The Safety and Efficacy of a "No Touch" Abortion Program Implemented in the Greater Toronto Area During the COVID-19 Pandemic.

OBJECTIVES: To evaluate the safety and efficacy of first-trimester "No Touch" medication abortion programs at 2 clinics in Toronto, Ontario during their early implementation in response to the COVID-19 pandemic. METHODS: This retrospective study included all patients who underwent virtual consultation for mifepristone-misoprostol medication abortion between April 2020-August 2022 at 2 reproductive health clinics. In response to the pandemic, "No Touch" abortion protocols have been developed that align with the Canadian Protocol for the Provision of Medical Abortion via Telemedicine. Records were reviewed for demographic information, clinical course, investigations required, confirmation of complete abortion and adverse events. The primary outcome was complete medication abortion, defined as expulsion of the pregnancy without requiring uterine aspiration. RESULTS: A total of 277 patients had abortions initiated in the "No Touch" or "Low Touch" care pathways and had sufficient follow-up to determine outcomes. Of these patients, 92.8% (95% CI 89.7%-95.8%) had a complete medication abortion (n = 257) and 76.1% (n = 159) remained "No Touch" throughout their care. Investigations were performed for 102 participants before or after their abortion, classifying them as "Low Touch". Nineteen patients (6.9%) underwent uterine aspiration. The rate of adverse events was low, with 1 case of a missed ectopic pregnancy and 1 patient requiring hospitalization for endometritis. CONCLUSIONS: "No Touch" provision of mifepristone-misoprostol medication abortion care was safe and effective with outcomes comparable to previous studies. These results provide evidence for the efficacy and safety of a "No Touch" approach in the Canadian context, which has the potential to reduce barriers to accessing abortion care.

The use of Community/Public Health Nursing Competencies during the COVID-19 pandemic.

OBJECTIVES: (1) Ascertain the use of the Quad Council Competencies for Community/Public Health Nursing (QCC-C/PHN) Competencies by community/public health nurses (C/PHNs) during the COVID-19 pandemic; (2) Inform from a systems-level the need to sustain the C/PHN workforce; (3) Assess the C/PHN infrastructure for response capacity. DESIGN: Cross-sectional. Statewide email distribution lists were used for dissemination. SAMPLE: Convenience sample (n = 169) obtained using emailed Qualtrics link with the eligibility criteria of self-identification as a C/PHN who works in the state of Missouri. MEASUREMENTS: Demographic questions included employment sector, nursing education level, years of nursing, and C/PHN experience. Two Likert-type questions and one optional open-text question were created for the eight domains. RESULTS: One hundred sixty-nine participants' data were analyzed. One hundred fifty-four were employed in a local public health agency. Total 63.2% held a bachelor's degree in nursing or higher. The average number of years of nurse experience was 20.84, and C/PHN experience was 9.84. The domain of Communication Skills scored highest and Cultural Competency was the lowest. Three themes emerged from the open-ended questions including vulnerabilities of the public health system. CONCLUSION: Understanding the experiences of C/PHNs in Missouri related to the utilization of QCC-C/PHN competencies informs efforts to strengthen public health infrastructure and target resources to equip Missouri's C/PHNs.

Screening for Gonococcal and Chlamydial Infections in the Third Trimester.

A retrospective study was conducted at our institution of all patients who delivered between May 2016 and April 2017. A change of practice had been instituted, which involved obstetricians testing for Neisseria gonorrhoeae and Chlamydia trachomatis universally in the first and third trimesters. Medical records were reviewed for N. gonorrhoeae and C. trachomatis results and for risk factors traditionally associated with sexually transmitted infections (STIs). A substantial proportion of patients (10.7%) had not undergone screening during pregnancy. We also identified third-trimester cases of infection in asymptomatic patients who had no traditional risk factors STI acquisition, which raised the question of optimal timing for STI screening during pregnancy.

Patient Satisfaction with Informed Consent for Cesarean and Operative Vaginal Delivery.

