undergraduate and postgraduate training is fragmented in its provision of educational supervision and patient care. The lack of continuity of relationships with patients, supervisors and peers, can make it harder to effectively address the increasing complexity of multi-morbidity at an individual and population level. Because this fragmentation continues in the educational experience of postgraduates, it has a domino effect on undergraduates placed within those fragmented clinical settings—it becomes easy to see how this cyclical lack of continuity could perpetuate workforce burnout and poor retention.4, 5 This cyclical lack of continuity could perpetuate workforce burnout and poor retention. There is also a need for the future workforce to better understand the effects of health inequity, both at an individual and community level. It is well-recognised that certain groups of patients have poorer health outcomes than others.6 However, a deeper understanding of local population health priorities is difficult to achieve within our current, fragmented teaching and training programmes and instead requires being embedded into a community over a period of time. A deeper understanding of local population health priorities is difficult to achieve within our current, fragmented teaching and training programmes and instead requires being embedded into a community over a period of time. LICs (Figure 2) are an ideal educational model to address the issues of fragmentation of the student experience, and the need for students to have a better grasp of local population health. LICs place a greater emphasis on continuity for students and patients,7 greater responsibility for patient care, with more rewarding outcomes for students/trainees, and their patients and communities.8 Furthermore, many of the LICs in the United Kingdom are based in primary care,9 which provides a fertile ground for students to develop meaningful longitudinal patient relationships, and allows students to be embedded within a local community. The discussions within our workshop were informed by the existing literature on LICs which provides an international lens on how to develop LICs, what benefit they can provide, and their pitfalls.10-12 This toolkit builds on this literature with our lived experience within a UK health care and higher education environment, and aims to re-frame the importance of LICs as an educational model that better aligns to new integrated care priorities in the United Kingdom. For consistency in this toolkit, we use the term 'Longitudinal Integrated Clerkship' as it is most commonly known within the literature. However, there is debate about whether this term is relevant to the UK context and whether a more general term such as 'longitudinal placement' would better capture what currently exists and is achievable within the UK landscape.13 Design & Development of an LIC Evaluation and Research of an LIC To ensure an LIC that is sustainable, it is important to identify and consult with key stakeholders from the outset. Consideration of your institution's culture will also be important to ensure the success of an LIC, particularly with regard to the assessment process and how the LIC will be perceived within the hidden curriculum.14 A co-created mission statement for your LIC can help to ensure that all stakeholders are on the same trajectory. The overarching aim of your LIC is likely to depend on your local context. For example, in your local area, a main driver may be the need to address workforce recruitment and retention. Alternatively, addressing health inequity within underserved communities in the local area may be your main driver. When considering learning outcomes for your LIC, these can be considered under the headings of educational and health outcomes to ensure mutual benefit for those served by health systems and educational institutions. Similarly to a programme's mission statement, LIC outcomes are best defined with input from educational, health and community stakeholders. Investment at this stage from all stakeholders will be important as there may be conflicting priorities that will need to be worked through. Educational outcomes should align with the broader priorities and values of your institution, as well as national priorities, such as the Medical Licencing Assessment and those from HEE. Creation of a curriculum blueprint will be useful at this stage. Health outcomes would consider NHS policy documents (such as the Five Year Forward view), as well as local policies relevant to health context. The success of an LIC will depend on how the principles of the longitudinal model are adapted to fit with existing educational and service delivery models in your institution and local area. While there are existing frameworks of what an LIC might look like, these are based on the international literature, and local context should be considered for the successful delivery of an LIC. For example, from current literature, an LIC should be long enough for students to establish meaningful relationships, and Worley et al. suggest that an appropriate length of time should be from 6 to 12 months.15 We would suggest the length of time should be conducive to students having repeated encounters with the same patients, educators and peers to maximise relationships. There is no formal consensus on how 'repeated encounters' should be defined but the aim is for students to experience patient care over time in different settings with different health care practitioners. Facilitating sustained patient–student partnerships across the course of an LIC lies at the heart of this educational model. It is through these partnerships that mutual benefit can be garnered. The aim is for students to experience patient care over time in different settings with different health care practitioners. Table 1 outlines some important factors to consider during the design of your LIC. Consider the overarching outcomes of your LIC. Use this to decide what stage of medical school it is best delivered in. Early years E.g., Key LIC outcome = deeper understanding of the health inequity and preventative care for your population. You may wish to introduce these foundational concepts via an LIC at an early stage of clinical training, when