Acute schistosomiasis in travelers: 14 years' experience at the Hospital for Tropical Diseases, London.

We report 79 cases of acute schistosomiasis. Most of these cases were young, male travelers who acquired their infection in Lake Malawi. Twelve had a normal eosinophil count at presentation and 11 had negative serology, although two had neither eosinophilia nor positive serology when first seen. Acute schistosomiasis should be considered in any febrile traveler with a history of fresh water exposure in an endemic area once malaria has been excluded.

The European reference condition concept: A scientific and technical approach to identify minimally-impacted river ecosystems.

One objective of the European Union (EU)'s Water Framework Directive (WFD: Directive 2000/60/EC) is for all European surface waters to achieve 'good status' by 2015. In support of this objective, the EU has facilitated an intercalibration exercise to ensure harmonized definitions of the status of water bodies, reflecting the deviation of their properties (mainly biotic assemblages) from a minimally disturbed state, termed the "reference condition". One of the major challenges of the WFD has been to find common approaches for defining reference conditions and to define the level of anthropogenic intervention allowed in reference sites. In this paper we describe how river reference sites were selected in the Central-Baltic region of Europe. A list of pressure criteria was provided and 14 Member States (MSs) categorized each criterion according to the method (i.e. measured, field inspection, etc.) used for reference site screening. Additionally, reference land-use and water-chemistry thresholds were agreed among countries in order to base reference site selection on objective criteria. For land-use criteria, a reference threshold and a rejection threshold were established. Sites with all criteria below the reference threshold were considered to be reference sites; sites having most criteria below the reference threshold and only some parameters between the reference and rejection threshold were "possible reference sites". These sites were retained only after carefully checking the cumulative effects of the pressures using local expertise, and a posteriori water-chemistry evaluation was necessary. In general, the most widespread method for defining a reference site was the measurement of pressures, followed by field inspections and expert judgment. However, some major pressures (e.g. hydromorphological alteration) were evaluated in a number of different ways (e.g. measured, field inspection, expert judgment). Our meta-analyses reveal a need to reinforce standardization in the application of pressure criteria by Member States. The pressure criteria identified in this exercise should be refined and tested with biological data to help in the further validation of minimally disturbed sites (i.e. the WFD "reference condition") and to provide a firm foundation for ecological status assessment. This in turn would ensure that there is pan-European comparability when evaluating the achievement of environmental objectives.

Developing a "frequent look and rapid remediation" assessment system for a new medical school.

The Peninsula College of Medicine and Dentistry (PCMD) was among the five new medical schools approved in the United Kingdom in 2000. PCMD required a new curriculum and a new outcomes-oriented assessment system based on sound educational theory. The resulting system was designed to use multiple sampling and show increasing authenticity as students progress through the curriculum. A "frequent look and rapid remediation" structure was incorporated to allow faculty to evaluate student competence throughout the year and take immediate action when warranted. Using a recently published framework, the authors retrospectively evaluate the assessment system and share many of the decisions they and their colleagues had to make. They discuss how to support stakeholders in understanding and contributing to the development of an assessment system and how to meet some of the challenges they encountered. They consider indicators of success in terms of the performance of the assessment system as a whole and the ways the system contributes to educational research. They suggest that future research should focus on building greater flexibility into the system so that assessment decisions can be individualized to particular students.

Further insights into the roles of the medical educator: the importance of scholarly management.

Medical educators need to be able to define excellence within the various roles they occupy so that they can demonstrate internationally recognized, high-quality scholarship. Previous definitions of scholarship have focused on research and teaching but have been unable to integrate other roles such as leadership, management, and administration. Clearer definition of the various roles of the medical educator, coupled with a broader understanding of medical education scholarship that is able to encompass management, as well as teaching and research, will help institutions to evaluate and reward faculty members appropriately. We propose that management should now be introduced as a third "priority of the professoriate." We outline the concept of the scholarly manager, particularly as it applies to management in medical education. We offer a new conceptual model which situates the role of the academic manager within the scholarship of medical education and shows it to be an essential part of the skills and competences of the excellent medical educator. We emphasize that at the heart of all scholarly activity in medical education lie the core skills, values, and behaviors shared by all involved in the education of doctors and medical students. Future research is needed to explore and, where possible, achieve consensus on the core skills, values, and behaviors of an excellent medical educator. In addition, work should commence to define and categorize the various stages in the development of a significant management portfolio in medical education teaching and research.