OBJECTIVE: To evaluate patient satisfaction with the informed consent process for elective cesarean delivery (CD), emergency CD, and operative vaginal delivery (OVD). METHODS: A cross-sectional, survey-based study was conducted among patients on the postpartum floor of our institution. Patients were approached after delivery to complete a previously pilot-tested questionnaire, based on validated literature. One hundred eighty-four surveys were included in the analysis. Levels of patient satisfaction were compared across modes of delivery using χ2 tests of independence. Secondary objectives included evaluating the relationship between satisfaction scores and the patient's recall of the consent process and emotional state during the consent process. RESULTS: A significant association was found between patient satisfaction with the consent process and mode of delivery (P < 0.001). Those in the elective and emergency CD groups were significantly more likely to express high rates of satisfaction compared with those in the OVD group (odds ratio [OR] 9.03; 95% CI 2.80-29.10 and OR 3.97; 95% CI 1.34-11.76, respectively). High levels of satisfaction were significantly more common among those who had greater recall of the consent process (OR 25.2; 95% CI 7.34-87.04) and those who reported low levels of distress during the process (OR 15.1; 95% CI 4.70-48.66). CONCLUSION: Informed consent during OVD is associated with lower rates of patient satisfaction compared with CD. Efforts are needed to improve the consent process for OVD to increase patient satisfaction and promote patient-centred care.

Neuropeptide- and serotonin- cells in the brain of Rhodnius prolixus (Hemiptera) associated with the circadian clock.

The neuronal pathways of the circadian clock in the brain of R. prolixus have been described in detail previously, but there is no information concerning the cells or their pathways which relay either inputs to the clock (e.g. for light entrainment), or outputs from it to driven rhythms. Here, we employ antisera to three neuropeptides (type A allatostatin-7, crustacean cardioactive peptide and FMRFamide), and serotonin in confocal laser scanning immunohistochemistry to analyze the distribution of cell bodies and their projections in relation to the principle circadian clock cells (lateral cells, LNs) for all four neuron types. LNs are revealed following labelling with anti- pigment dispersing factor in double labelled preparations. Regions of potential communication between ramifications of the LNs and each of the four other neuron types is described (identified by close superposition of their neurites in various brain regions), as is their detailed projections within the brain. Neuromodulation is sometimes suggested by close, but not intimate, proximity of varicosities of neurites. We infer that some neuron types comprise input pathways to the LNs, some are outputs to neuroendocrine or behavioral rhythms, and others participate in both input and output pathways, sometimes by the same neuron type but in different locations. For example, one retinula cell in each ommatidium is immunoreactive for allatostatin A; its axon projects to the medulla making superpositions with LNs, as do serotonin cells in the optic lobe, indicating roles of both neuron types in light input (entrainment) to the clock. But in other brain areas, these same types appear to mediate outputs from the clock. The accessory medulla has been widely reported as the principle center of integration in other insects; but we found sparse evidence of this in R. prolixus as it contains few neurites other than those from the clock cells. Rather, the importance of neural pathways involving the medulla and the superior protocerebrum is emphasized. We conclude that there is a vast and complex web of interactions in the brain with the LNs, which potentially receive multiple pathways of inputs and outputs that could drive rhythmicity in a multitude of downstream cells, rendering a host of output pathways rhythmic, notably hormone release from neurosecretory cells and behaviors.

A Case of Epidural Lipomatosis in Pregnancy: Management during Labour and Caesarean Section.

BACKGROUND: Spinal epidural lipomatosis (SEL) is a rare condition of adipose tissue accumulation in the epidural space. As a result of excess adipose tissue, neuraxial anaesthesia has been reported to behave unpredictably in patients with this condition. CASE: A 36-year-old woman had worsening postural headaches during pregnancy. MRI revealed SEL involving the thecal sac between L3/L4 and L5/S1. She had induction of labour but ultimately required a CS for delivery. Her anaesthesia was managed with an epidural inserted at L3/4. She developed a high block with relative sacral sparing. CONCLUSION: Although neuraxial anaesthesia was thought to be contraindicated in patients with SEL, it can be done safely. Care must be taken to provide slow epidural titration to avoid high sensory block in patients with this condition.

Pharmacological and non-pharmacological interventions for reducing rocuronium bromide induced pain on injection in children and adults.

