Selecting Instruments for Measuring the Clinical Learning Environment of Medical Education: A 4-Domain Framework.

Learning environments shape the experiences of learners and practitioners, making them an important component of program evaluation. However, educators find it challenging to decide whether to measure clinical learning environments with existing instruments or to design their own new instrument and, if using an existing instrument, which to choose. To assist educators with these decisions, the authors compared clinical learning environment instruments based on their characteristics, underlying constructs, and degree to which items reflect 4 domains (personal, social, organizational, material) from a recently developed model for conceptualizing learning environments in the health professions. Building on 3 prior literature reviews as well as a literature search, the authors identified 6 clinically oriented learning environment instruments designed for medical education. They collected key information about each instrument (e.g., number of items and subscales, conceptual frameworks, operational definitions of the learning environment) and coded items from each instrument according to the 4 domains. The 6 instruments varied in number of items, underlying constructs, subscales, definitions of clinical learning environment, and domain coverage. Most instruments focused heavily on the organizational and social domains and less on the personal and material domains (half omitted the material domain entirely). The variations in these instruments suggest that educators might consider several guiding questions. How will they define the learning environment and which theoretical lens is most applicable (e.g., personal vitality, sociocultural learning theory)? What aspects or domains of the learning environment do they most wish to capture (e.g., personal support, social interactions, organizational culture, access to resources)? How comprehensive do they want the instrument to be (and correspondingly how much time do they expect people to devote to completing the instrument and how frequently)? Whose perspective do they wish to evaluate (e.g., student, resident, fellow, attending, team, patient)? Each of these considerations is addressed.

The IMCO scheme as a tool in developing team-based treatment for people with multiple sclerosis.

BACKGROUND: The Danish Multiple Sclerosis Society (a patient organization) has initiated a research-based bridge-building and integrative treatment project to take place from 2004 to 2010 at a specialized MS hospital. The background for initiating the project was an increasing use of alternative treatment documented among persons with multiple sclerosis (PwMS). From PwMS there has been an increasing demand upon The Danish Multiple Sclerosis Society to initiate the project. OBJECTIVE: The overall purpose of the project is to examine whether collaboration between 5 conventional and 5 alternative practitioners may optimize treatment results for people who have multiple sclerosis (MS). The specific aim of this paper is to present tools used in developing collaboration between the conventional and alternative practitioners. MATERIALS AND METHODS: Two main tools in developing collaboration between the practitioners are described: (1) the planning and conduction of 4 practitioner-researcher seminars in the prephase of the project before recruiting patients with MS; and (2) the IMCO scheme (which is an abbreviation of Intervention, Mechanism, Context, and Outcomes). This tool was developed and used at practitioner-researcher seminars to make visible the different practitioners' treatment models and the patient-related treatment courses. RESULTS: Examples of IMCO schemes filled in by the medical doctor and the classical homeopath illustrate significant differences in interventions, assumptions concerning effect mechanisms, and awareness of contexts facilitating and inhibiting the intervention to generate the outcomes expected and obtained. CONCLUSIONS: The IMCO schemes have been an important tool in developing the team-based treatment approaches and to facilitate self-reflection on the professional role as a health care provider. We assume that the IMCO scheme will be of real value in the development of effective treatment based on collaboration between conventional and alternative practitioners.

Introducing alternative/complementary healing to allopathic medical students.

We have designed a senior elective, Introduction to Alternative Medicine, to prepare our students better to practice in multicultural environments, and to expand their views of health and healing. We combined didactic lecture, films, first-hand experience with some methods, and observation of alternative practitioners in their offices/clinics. Students explored hypnosis, chiropractic, therapeutic touch, meditation, biofeedback, acupuncture, homeopathy, naturopathy, and massage therapy. Discussions of scientific efficacy, legal and ethical considerations, and the role of spirituality in health and healing focused on limitations of science-based approaches and reasons why alternative/complementary methods are popular with patients and allopathic physicians. We conclude that allopathic medical schools have an important role in reducing the isolation of their students from alternative health beliefs, practices, and systems of care that are common in our communities.

[Evaluation of measles, mumps and rubella vaccine coverage in 3 year old children in twelve French counties. Time-trends and related factors]. / Evaluation de la couverture vaccinale rougeole-oreillons-rubéole chez les enfants de trois ans dans douze départements français. Evolution temporelle et facteur associés.