there may be more curriculum space to dedicate to these concepts, and students are establishing their values around health equity. Later years E.g., Key LIC outcome = enhancing preparation for practice in line with national priorities In this case, the LIC may be better suited for those who are about to graduate New medical schools or those undergoing curriculum review may wish to implement an LIC for an entire cohort Medical schools with an established curriculum could pilot an LIC with a small group of students, with a phased roll-out in future years, allowing for improvements in your model if you fully roll out. Or there are many LICs that are small cohort student-selected programmes. If do you choose to run a pilot LIC, consider how you will advertise and recruit prospective students. The format of an LIC can vary internationally. Within the United Kingdom, LIC structure can range from a full time LIC to 1 day a week. Also consider the balance between Consider if your original LIC outcomes can be achieved in your chosen format and whether you can evaluate and assess these outcomes (see below for evaluation and assessment) within the constraints of your given structure. LICs can take place in a variety of settings with one setting usually acting as the main base for student learning Adequate supervision ensures clinical and educational safety for students and the patients they care for. This is an important consideration across all clinical settings. Also consider how undergraduates and postgraduates, and students from different health professions within the same learning environment can be brought together to enhance learning for both groups, e.g., through group supervision, tutorials or patient care. Assessment should be considered from the outset of LIC planning to ensure there is alignment with learning outcomes, as well as medical school and national assessments. Consider How and when these assessments will be reviewed should also be factored into the timetable for students and supervisors. LICs are likely to require a shift in mindset and logistics from the existing culture of learning at your institution, not only from the perspective of students, but also placement supervisors and central faculty. Adequate support for all relevant groups will help to identify early teething problems and ensure smoother transitions during implementation (see Table 2). With any educational intervention, particularly one that is new to an institution, there will be multiple reasons to collect data. For future iterations of the course, it is important to establish what worked well and what could be improved. Broadly, this type of data would be regarded as evaluation. Additionally, different stakeholder groups will have particular outcomes they are interested in, and these data might fall under the category of research. When deciding what data to collect, it is worth looking back at the primary LIC objectives, and planning from the outset how evaluation will be conducted and data collected, alongside the design and development of the overall LIC. This will help make early decisions regarding why the data are being collected, when and from whom, and ensures timely ethics and funding applications. Reviewing the existing literature at this stage will help shape both the LIC and your evaluation and research questions. Kirkpatrick's hierarchy can be a useful heuristic when considering what type of data to collect—for example, collecting qualitative data from different stakeholders on their perceptions and experience of the LIC. You may also choose to collect specific quantitative student or patient outcome data. When deciding who to collect data from, consider the whole range of stakeholders. For example, if a key aim of your LIC is to improve patient access to health care in your local area, it would be important to hear from patients themselves on their experiences. When deciding who to collect data from, consider the whole range of stakeholders. While data are often collected to look at what additional value an intervention provided, it is equally important to ensure no harm has inadvertently been inflicted on stakeholder groups in the process. This is also something to consider when deciding what parameters should be evaluated. The timeframe of data collection is also an important consideration. In keeping with a longitudinal process, some research questions may be better answered by looking at different points across the course, to capture how data change over time. When writing up and presenting data, consider involving all stakeholders in this process. It would be worth looking at presenting and publishing avenues that reach a broad audience—for example, health care arenas, patient and community facing publications, and medical educators. The future health workforce will require new complex skills to manage increasingly complex population needs. Current undergraduate training needs to consider how it is preparing future graduates to develop the skills needed to adapt to the rapidly changing health care landscape. An LIC places continuity and integration at its core and is an ideal educational model to embed these key skills within the curriculum. This, in turn, could help prepare our future workforce in providing person-centred integrated care that meets population need. This toolkit can be used to guide those considering educational reform in line with population need. Finally, it is the collaborative partnerships with students, policy makers, educators, and health and social care providers that will help ensure alignment between population priorities, workforce needs and medical education. Current undergraduate training needs to consider how it is preparing future graduates to develop the skills needed to adapt to the rapidly changing health care landscape. We would like to thank Mohammed-Hareef Asunramu, one of our LIC students, and Monika Gupta from Health Education England's London Enhancing Generalist Skills Team for their contribution to this work. The authors have no conflict of interest to disclose. No data have been used in this submission that would require formal ethical approval. All participants of our workshop have been listed as authors and have contributed and consented to the work.