BACKGROUND: Rocuronium bromide is a routinely used muscle relaxant in anaesthetic practice. Its use, however, is associated with intense pain on injection. While it is well established that rocuronium bromide injection causes pain in awake patients, anaesthetized patients also tend to show withdrawal movements of the limbs when this muscle relaxant is administered. Various strategies, both pharmacological and non-pharmacological, have been studied to reduce the incidence and severity of pain on rocuronium bromide injection. We wanted to find out which of the existing modalities was best to reduce pain on rocuronium injection. OBJECTIVES: The objectives of this review were to assess the ability of both pharmacological and non-pharmacological interventions to reduce or eliminate the pain that accompanies rocuronium bromide administration. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE via Ovid SP (1966 to July 2013) and EMBASE via Ovid SP (1980 to July 2013). We also searched specific websites. We reran the searches in February 2015 and will deal with the 11 studies of interest found through this search when we update the review. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) that compared the use of any drug or a non-pharmacological method with control patients, or those receiving no treatment to reduce the severity of pain with rocuronium injection. Our primary outcome was pain on rocuronium bromide injection measured by a pain score assessment. Our secondary outcomes were rise in heart rate and blood pressure following administration of rocuronium and adverse events related to the interventions. DATA COLLECTION AND ANALYSIS: We used the standardized methods for conducting a systematic review as described in the Cochrane Handbook for Systematic Reviews of Interventions. Two authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis. We used a fixed-effect model where there was no evidence of significant heterogeneity between studies and a random-effects model if heterogeneity was likely. MAIN RESULTS: We included 66 studies with 7840 participants in the review, though most analyses were based on data from fewer participants. In total there are 17 studies awaiting classification. No studies were at a low risk of bias. We noted substantial statistical and clinical heterogeneity between trials. Most of the studies reported the primary outcome pain as assessed by verbal response from participants in an awake state but some trials reported withdrawal of the injected limb as a proxy for pain after induction of anaesthesia in response to rocuronium administration. Few studies reported adverse events and no study reported heart rate and blood pressure changes after administration of rocuronium. Lidocaine was the most commonly studied intervention drug, used in 29 trials with 2256 participants. The risk ratio (RR) of pain on injection if given lidocaine compared to placebo was 0.23 (95% confidence interval (CI) 0.17 to 0.31; I² = 65%, low quality of evidence). The RR of pain on injection if fentanyl and remifentanil were given compared to placebo was 0.42 (95% CI 0.26 to 0.70; I² = 79%, low quality of evidence) and (RR 0.10, 95% CI 0.04 to 0.26; I² = 74%, low quality of evidence), respectively. Pain on injection of intervention drugs was reported with the use of lidocaine and acetaminophen in one study. Cough was reported with the use of fentanyl (one study), remifentanil (five studies, low quality evidence) and alfentanil (one study). Breath holding and chest tightness were reported with the use of remifentanil in two studies (very low quality evidence) and one study (very low quality evidence), respectively. The overall rate of complications was low. AUTHORS' CONCLUSIONS: The evidence to suggest that the most commonly investigated pharmacological interventions reduce pain on injection of rocuronium is of low quality due to risk of bias and inconsistency. There is low or very low quality evidence for adverse events, due to risk of bias, inconsistency and imprecision of effect. We did not compare the various interventions with one another and so cannot comment on the superiority of one intervention over another. Complications were reported more often with use of opioids.

Bone formation is suppressed with multi-stressor military training.

PURPOSE: To determine the effects of US Army Ranger Training, an 8-week, physically demanding program (energy expenditure of 2,500-4,500 kcal/day) with energy restriction (deficit of 1,000-4,000 kcal/day) and sleep deprivation (<4 h sleep/night) on bone metabolism. METHODS: Blood was collected from 22 men (age 24 ± 4 years) before and after training. Follow-up measurements were made in a subset of 8 subjects between 2 and 6 weeks after training. Serum was analyzed for bone formation biomarkers [bone alkaline phosphatase (BAP) and osteocalcin (OCN)], bone resorption biomarkers [C-telopeptide cross-links of type I collagen (CTX) and tartrate-resistant acid phosphatase (TRAP5b)], calcium, parathyroid hormone (PTH), and vitamin D 25(OH)D increased significantly by 37.3 ± 45.2 % with training [corrected]. A repeated-measures ANOVA with time as the only factor was used to analyze data on the subset of 8 subjects who completed follow-up data collection. RESULTS: BAP and OCN significantly decreased by 22.8 ± 15.5% (pre 41.9 ± 10.1; post 31.7 ± 7.8 ng/ml) and 21.0 ± 23.3% (pre 15.0 ± 3.5; post 11.3 ± 2.1 ng/ml), respectively, with training, suggesting suppressed bone formation. OCN returned to baseline, while BAP remained suppressed 2-6 weeks post-training. TRAP5b significantly increased by 57.5 ± 51.6% (pre 3.0 ± 0.9; post 4.6 ± 1.4 ng/ml) from pre- to post-training, suggesting increased bone resorption, and returned to baseline 2-6 weeks post-training. PTH Increased significantly by 37.3 ± 45.2% with training. No changes in CTX, calcium, or PTH were detected. CONCLUSIONS: These data indicate that multi-stressor military training results in increased bone resorption and suppressed bone formation, with recovery of bone metabolism 2-6 weeks after completion of training.

