The evolution of medical education in the Commonwealth Caribbean

Medical education had taken place in the Commonwealth Caribbean for well over a century, influenced by political, economic, geographical and professional factors. The establishment of the University College of the West Indies as a College of London University in 1948 (UCWI) allows us to describe three distinct periods: pre-UCWI, UCWI and post-UCWI. In the pre-UCWI period, some British doctors were supplied by the Colonial Medical Services (CMS), based in London. The lack of colonial medical schools meant that natives had to train, at their own cost, in the United Kingdom (UK), United States of America (USA) or Canada. UK graduates (unlike North American), returning home, were allowed to serve as unpaid apprentices in CMS hospitals where they often received exemplary and rigorous training - in service from well qualified and dedicated doctors. By World War II, however, most of the CMS hospitals needed rebuilding, but the war postponed plans for this. The UCWI began in 1948 in this colonial setting. It was financing by the British government and supported by all Caribbean colonies except the Bahamas. With a London curriculum modified to accommodate Preventive Medicine, Public Health and Dentistry, the Medical Faculty aimed to train general practitioners; but many graduates opted for specialist careers instead. Staff shortages in Government services continued, especially in the Lesser Antilles. However, the new medical academics at Mona quickly made an international name for the school from the clinical strength of its graduates, the quality of services and the output of research. Politically by the late 1950s the major colonies had achieved a measure of self government, giving them local Ministerial control of higher education and health affairs, and they inherited from the CMS all the physical and manpower problems and administrative structures, warts and all!! This period also saw the birth and death of the West Indian Federation (which would have had responsibility for the UCWI). Extramural centres built in each island had little impact on medical affairs. The College became an independent University (UWI) in 1962, and awarded its first degrees in 1967.(AU)

Problem-based learning and problem-solving: sowing seeds of confusion - abstract

A major principle of problem-based learning (PBL) is that knowledge gained in a specific context is more easily incorporated into one's fund of usable information. In PBL curricula, students are self-directed, meet regularly in small tutorial groups to consider a clinical problem at each session. Problems are presented in blocks based on biologic development or organ systems. The issues identified determine the disciplines learned and focus the subsequent discussion. Issue guides help students and tutors cover the disciplines and topics each problem involves. The emphasis is on learning principles and mechanisms of disease that explain clinical phenomena, preventive and management strategies for individuals and communities. Problem-solving follows steps involving specific and discriminating application of knowledge and skills already acquired. In this process, the clinical situation provides the cues needed to define the problem medically and to suggest explanations. The expertise of the observer will dictate the choice, efficiency, utility, discrimination etc. of data-gathering strategies used to make a final diagnosis, assess prognosis and plan management. With expert monitoring of outcomes, changes are readily made. PS is thus a process for experts not novices. PBL curricula claim to teach students the elements of PS quickly, consistently and usefully. PS is thus the outcome of PBL and the lasting skills needed will be mastered if students pursue PS and ignore the wider scope and ramifications of PBL (AU)

Evaluation of student learning in a problem-based curriculum - abstract

The Faculty of Health Services at McMaster University adopted, at its founding, continuous evaluation by peers and tutors as the primary tool to measure learning progress in its problem-based curriculum (PBL). Results were uneven and the student performance data showed poor reproducibility and little correlation with achievement in the final licensing examination (LMCC). Other tests were then introduced: the "triple jump" exercise for tutorial learning and standardized patients for clinical skills, supplemented sporadically with short essays, free response items and patient management problems. These were costly and posed logistic problems, not justified by their psychometric properties. The objectives structured clinical examinations (OSCE) was added to test clinical skills and showed good results. But a reliable test of knowledge remained elusive. Having a fairly extensive experience with objective tests and knowing their positive psychometric properties, I introduced MCQs to my student groups in required and elective studies, in formative and summative fashion, to provide individual and group data. Administrators and unit supervisors, mostly unfamiliar with MCQs , disagreed with their use, asserting that they steered students to "cram for examinations" and were therefore anti-PBL! However, the higher LMCC failure rate of McMaster students compared with others persuaded the school to adopt an MCQ format based on one developed by the University of Limburg, Maastricht, Holland. The test is offered annually to all students, of all years, and samples the entire curriculum. When the three scores are obtained, a profile of performance emerges for each student. Results have shown higher percentages of correct answers in years 2 & 3, suggesting incremental learning. MCQs are a valued tool in evaluating knowledge. Future use should include extended choice and extended matching formats, which have been shown to improve the tests psychometrically (AU)