The Education Data Warehouse: A Transformative Tool for Health Education Research

The research investigated the extent to which students, residents, and faculty members in Canadian medical faculties use mobile devices, such as smartphones (e.g., iPhone, Android, Blackberry) and tablet computers (e.g., iPad), to answer clinical questions and find medical information. The results of this study will inform how health libraries can effectively support mobile technology and collections. An electronic survey was distributed by medical librarians at four Canadian universities to medical students, residents, and faculty members via departmental email discussion lists, personal contacts, and relevant websites. It investigated the types of information sought, facilitators to mobile device use in medical information seeking, barriers to access, support needs, familiarity with institutionally licensed resources, and most frequently used resources. The survey of 1,210 respondents indicated widespread use of smartphones and tablets in clinical settings in 4 Canadian universities. Third- and fourth-year undergraduate students (i.e., those in their clinical clerkships) and medical residents, compared to other graduate students and faculty, used their mobile devices more often, used them for a broader range of activities, and purchased more resources for their devices. Technological and intellectual barriers do not seem to prevent medical trainees and faculty from regularly using mobile devices for their medical information searches; however, barriers to access and lack of awareness might keep them from using reliable, library-licensed resources. Libraries should focus on providing access to a smaller number of highly used mobile resources instead of a huge collection until library-licensed mobile resources have streamlined authentication processes.

Independent foundations' primary focus is grant making.In general, their assets come from the gift of an individual or family.Community foundations' assets usually come from many donors rather than a single source, and grant making is limited to a particular region.Community foundations are usually classified as private charities under the tax law and are subject to different rules and regulations than are other private foundations. Access To CareAccording to 1988 Census Bureau estimates, over thirty-one million Americans are without health insurance.The demographics of these people are diverse, and their ranks continue to grow as the service industry burgeons and as competition in health care increases.Regional disparities in access also exist.Foundation funding in this area ranges from economic analyses of the problem to direct provision of care.

Elective rotations in health departments expose medical students to public health practice and career opportunities in applied epidemiology and preventive medicine. State and county epidemiologists and health officers can serve as excellent role models for medical students. In 2000-2001, the authors identified such electives by consulting medical schools' Web sites and by contacting state epidemiologists, teachers of preventive medicine, and medical school associate deans. The authors found that electives were offered in nine state and five local health departments; these are described in detail. Those electives usually focused on infectious diseases, involved students in outbreak investigations when possible, lasted four or more weeks, were open to other students and medical residents, and were overseen by a health department preceptor with a medical school faculty appointment and a commitment to train students. Some electives included more didactic components, encouraged the student to publish a manuscript, or were coordinated by a preventive medicine residency director. The authors observe that health departments can benefit from training enthusiastic medical students via such electives; these students bring fresh ideas to the departments. Medical school catalogs, Web sites, and word of mouth are important means for promoting these electives. Ideally, in the future every medical school will offer a state or local health department elective so that all medical students will become aware of epidemiology and public health career options. The electives reported in this article can help guide additional medical schools and health departments as they initiate such rotations.

In June 2004, an article in American Journal of Nursing reported findings of a three-year study of organizational culture, attitudes, and assignment of responsibility for patient safety in small, rural hospitals in nine Western states. The study found that most errors fall within realm of nursing practice and that physicians, administrators, and nurses themselves tend to see patient safety as largely a nursing responsibility. Asked to identify which profession has primary responsibility for ensuring patient safety, 96 percent of nurses and more than 90 percent of physicians, administrators, and pharmacists assigned primary responsibility to nurses. Only 22 percent of respondents believed that physicians, nurses, pharmacists, and administrators share responsibility for patient safety equally. Unfortunately, however, nurses and physicians differed on role of nurses in effecting change. Most of nurses indicated that they had several responsibilities in reducing medical errors, including reporting them, educating themselves and colleagues, serving as role models, making recommendations for changes in procedure and policy, reviewing reported adverse patient-safety events, and participating in investigations. Only 8 percent of physicians who responded to survey identified nurses as members of decisionmaking team. Nurses have a genuine impact on patient safety. Studies have found a link between patient safety and RN staffing and an increased rate of error when hospital nursing staff has a smaller proportion of RNs. These are worrisome findings in light of severe national shortage of nurses. Part of medical malpractice crisis, then, is confusion in health care system and how it affects role of nurse. There is no confusion in American Nurses Association's code of ethics. This document, first adopted in 1950 and revised in 2001 to reflect and embrace role of today's nurse, consists of a set of planks that set out nurses' fundamental values and commitments. They also offer a starting point for understanding how nurses should be involved in thinking about medical error, and why nurses blame themselves for medical errors. The first few planks are most important. These planks state that nurse's primary commitment is to patient (plank 2), and that nurse promotes, advocates for, and strives to protect health, safety, and rights of patient (plank 3). Interpretive Statements that accompany code add that nurses are committed to patient's health, well-being, and safety throughout patient's life span, and in all settings in which health care needs are addressed. Further, code directs that, as an advocate for patient, the nurse must take appropriate actions regarding any instances of incompetent, unethical, and illegal practice by any member of health care team or health care system or any action on part of others that places rights or best interest of patient in jeopardy. For nurses to function effectively in this role, they must be knowledgeable about code of ethics, standards of practice, relevant laws, and their own organization's policies and procedures. Moreover, when nurse is aware of inappropriate or questionable practice in provision or denial of health care, concerns should be expressed to person engaging in questionable practice. Attention should be called to possible detrimental effect upon patient's well-being or best interests, as well as to integrity of nursing practice. When factors in health care delivery system or health care organization threaten welfare of patient, concerns should be directed to responsible administrator. If indicated, problem should be reported to an appropriate higher authority within institution or agency, or to an appropriate external authority. The interpretive statements for third plank also remind nurses that they have a responsibility to implement and maintain standards of professional nursing practice. …