Understanding intentions to override intelligent speed assistance prior to widespread availability: An application of the theory of planned behaviour.

Intelligent Speed Assistance (ISA) offers a technological solution to reduce speeding that will become more common in vehicles in the short to medium term. Many implementations allow drivers to override the system's speed control and minimising such interventions can optimise safety benefits. This paper aims to inform behaviour change interventions to reduce ISA overriding targeted to drivers as they obtain vehicles fitted with ISA. We explore the beliefs underlying intentions to override ISA to exceed the speed limit in drivers with limited ISA experience using the Theory of Planned Behaviour. In a sample of 121 drivers (mean age 36 years), regression modelling showed that attitudes strongly predicted intentions with an additional contribution from subjective norms but not perceived behavioural control. Behavioural beliefs underlying attitudes addressed overriding ISA for (1) responsibly controlling the car to minimise crash risk and (2) reducing journey times and enjoying fast driving. Salient normative beliefs focussed on groups that would disapprove of overriding ISA including emergency services and parents. We discuss how these beliefs might be addressed in interventions to maximise the safe adoption of ISA.

Differential recovery rates of fitness following U.S. Army Ranger training.

OBJECTIVES: To investigate tactically-related physical performance and body composition recovery following U.S. Army Ranger training. DESIGN: Prospective cohort. METHODS: Physical performance was comprehensively assessed using a tactically-related performance battery (i.e., Ranger Athlete Warrior assessment) in 10 male Soldiers at baseline (BL) two-weeks (P1), and six-weeks (P2) post-Ranger School. Body composition was determined using DXA. A one-way repeated measures ANOVA was used followed by Bonferroni-adjusted pairwise comparisons when group differences existed (p≤0.05). Pearson correlation coefficients were used to establish associations between changes in fitness and body composition. RESULTS: All performance domains except the bench press and deadlift worsened following training. Speed/mobility (Illinois agility test, seconds - BL: 16.20±0.86 vs. P2: 18.66±2.09), anaerobic capacity (300-yard shuttle run, seconds - BL: 62.95±6.17 vs. P2: 67.23±5.91), core strength (heel clap, repetitions - BL: 15.80±4.08 vs. P2: 11.50±4.95), and aerobic endurance (beep test, stage - BL: 9.95±2.18 vs. P2: 7.55±1.07) had not recovered by P2. Only upper body muscular endurance and strength (metronome push-up and pull-up, respectively) were similar to BL by P2. Percent body fat increased from 15.62±3.94 (BL) to 19.33±2.99 (P2) (p<0.001). There were no significant associations between changes in body composition and performance. CONCLUSIONS: A comprehensive characterization of physical performance and body composition revealed Rangers did not experience full recovery of fitness six weeks after training. Optimal recovery strategies are needed to return Soldiers to a state of readiness following arduous training.

Not playing by the rules: Unusual patterns in the epidemiology of parasites in a natural population of feral horses (Equus caballus) on Sable Island, Canada.