BACKGROUND: The aims of our study were to estimate the measle-mumps-rubella (MMR) vaccine coverage in 3 years old children in 12 French countees, to document the evolution between 1997 and 1999 in two groups of 6 countees (pilot group and control group) before and after the implementation of promotion programmes in the pilot group, and to identify factors related to measle-mumps-rubella vaccination. METHODS: Two telephone surveys were carried out in 1997 and 1999 among children randomly selected in the birth rolls of 12 French countees. Parents of 3 years old children were interviewed on measle-mumps-rubella vaccination, knowledge and opinions on vaccinations, utilisation of health care and socio-demographic characteristics. RESULTS: The participation rate was 97% in both surveys. Among the 7382 respondent parents, 98% had immediate access to the child's medical file and could document the vaccine status. The vaccine coverage did not increase significantly between 1997 and 1999 (86.7% versus 87.2%), both in control (89.3% vs. 90.2%) and pilot groups (84.3% vs. 84.3%). A logistic regression model showed that several factors were independently and significantly related to measle-mumps-rubella vaccination (utilisation of homeopathic medicines, mother's age, number of children, physician speciality (general practitioner or pediatrician) and opinion on vaccinations). CONCLUSION: Our study shows that there is a stagnation of vaccine coverage in several French countees, which makes unlikely the national objective of viruses eradication. This epidemiological situation makes very likely outbreaks of measles, mumps and rubella in these countees. National and local pilot programmes did not succeed to promote vaccination in countees with a low measle-mumps-rubella vaccine coverage. Our study identified sub-groups of parents who should be targeted by promotion programmes.

Integrating modern dermatology and Ayurveda in the treatment of vitiligo and lymphedema in India.

BACKGROUND: Globally, governments have recognized the growing popularity of Complementary and Alternative Medicines and the possibility of their combined use with biomedicine. Decisions within the Government of India have led to a conducive environment for conducting clinical studies, to achieve integration of more than one system of medicine, so that their combined benefits can be brought to bear on chronic, difficult-to-treat conditions. AIM: To develop integrative dermatology treatment protocols for patients with long-standing skin diseases who have received treatment from many centers. MATERIALS AND METHODS: A team of doctors from modern dermatology, Ayurveda, yoga therapy, and homeopathy studied recruited patients to develop mutual orientation on each therapeutic system and a working knowledge of approach to their clinical diagnosis. Six-hundred thirty-eight patients affected by lower limb lymphedema requiring skin care as a major part of treatment were treated integrating modern dermatology and Ayurveda. Three-hundred eighty-one vitiligo patients were examined and treated to understand the clinical presentations and treatment options in Ayurveda. RESULTS: A two-step cluster analysis performed by SPSS Version 16 showed average volume reductions of 13.3% and 23% on day 14, 19.7% and 31.1% on day 45, and 23.4% and 39.7% on day 90 of treatment in small and large lymphedematous limbs. Inflammatory episodes before the onset on this treatment was reported by 79.5% of our lymphedema patients, and 9.4% reported this at the end of three months after our treatment. Among vitiligo patients, we found that 39.6% of patients had kapha, 39.8% pitta, 10.8% had vatha and 0.52% has tridoshaja presentation. There are over 100 treatment options available in Ayurveda to treat vitiligo. DISCUSSION: Each system of medicine recognizes the same disease albeit with minor difference in description. Skin care procedures like washing and emollients restore the barrier function and skin health. We have converged Ayurvedic skin care with that of dermatology with an aim of achieving patient management that is better than that achievable by a single system alone. Overload of the lymphatic system due to loss of epidermal barrier function and consequent inflammation from bacteria and soil irritants is responsive to selected Ayurvedic herbal preparations. CONCLUSION: It is evident that integration at the therapeutic level is possible, although the pathological basis is interpreted differently. Irrespective of background understanding of the given disease, a mutually oriented multisystem therapeutic team was able to effectively use medicines from more than one system of medicine and to develop guidelines for their prescription and a patient care algorithm.

Injection drug use in Rural Iran: integrating HIV prevention into iran's rural primary health care system.

Major opium trafficking routes traverse rural Iran, but patterns of drug use and HIV infection in these areas are unknown. In 2004, Iran's Ministry of Health integrated substance use treatment and HIV prevention into the rural primary health care system. Active opium or heroin users (N = 478) were enrolled in a rural clinic. Participants received counseling for abstinence from substances, or daily needle exchange and condoms. On enrollment, 108 (23%) reported injecting; of these, 79 (73%) reported sharing needles. Of 65 participants tested for HIV, 46 (72%) tested positive. Participants who received daily needle exchange/condoms stayed in the program longer than those who did not (AOR 2.08, 95% CI 1.1-3.88). This project demonstrates that HIV risks exist in rural Iran and suggests the innovative use of Iran's rural health care system to extend prevention and treatment services to these populations.

Learning experiences--what works for postgraduates.

Supervision and postgraduate education for health professionals studying homeopathy was investigated using feedback and comparative questioning of participants who have taken part in group supervision. Objectives set by supervisors, influenced by previous feedback, are scored and ranked. The key areas of postgraduate learning of homeopathy and how well the supervision model met these are analysed and discussed. Learning experiences are ranked in order of preference. Aspects of case presentation are compared for interest and relevance.

Operating needle exchange programmes in the hills of Thailand.