Assessing clinical competence in practising physicians - abstract

A multi-method assessment of clinical competence was developed and tested by a team at McMaste University from 1987 to 1989. The chosen tests were chart-stimulated recall (CSR), stimulated office practice using standardised patients (SOSP), structured oral (SO), objective structured clinical examinations (OSCE) and a multiple choice test of between 100 and 120 items. Each test was scored as several categories of performance criteria: seven for CSR, five and three patients for SOSP, four and three cases for SO, and twelve stations in the OSCE. Twenty randomly selected physicians in good standing (reference group) were tested, and the results compared with thsoe from physicians subsequently referred from the College of Physicians and Surgeons of Ontario for a variety of reasons. Two trained peers, blinded as to physician category, assessed each examination, viewing performance through two-way mirrors. The examination lasted one full day. Both tested groups were similar in age and country of graduation, 65 and 50 percent, respectively, being Canadians. Half were in solo practice, 21 percent in partnerships, 29 percent in group practice. Analysis of results Canadians. Half were in solo practice, 21 percent in partnerships, 29 percent in group practice. Analysis of results showed good to high inter-rater reliabilities in all components: 0.6-0.9. Inter-case reliabilities for CSR, SOSP, and SO were 0.63-0.78, higher than usually reported. The OSCE was not satisfactory. Inter-test correlations were generally good. Discriminant function analysis showed that all tests and subtests except the observed OSCE discriminated among the groups; SOSP was the most sensitive. The results established the reliability and validity of the method. Details of rationale, methods, results, cost and implications of the study will be discussed (AU)

Lupus nephritis in Jamaica

The renal biopsies of 48 patients with systemic lupus erythematosus were categorized into four histological groups - minimal change, focal proliferative, diffuse proliferative and membranous glomerulonephritis. Attempts at clinical correlation showed the broad grouping to have some prognostic value. However, the histological appearances within the various groups were quite diverse and this was especially so in the diffuse proliferative category where at least 6 sub-groups are described. Two sub-groups were of particular interest. The patients with a membranous glomerulonephropathy and superimposed endothelial cell proliferation accounted for 33 percent of our biopsies in the diffuse proliferative group and may be in part reponsible for the relatively good prognosis of this group. This histological picture raises the question of progression from membranous to diffuse proliferative lupus glomerulonephritis. The small sub-group of two patients with endothelial cell proliferation and polymorph infiltration is also of importance since it appears to have a good prognosis (AU)

The spectrum of glomerular pathology in a West Indian population - abstract

Renal diseases account for up to 10 percent of deaths at University Hospital of the West Indies. (Hayes, Thorburn). In 1967 a grant from the Wellcome Trust enable us to begin a study of the morphology of kidney diseases as they presented in Jamaica and to relate the changes seen with the clinical syndromes, to provide a guide for clinical mangement and to ascertain, where possible, the aetiology of the various diseases. From 1967 to the present time 235 renal biopsies were performed by physicians using a Vim-Silverman needle usually under fluoroscopic control. Biopsy material was transferred directly from the needle into buffered glutaralde-hyde, minced into 1 mm cubes selected for electron microscopy and the rest was prepared for light microscopy in the standard way and stained with H&E, P.A.S. and memhenamine silver. Sections for electron microscopy were cut with an ultranmicrotome at 1 u and stained with alcian blue and silver. The pathological classification of the 235 renal biopsies were as follows: 16 percent were inadequate for proper assessment. 5 percent showed "minimal change" glomerulonephritis and were mainly from children with the nephrotic syndrome. 23 percent showed a diffuse proliferative glomerulonephritis and included three cases (1 percent) of the rapidly progressive type with extensive crescent formation. 10 percent showed a focal proliferative glomerulonephritis. 15 percent were from clinical proven cases of systemic lupus erythematosis. A further 2 percent had changes compatible with Systematic Lupus enthematosis although I.E. cells were negative. 2 percent (6) showed an epimembranous nephropathy but included 2 bio from proven cases of S.L.E. 6 percent showed a chronic glomerulonephritis. The remaining 18 percent constituted biopsies from patients with Leptospirosis (2 percent); Amyloidosis (1 percent) toxaemia of pregnancy, multiple myelomatosis, malignant lymphoma. hypertension, acute tubular necrosis interstitial nephritis and some cases of albuminuria associated with throtoxic patients treated with neomercazole (AU)

The prevalence of pyelonephritis among sicklers and non-sicklers in an autopsy population - abstract

It has been reported that there is a two-fold increase in the incidence of bacteriuria in pregnant Jamaican patients with the sickle cell trait. It has also been shown that the incidence of bacteriuria in sicklers as a whole is four times that of people who do not have S haemoglobin. Because of the correlation between bacteriuria and pyelonephritis, it could be inferred that the prevalence of pyelonephritis in sicklers might be higher than in non-siclklers. 6,750 consecutive autopsies done at the University Hopsital of the West Indies were reviewed. Of these 570 (approximately 8 percent) were stated as showing evidence of pyelonephritis or interstitial nephritis. Haemoglobin electrophoresis was attempted in a consecutive sereis of 645 autopsies. No results were available in 244 cases, but in 401 there were 33 patients with Hb AS. Six (18 percent) had pyelonephritis compared with 28 of 299 patients (9 percent) with Hb AA. One patient had Hb SS but had no pyelonephritis. The autopsy protocals of 31 patients with Hb SS were studied. Two of these (7 percent) had pyelonephritis. From the above it can be seen that there is no significant difference in the overall prevalence of pyelonephritis in the general population and the sicklers with Hb SS. There is, however, a difference in prevalence between the Hb AS group on the one hand, and the Hb AA and HB SS group on the other. This higher prevalence of pyelonephritis in the Hb SS group would be in keeping with the findings of others of an increased incidence of bacteriuria in Hb AS patients. The age relationship of pyelonephritis in our various grougps showed, in the Hb AA cases, a fairly even distribution of the majority between 40-80 years of age. However, 5 of the 6 cases in Hb AS group were between 60-80 years of age, whilst both Hb SS cases were between 30-40 years of age. The low prevalence of pyelonephritis in the SS patients may be attributed to the fact that about half died before the age of 10, thus there might not have been time for them to develop pyelonephritis (AU)