Sable Island, Nova Scotia, Canada hosts one of few natural populations of feral horses (Equus caballus) never exposed to anthelmintics. Coproculture revealed cyathostomes, Strongylus equinus, S. edentatus, and S. vulgaris, with S. equinus (unusually) dominating in adult horses and cyathostomes dominating in young horses (<3 years of age). We examined 35 horses found dead in the springs of 2017 and 2018, as well as fecal samples from live horses in spring (n = 45) and summer 2018 (n = 236) using McMaster fecal flotation and Baermann larval sedimentation on fresh samples, and modified Wisconsin flotation and sucrose gradient immunofluorescent assay for Giardia and Cryptosporidium on frozen samples. Mean strongyle fecal egg counts were 666 eggs per gram (EPG) in dead horses, 689 EPG in live horses in spring, and 1105 EPG in summer; domestic horses are usually treated at counts exceeding 200 EPG. Adult horses (unusually) had patent infections with the lungworm Dictyocaulus arnfieldi and ascarids (Parascaris spp.), and in spring, dead horses had 5 times higher odds of having patent ascarid infections than live horses, likely due to malnutrition and corresponding immunodeficiency. Fecal prevalence and intensity of D. arnfieldi and Parascaris spp. were significantly higher in young horses, and in spring versus summer. A higher proportion of fecal samples were positive for strongyle and ascarid eggs using a centrifugal flotation technique on previously frozen feces, as compared to a passive flotation method on fresh feces. Eggs of the tapeworm Paranoplocephala mamillana were present in fecal samples from 28% of live, and 42% of dead, horses in spring. This research represents several new geographic records (S. edentatus, D. arnfieldi, and Eimeria leuckarti), provides insight into unusual patterns of parasite epidemiology in a nutrition-limited environment, and has conservation and biosecurity implications for this unique equine population, as well as for parasite management in domestic horses.

Hospitalizations of children who have fetal alcohol syndrome or incomplete fetal alcohol syndrome.

INTRODUCTION: The study describes the hospitalization rates and medical diagnoses of children with fetal alcohol syndrome (FAS) and incomplete FAS. METHODS: Two retrospective case-control studies were conducted of Northern Plains American Indian children with FAS or incomplete FAS identified from 1981-93 by using the ICD-9-CM code 760.71. Children who had FAS or incomplete FAS were compared to each other and to children who did not have FAS. RESULTS: Compared to the controls, the 43 children with FAS (Study 1) and 35 children with incomplete FAS (Study 2) were hospitalized more often with otitis media (51.2 percent OR=4.32 and 31.4 percent OR=3.02 respectively), pneumonia (46.5 percent OR=4.21 and 34.3 percent OR=2.54), fetal alcohol syndrome (32.6 percent p=.001 and 14.3 percent p=.007), dehydration (23.3 percent OR=9.29 and 17.1 percent OR=4), and anemia (11.6 percent OR=10 and 17.1 percent p=.002) respectively. Children with FAS were hospitalized more often with failure to thrive (32.6 percent p=.001) and neglect (23.3 percent OR=10.0) than children with incomplete FAS and controls. Children with FAS were hospitalized with child sexual abuse (11.6 percent OR=10.0) and feeding problems (11.6 percent p=.007), and children with incomplete FAS were hospitalized with gastroenteritis (22.9 percent OR=14.55) and bronchitis (22.9 percent OR=3.0) more than control children. CONCLUSIONS: Children with FAS or incomplete FAS had more hospitalizations and longer average length of stays than control children.

Residency education, preventive medicine, and population health care improvement: the Dartmouth-Hitchcock Leadership Preventive Medicine approach.

In 2003, Dartmouth-Hitchcock Medical Center (DHMC) inaugurated its Leadership Preventive Medicine residency (DHLPMR), which combines two years of leadership preventive medicine (LPM) training with another DHMC residency. The aim of DHLPMR is to attract and develop physicians who seek to become capable of leading change and improvement of the systems where people and health care meet. The capabilities learned by residents are (1) leadership -- including design and redesign -- of small systems in health care, (2) measurement of illness burden in individuals and populations, (3) measurement of the outcomes of health service interventions, (4) leadership of change for improvement of quality, value, and safety of health care of individuals and populations, and (5) reflection on personal professional practice enabling personal and professional development. The DHLPMR program includes completion of an MPH degree at The Dartmouth Institute for Health Policy and Clinical Practice (formerly the Center for Evaluative Clinical Sciences) and a practicum during which the resident leads change to improve health care for a defined population of patients. Residents also complete a longitudinal public health experience in a governmental public health agency. A coach in the resident's home clinical department helps the resident develop his or her practicum proposal, which must then be approved by a practicum review board (PRB). Twelve residents have graduated as of July 2007. Residents have combined anesthesia, family medicine, internal medicine, infectious disease, pain medicine, pathology, psychiatry, pulmonary and critical care medicine, surgery, gastroenterology, geriatric psychiatry, obstetrics-gynecology, and pediatrics with preventive medicine.