Who can resist Foucault?

Michel Foucault's analysis of "the birth of the clinic" describes the genesis of a unified discourse that, in retrospect, has shaped western medicine for two centuries. However, in looking prospectively toward a 21st century medicine, Foucault's analysis is necessary but not sufficient. To better critically address medicine and medical education in the era of simulation, we could draw on frameworks developed by futurists such as Jean Baudrillard. Foucault's analysis does not account for contemporary, complex developments of the clinical gaze as the gaze is distributed across practitioners in increasing use of sophisticated, representational diagnostic imaging. Further, Foucault's antihumanist rhetoric sometimes strays into the antihumane, and this is disturbing for those who support the development of patient-centered medicine. Yet we are increasingly teaching aspects of medicine, such as communication, in simulated learning environments in which complex reality is absent, perhaps inadvertently creating an "inhumanity" in medical education.

Content specificity: is it the full story? Statistical modelling of a clinical skills examination.

OBJECTIVE: This study sought to determine the relative contributions made by transferable skills and content-specific skills to Year 2 medical student performance in a clinical skills examination. METHODS: Correlated trait-correlated method models were constructed to describe the performance of 2 year groups of students in examinations held in the summers of 2004 and 2005 at Peninsula Medical School in the UK. The transferable skills components of the models were then removed to indicate the contribution made to the fit of the models to the data. RESULTS: Although content-specific skills made the greater contribution to the 2 models of student performance (accounting for averages of 54% and 43% of the variance, respectively), transferable skills did make an important but smaller contribution (averages of 13% and 16%, respectively). When the transferable skills components of the models were removed, the fit was not as good. CONCLUSIONS: Both content-specific skills and transferable skills contributed to performance in the clinical skills examination. This challenges current thinking and has important implications, not just for those involved in clinical skills examinations, but for all medical educators.

Thinking the post-colonial in medical education.

CONTEXT: Western medicine and medical techniques are being exported to all corners of the world at an increasing rate. In a parallel wave of globalisation, Western medical education is also making inroads into medical schools, hospitals and clinics across the world. Despite this rapidly expanding field of activity, there is no body of literature discussing the relationship between post-colonial theory and medical education. DISCUSSION: Although the potential benefits of international partnerships and collaborations in education are incontrovertible, many medical educators are sometimes too unreflecting about what they are doing when they advocate the export of Western curricula, educational approaches and teaching technologies. The Western medical curriculum is steeped in a particular set of cultural attitudes that are rarely questioned. We argue that, from a critical theoretical perspective, the unconsidered enterprise of globalising the medical curriculum risks coming to represent a 'new wave' of imperialism. Using examples from Japan, India and Southeast Asia, we show how medical schools in non-Western countries struggle with the ingrained cultural assumptions of some curricular innovations such as the objective structured clinical examination, problem-based learning and the teaching of clinical skills. CONCLUSIONS: We need to develop greater understanding of the relationship between post-colonial studies and medical education if we are to prevent a new wave of imperialism through the unreflecting dissemination of conceptual frameworks and practices which assume that 'metropolitan West is best'.

Students learning from patients: let's get real in medical education.

Medical students must be prepared for working in inter-professional and multi-disciplinary clinical teams centred on a patient's care pathway. While there has been a good deal of rhetoric surrounding patient-centred medical education, there has been little attempt to conceptualise such a practice beyond the level of describing education of communication skills and empathy within a broad 'professionalism' framework. Paradoxically, while aiming to strengthen patient-student interactions, this approach tends to refocus on the role modelling of the physician, and opportunities for potentially deep collaborative working relationships between students and patients are missed. A radical overhaul of conventional doctor-led medical education may be necessary, that also challenges the orthodoxies of individualistic student-centred approaches, leading to an authentic patient-centred model that shifts the locus of learning from the relationship between doctor as educator and student to the relationship between patient and student, with expert doctor as resource. Drawing on contemporary poststructuralist theory of text and identity construction, and on innovative models of work-based learning, the potential quality of relationship between student and patient is articulated in terms of collaborative knowledge production, involving close reading with the patient as text, through dialogue. Here, a medical 'education' displaces traditional forms of medical 'training' that typically involve individual information reproduction. Students may, paradoxically, improve clinical acumen through consideration of silences, gaps, and contradictions in patients as texts, rather than treating communication as transparent. Such paradoxical effects have been systematically occluded or denied in traditional medical education.