To elucidate the associations between geographic locations, rankings, and size/funding of medical schools and residency programs among the current otolaryngology residents. This retrospective cross-sectional study queried otolaryngology residency program websites for relevant publicly accessible information. Location was categorized as Midwest, Northeast, South, and West. Ranking was according to Doximity (residency) and US News and World Report (medical school). Medical school and residency programs were labeled large if they had >704 students or >15 residents, respectively. A total of 1413 residents from 98 (89%) otolaryngology residency programs were included. Residents attending their home medical schools (18%) were equally distributed among regions (P = .845). Residents who attended medical schools in the same US regions (54%) were more likely from top-25 (P = .001) or private (P < .001) medical schools. Southern residents were most likely (64%) and Western residents were least likely (39%) from regional medical schools (P < .001), while residents from Midwest and Northeast had similar rates (54%-55%). The percentage of Midwest residents coming from regional medical schools has decreased from the 2013 to 2014 residency cycle (P = .037). Completing undergraduate school, medical school, and residency in the same region (38%) was also highest in the South (45%) and lowest in the West (25%) (P < .001). Residents at top-ranked residency programs were more likely from top-ranked (P < .001), large (P = .025), and private (P = .018) medical schools. There exist significant associations between otolaryngology residents' medical school location, ranking, size, and funding source and their residency destination. More than half of the current otolaryngology residents attended medical school in the same geographic region, and about one-fifth have attended medical school and residency at the same institution. Future studies are warranted to evaluate how these results change as the match process evolves in the future. N/A.

Health Care Infrastructure Post-Katrina: Disaster Planning to Return Health Care Workers to Their Home Communities

The turn of the tide.

The article is based on the prospective analysis approach to medical education. The instrument of analysis is a questionnaire on the medical education process and on the professional training institution, in which a series of indicators can be used that are grouped in four categories: context, structure, function, and integration. The article concludes with an enumeration of the basic principles to be borne in mind in planning, and with a scheme for the organization of a medical school suitable for attaining the goal of health for all.

High school students should already be thinking about the plan to continue their study to higher levels in accordance with their interests. Many programs offered by public and private universities, one of them is Business Administration Program. The aims of this research are, firstly to examine the significance of interests of high school students in the city and region of Bogor, specifically on choosing the Business Administration program. Secondly, this research tries to investigate the factors influencing the interests of high school students to continue their study in higher education. The method used in this research is descriptive statistics using Survey. Data collection is conducted by way of observations assisted with questionnaire instruments and interview. Samples are gathered using Purposive Sampling. Slovin formula is used to determine the amount of samples needed. The results show that the students are interested in taking the major of Business Administration and that they are supported with Office Administration background in their current study, this is followed by other students with different backgrounds. The research concludes that high school students’ interest in Business Administration Program is influenced by their own current background study. Other factors also significant in influencing the students’ interest are the parents’ social condition and the campus’ facilities.

BACKGROUND AND OBJECTIVES:Twelve “good death” principles have been identified that apply to Westerners. This study aimed to review the TFHCOP good death perception to determine its validity for Muslim patients and health care providers, and to identify and describe other components of the Muslim good death perspective.SUBJECTS AND METHODS:Participants included 284 Muslims of both genders with different nationalities and careers. We used a 12-question questionnaire based on the 12 principles of the TFHCOP good death definition, followed by face-to-face interviews. We used descriptive statistics to analyze questionnaire responses. However, for new themes, we used a grounded theory approach with a “constant comparisons” method.RESULT:On average, each participant agreed on eight principles of the questionnaire. Dignity, privacy, spiritual and emotional support, access to hospice care, ability to issue advance directives, and to have time to say goodbye were the top priorities. Participants identified three main domains. The first domain was related to faith and belief. The second domain included some principles related to self-esteem and person>s image to friends and family. The third domain was related to satisfaction about family security after the death of the patient. Professional role distinctions were more pronounced than were gender or nationality differences.CONCLUSION:Several aspects of «good death,» as perceived by Western communities, are not recognized as being important by many Muslim patients and health care providers. Furthermore, our study introduced three novel components of good death in Muslim society.