Alcohol use, injuries, and prenatal visits during three successive pregnancies among American Indian women on the Northern Plains who have children with fetal alcohol syndrome or incomplete fetal alcohol syndrome.

INTRODUCTION: The purpose of the study was to compare three sequential pregnancies of American Indian women who have children with FAS or children with incomplete FAS with women who did not have children with FAS. METHODS: Two retrospective case-control studies were conducted of Northern Plains American Indian children with fetal alcohol syndrome (FAS) (Study 1) or incomplete FAS (Study 2) in 1981-1993. Three successive pregnancies ending in live births of 43 case mothers who had children with FAS, and 35 case mothers who had children with incomplete FAS were compared to the pregnancies of 86 and 70 control mothers who did not have children with FAS, respectively, in the two studies. Prenatal records were abstracted for the index child (child with FAS or incomplete FAS) and siblings born just before and just after the index child, and comparable prenatal records for the controls. RESULTS: Compared to the controls, significantly more case mothers used alcohol before and after all three pregnancies and during pregnancy with the before sibling and the index child. Mothers who had children with FAS reduced their alcohol use during the pregnancy following the birth of the index child. All Study 1 case mothers (100%) and 60% of Study 2 case mothers used alcohol during the pregnancy with the index child compared to 20 and 9% of respective control mothers. More study 1 case mothers experienced unintentional injuries (OR 9.50) and intentional injuries during the index pregnancy (OR 9.33) than the control mothers. Most case mothers began prenatal care in the second trimester. CONCLUSIONS: Alcohol use was documented before, during and after each of the three pregnancies. Women of child-bearing age should be screened for alcohol use whenever they present for medical services. Mothers who had a child with FAS decreased their alcohol consumption with the next pregnancy, a finding that supports the importance of prenatal screening throughout pregnancy. Women who receive medical care for injuries should be screened for alcohol use and referred for appropriate treatment. Protective custody, case management and treatment services need to be readily available for women who use alcohol.

Normal Weight Status in Military Service Members Was Associated With Intuitive Eating Characteristic.

The purpose of this study was to determine the relationship between individual weight status and intuitive eating or motivation for eating characteristics. Participants were predominantly white (57%), Army (91%), enlisted (72%), males (71%), with a mean age of 30 ± 9 years and mean body mass index (BMI) of 27.0 ± 4.2 kg/m(2). The cross-sectional, descriptive study included active duty service members (n = 295) recruited from Texas and Washington. Validated Motivation for Eating Scale (MFES) and Intuitive Eating Scale were administered and BMI (m/kg(2)) was dichotomized at <25 or ≥25 kg/m(2). Descriptive, correlation, t-test, and logistic regression analysis were conducted for BMI category with demographic, lifestyle, and MFES/Intuitive Eating Scale scores (α = 0.05; 80% power). Thirty-six percent were normal BMI (22.7 ± 1.6 kg/m(2)) and 64% were overweight/obese BMI (29.3 ± 3.3 kg/m(2)). Mean BMI was 27.8 ± 4.2 kg/m(2) (males) and 24.8 ± 3.4 kg/m(2) (females) (p < 0.001). Physical MFES type was predominant (77% normal BMI vs. 66% overweight; p = 0.001). Males ate for physical rather than emotional reasons (p = 0.014). Each 1-point increase in Reliance on Internal Hunger Satiety Score was associated with 34% lower odds of being overweight. Disparity existed between sex and intuitive eating characteristic. Increasing awareness of eating influences may improve weight-related dietary behaviors.

An efficient and effective teaching model for ambulatory education.

Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. Practice redesign made learners active members of the patient care team by involving them in such tasks as patient intake, histories and physicals, patient education, and monitoring of patient progress between visits. So that learners can be active members of the patient care team on the first day of clinic, pre-training is provided by the clerkship or residency so that they are able to competently provide care in the time available. To assure effective education, teaching and learning times are explicitly scheduled by parallel booking of patients for the learner and the preceptor at the same time. In the pilot settings this teaching model maintained or improved preceptor productivity and on-time efficiency compared with these outcomes of traditional scheduling. The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.