Renal ultrastructure in leptospirosis - abstract

Electron microscopy of renal biopsy material from five cases of leptospirosis revealed ultrastructural changes in glomeruli and tubules, in addition to the changes of acute tubuler necrosis seen by light microscopy. Glomerular alterations consisted of enlargement and increase of epithelial cells, focal fusion of foot processes, subendothelial oedema, accumulation of granular material in Bowman's space, and small patches of electron dense deposits in theouter aspect of basement membranes. Epithelial cell mitochondria were swollen and various intracytoplasmic inclusions were seen. There were small foci with endothelial cell increase, and in an occasional tuft increase in mesangial matrix. Tubular degenerative and necrotic changes were most severe in the distal nephron. Light microscopy of proximal tubules had revealed little specific abnormality; significant ultrastructural changes had however occurred. These were disruptions of the brush border, gross enlargement of mitochondria, accumulation of dense bodies, dilatation of endoplasmic reticulum, and increased complexity of intracytoplasmic membranes. These studies show that there are significant ultrastructural changes in those parts of the nephron which by light microscopy usually appear undamaged (AU)

Peritoneal dialysis in severe leptospiral renal failure

Three cases of severe leptospiral renal failure have been described. They had all intrinsic renal damage and were treated satisfactory by peritoneal dialysis. Renal biopsies were done in 2 patients in the recovery phase of their illness and showed signs of severe tubular damage (AU)

The influence of changes in dietary regimen on spontaneous tumours of the pituitary gland in rats

Our findings firmly establish that the nutrition of early life does have long lasting effects and can also influence the incidence of disease later in life. This will be discussed and demonstrated for chromophobe adenoma's of the pituitary gland. These were seen in relatively high frequency in animals on ad libitum feeding. The incidence in animals on restricted food intake dropped sharply. Again changing the dietary regimen at 70 days of age from ad libitum to restricted feeding or vice versa markedly influenced the incidence of these tumours (AU)

Spontaneous tumours and degenerative diseases in rats as influenced by diet

The response to a dietary regimen may differ at different ages: a diet high in protein and carbohydrates which appeared to be satisfactory as regards development and maintenance was unsatisfactory with respect occurence of degenerative diseases and length of life. Restriction in protein and carbohydrate with simultaneous restriction in caloric intake while not conducive to expression of maximum growth potential, and responsible for a number of early deaths, ultimately did enhance life expectancy to greatest degree. These restricted regimens were also most effective in decreasing the prevalence and severity of those diseases usually found in "well fed" aging rats. Under isocaloric conditions, a direct relationship was found between life expectancy and the proportion of protein in the diet. The effects of differences in the protein content were more pronounced when rats were restricted in their intake of food than when the rats were permitted to feed ad libitum. The expectancy at 21 days of age of rats fed a high protein diet under calorically restricted conditions was twice that of rats fed a low protein diet ad libium. For some rats fed on a restricted basis, life spans in excess of 1800 days were obtained (equivalent to 180 years for the human). Certain aspects of the histopathological findings in these experiments will be demonstrated (AU)

Kaposi's sarcoma in West Indies

Clinical and pathological features are presented of 3 cases of Kaposi's sarcoma, thought to be the first confirmed cases in the British Commonwealth West Indies. The results of angiography done on one case is given; amyloidosis complicated the natural history in this case. An association between Kaposi's sarcoma and amyloidosis has not been previously noted in the available literature. The rarity of the disease in this predominantly African population, derived mainly from West Africa, is added evidence that environmental factors are responsible for the disease (AU)

The influence of dietary regimens on the incidence of spontaneous neoplasms in the rat - abstract

The levels of caloric and of protein intake were demonstrated to have modifying influence on tumour incidence patterns in the male rat. In a study using five uniform life-long dietary regimens differing only in allotments and in-takes of protein (casein), carbohydrates (sucrose) or of total calories, the total turmour risk was directly and exponentially related to caloric intake. Malignant lymphomas were predominant in rats with high protein in-take, whereas fibromas and fibrosarcomas predominated in rats with low intake. The lowest incidence, the greatest delay in time of occurence, absence of malignant epithelial tumours and greatest life expectancy, were observed when intakes of protein, carbohdrates and total calories were low. Other experiments designed to test the influence of dietary regimens in early life upon tumour incidence later in life will also be discussed briefly (AU)