Looking forward-looking back: aspects of the contemporary debate about teaching and learning medicine.

Does the tired oppositional debate between student-centredness and teacher-centredness leave the patient stranded, where the patient is surely the focus of a medical education? How might an authentic patient-centred practice be shaped, informed and nourished theoretically? We describe an intellectual landscape of critical, interdisciplinary inquiry that, so far, many medical educators have not inhabited. For example, texts written to inform medical education rarely examine intellectual premises and ideological implications. We offer a number of theoretical frameworks that can inform critical practice, asking 'why do we do it this way?'; 'what are the alternatives?'; and 'how do we justify our approaches intellectually?' We conclude that medical education needs to take stock of its intellectual resources.

Medical student attendance at non-compulsory lectures.

The General Medical Council in the UK recommends that undergraduate medical students be exposed to a variety of learning opportunities and increasingly take responsibility for their own learning. This study presents quantitative and qualitative data relating to attendance at non-compulsory plenary lectures in order to understand factors affecting the value placed by students on this component of the first 2 years of a contemporary medical curriculum. Attendance data were available for 87% first year and 78% second year plenary lectures. There was no difference in attendance at lectures that were delivered telematically to a remote site when compared with those where the speaker was present. There were markedly more students attending lectures at the beginning of the first academic year, with numbers decreasing as the year progressed. More first year students attended lectures on biomedical science and clinically focussed topics than on human science and public health whereas second year student attendance was similar across topics. Reasons given for non-attendance at plenary sessions fell into "student-related" factors (e.g. dislike of lecture-based learning) and "teaching-related" factors (e.g. perceived variable quality of lectures). This study confirms that some students value lectures highly as a method to supplement other learning opportunities, whereas others find they learn better by other means.

Physicians' perceptions of clinical teaching: a qualitative analysis in the context of change.

BACKGROUND: Change is ubiquitous. Current trends in both educational and clinical settings bring new challenges to clinicians and have the potential to threaten the quality of clinical teaching. OBJECTIVE: To investigate hospital specialists' perceptions of clinical teaching in the context of change. DESIGN: Qualitative study using in-depth semi-structured interviews. SETTING: Three hospital trusts in the United Kingdom associated with a new medical school. PARTICIPANTS: A purposive sample of 15 clinicians from each of the three participating hospitals was approached. A total of 13 participated in the in-depth interviews: three from hospital A, six from hospital B and four from hospital C. RESULTS: The two main themes of 'Characteristics of Good and Bad Teachers' and 'Clinical Teaching Approaches' emerged. These were underpinned by a number of sub-themes; including some seen by participants as potential barriers to teaching and learning, for example, organisational and personal issues. CONCLUSIONS: Potential barriers to teaching and learning, including why good clinical teachers may at times seen to be intimidating or to cause humiliation and problems of engaging with new educational practices, can be understood within the context of change resistance. Knowing more about how clinical teachers think about their task as educators is essential and this should underpin staff development and training programmes.

Undergraduate ethics teaching: revisiting the Consensus Statement.

OBJECTIVE: To determine whether the recommendations of the Consensus Statement published 7 years ago have been implemented. DESIGN: Postal questionnaire survey of 28 UK medical schools. METHODS: A survey was sent to the lead individual for teaching and learning at each medical school. This questionnaire inquired about the undergraduate ethics and law curriculum, including its design, teaching, assessment, staffing, and individuals' hopes and concerns for the future. MAIN OUTCOME MEASURES: Information relating to undergraduate ethics teaching in UK medical schools. RESULTS: Significant changes in the teaching and assessment of medical ethics and law that could be directly attributed to the Consensus Statement were identified. Whilst most schools covered all 12 recommended topics in their curriculum, only 3 felt all the topics were covered thoroughly and 3 schools said at least 1 topic was not covered at all. Only 16 schools identified 1 or more full-time academics who took direct responsibility for ensuring undergraduate medical students learnt about ethics; these were usually at lecturer grade. CONCLUSIONS: The Consensus Statement has had a significant impact on the teaching of undergraduate ethics but, even 7 years on, not all its recommendations have been implemented fully.