Injecting drug use is increasingly markedly amongst the ethnically distinct Hilltribe peoples of northern Thailand in the notorious 'Golden Triangle'. This paper reports on the establishing of needle exchanges in three remote Hilltribe villages, examining the success and the failure. Up to 60% of adult males and a smaller percentage of adult females in these villages are habitual users of opium and/or heroin. Overcoming initial concern that needle distribution would encourage increased use, the villagers themselves have assumed responsibility for much of the needle exchange operation. Prior to the introduction of the needle exchanges all the injecting drug users were sharing needles. This behaviour changed significantly with the introduction of the exchanges. Reluctance on the part of locally-based government officials to participate fully in the programme created difficulties in maintaining needle supplies which saw some resumption in needle sharing. HIV seroprevalence rates amongst the tested injecting drug users remained fairly stable at 33% in February 1993 and 32% in February 1994. The conclusion can be drawn that needle exchange programmes are operable in the Hilltribe context and that they are the best means of limiting HIV/AIDS transmission amongst injecting drug users and the wider community. The success of needle exchange programmes, however, is dependent upon co-operation from various government agencies and non-government agencies, in addition to the local communities. To this end mechanisms ensuring co-operation, training, monitoring and evaluation need to be developed alongside the introduction of needle exchanges.

PIP: Injecting drug use is increasing markedly among the ethnically distinct Hilltribe people of northern Thailand in the notorious Golden Triangle. This paper reports on the establishment of needle exchanges in 3 remote Hilltribe villages. The needle and syringe exchanges were established in 3 villages: Anamai Village 1, 2, and 3, each with an average of 47 households and 5-6 people per household. Altogether there were 46 injecting drug users participating: 16 from Anamai Village 1; 12 from Anamai Village 2; and 18 from Anamai Village 3. Up to 60% of adult males and a smaller percentage of adult females in these villages were habitual users of opium and/or heroin. Through a series of meetings in the villages various means available to prevent the transmission of HIV/AIDS in an injecting drug use context were discussed. The villagers themselves have assumed responsibility for much of the needle exchange operation. The sharing of needles by injecting drug users changed significantly with the introduction of the exchanges. Reluctance on the part of local government officials to participate in the program created difficulties in maintaining needle supplies, which led to some resumption in needle sharing. The needle and syringe exchanges in November 1992 supplied 5000 1 cc needle and syringe fits, a 1-years' supply. HIV seroprevalence rates among the tested injecting drug users remained fairly stable at 5 cases (33%) of 15 IDUs tested in February 1993. In February 1994, 8 (32%) of 25 IDUs tested were found to be HIV seropositive. The 17 men found to be HIV negative in February 1994 despite their injecting behavior would seem to indicate that the needle exchange programs in the Hilltribe context are effective in limiting HIV/AIDS transmission among injecting drug users and the wider community. The success of needle exchange programs is dependent upon cooperation from various government agencies and nongovernment agencies as well as the local communities.

Maternity care for all.

PIP: Until the 20th century, women and families worldwide knew that it was always a possibility that women would die from childbearing (e.g., over 2000 maternal deaths/100,000 births in Europe). Increased knowledge about pregnancy and its complications and the application of that knowledge in maternal health care systems in developed countries reduced maternal mortality considerably (e.g., 20 in northern Europe). Improvements in delivery management helped greatly to reduce maternal deaths, which include aseptic techniques, appropriate use of forceps, safe blood transfusion, sulphonamides, and proper management of preeclampsia and eclampsia. Maternal mortality is still high in developing countries (e.g., 5% of women in some parts of Africa die from a pregnancy-related condition) where 99% of all maternal deaths occur. These pillars of family life die in the prime of their life and often leave other children. Their loss adversely affects social and economic development. Just 78 countries (35% of the world's population) have a vital registration system recording causes of death, thereby making it difficult to understand the extent of maternal mortality. The 1st cause of maternal death to fall in developed countries and now in developing countries is sepsis. Other causes of maternal death are obstetric hemorrhage, eclampsia, ectopic pregnancy, unsafe abortions, and obstructed labor. Lack of access to maternal health services keeps many women with pregnancy complications from receiving the care they need to survive. Trained persons help only about 50% of women worldwide with labor and delivery. Upgrading of local health centers and training midwives in recognizing complications and in aseptic delivery techniques are needed to improve the quality of maternal health care. Each health center must have the means to transport women to district hospitals. Health centers must offer contraception to prevent unwanted pregnancies. Countries need to reduce the social inequalities that women face.^ieng

O Programa de Saude da Familia em um grande centro urbano na perspectiva da equipe gestora: o caso de goiania / Family Health Program in great urban center from the perspective of the managers and controllers: Goiania case

Este estudo resgatou a trajetoria do Programa de Saude da Familia em um grande centro urbano, o municipio de Goiania, durante o periodo historico de cinco anos, que vai de 1998 a 2003, a aprtir da visao dos gestores e gerentes. Descreve o contexto politico-administrativo da Secretaria Municipal de Saude, que permeou tanto a fase de implantacao quanto a implementacao do PSF em Goiania, no sentido de identificar a concepcao e expectativas desses atores sociais sobre o Programa de Saude da Familiae, em especial, discutir os fatores facilitadores e dificultadores que tem interferido no desenvolvimento do programa em Goiania, que possam servir de subsidios para corrigir suas debilidades e ampliar fortalezas...