Task modulation of brain responses in visual word recognition as studied using EEG/MEG and fMRI

Do task demands change the way we extract information from a stimulus, or only how we use this information for decision making? In order to answer this question for visual word recognition, we used EEG/MEG as well as fMRI to determine the latency ranges and spatial areas in which brain activation to words is modulated by task demands. We presented letter strings in three tasks (lexical decision, semantic decision, silent reading), and measured combined EEG/MEG as well as fMRI responses in two separate experiments. EEG/MEG sensor statistics revealed the earliest reliable task effects at around 150 ms, which were localized, using minimum norm estimates (MNE), to left inferior temporal, right anterior temporal and left precentral gyri. Later task effects (250 and 480 ms) occurred in left middle and inferior temporal gyri. Our fMRI data showed task effects in left inferior frontal, posterior superior temporal and precentral cortices. Although there was some correspondence between fMRI and EEG/MEG localizations, discrepancies predominated. We suggest that fMRI may be less sensitive to the early short-lived processes revealed in our EEG/MEG data. Our results indicate that task-specific processes start to penetrate word recognition already at 150 ms, suggesting that early word processing is flexible and intertwined with decision making.

Towards the routine use of brain imaging to aid the clinical diagnosis of disorders of consciousness

Clinical audits have highlighted the many challenges and dilemmas faced by clinicians assessing persons with disorders of consciousness (vegetative state and minimally conscious state). The diagnostic decision-making process is highly subjective, dependent upon the skills of the examiner and invariably dictated by the patients' ability to move or speak. Whilst a considerable amount has been learnt since Jennett and Plum coined the term 'vegetative state', the assessment process remains largely unchanged; conducted at the bedside, using behavioural assessment tools, which are susceptible to environmental and physiological factors. This has created a situation where the rate of misdiagnosis is unacceptably high (up to 43%). In order to address these problems, various functional brain imaging paradigms, which do not rely upon the patient's ability to move or speak, have been proposed as a source of additional information to inform the diagnostic decision making process. Although accumulated evidence from brain imaging, particularly functional magnetic resonance imaging (fMRI), has been encouraging, the empirical evidence is still based on relatively small numbers of patients. It remains unclear whether brain imaging is capable of informing the diagnosis beyond the behavioural assessment and whether brain imaging has any prognostic utility. In this study, we describe the functional brain imaging findings from a group of 41 patients with disorders of consciousness, who undertook a hierarchical speech processing task. We found, contrary to the clinical impression of a specialist team using behavioural assessment tools, that two patients referred to the study with a diagnosis of vegetative state did in fact demonstrate neural correlates of speech comprehension when assessed using functional brain imaging. These fMRI findings were found to have no association with the patient's behavioural presentation at the time of investigation and thus provided additional diagnostic information beyond the traditional clinical assessment. Notably, the utility of brain imaging was further underlined by the finding that the level of auditory processing revealed by functional brain imaging, correlated strongly (rs = 0.81, P < 0.001) with the patient's subsequent behavioural recovery, 6 months after the scan, suggesting that brain imaging may also provide valuable prognostic information. Although further evidence is required before consensus statements can be made regarding the use of brain imaging in clinical decision making for disorders of consciousness, the results from this study clearly highlight the potential of imaging to inform the diagnostic decision-making process for persons with disorders of consciousness.

Consultants in Scotland: survey of educational qualifications, experience and needs of Scottish consultants

AIMS

To survey Scotland's NHS consultants regarding their teaching roles; educational qualifications/training; attitudes to educational qualifications; perceptions of health boards' attitudes to educational activities; usefulness of various educational courses and preferred delivery methods.

METHODS

Postal questionnaire (n=3615).

RESULTS

Sixty two percent response rate (n=2246). 98% had one or more roles in education/training. 54% spent more time in educational roles than job-plan allocations. 6% had educational qualifications. 30% rated educational qualifications valuable to their educational role; 21% to their career. 48% had not attended any educational training. 19% of respondents rated their health board as supportive of their educational activities. Respondents rated dealing with underperforming students (74%), dealing with challenging behaviour (63%), appraising students (63%), trainee assessment (61%) and feedback (58%) as the most useful topics.

CONCLUSIONS

Scottish consultant involvement in educational activities is virtually universal but consultants perceive they need more time than allocated in job plans. Most consultants had no teaching qualifications. Nearly half had no formal training for educational activities. Educational qualifications were valued by a minority regarding both career development and educational activities. Increased access to staff development for teaching is required as NHS sources are not meeting the need for teacher training of consultant staff.

When thoughts become action: an fMRI paradigm to study volitional brain activity in non-communicative brain injured patients

The assessment of voluntary behavior in non-communicative brain injured patients is often challenging due to the existence of profound motor impairment. In the absence of a full understanding of the neural correlates of consciousness, even a normal activation in response to passive sensory stimulation cannot be considered as proof of the presence of awareness in these patients. In contrast, predicted activation in response to the instruction to perform a mental imagery task would provide evidence of voluntary task-dependent brain activity, and hence of consciousness, in non-communicative patients. However, no data yet exist to indicate which imagery instructions would yield reliable single subject activation. The aim of the present study was to establish such a paradigm in healthy volunteers. Two exploratory experiments evaluated the reproducibility of individual brain activation elicited by four distinct mental imagery tasks. The two most robust mental imagery tasks were found to be spatial navigation and motor imagery. In a third experiment, where these two tasks were directly compared, differentiation of each task from one another and from rest periods was assessed blindly using a priori criteria and was correct for every volunteer. The spatial navigation and motor imagery tasks described here permit the identification of volitional brain activation at the single subject level, without a motor response. Volunteer as well as patient data [Owen, A.M., Coleman, M.R., Boly, M., Davis, M.H., Laureys, S., Pickard J.D., 2006. Detecting awareness in the vegetative state. Science 313, 1402] strongly suggest that this paradigm may provide a method for assessing the presence of volitional brain activity, and thus of consciousness, in non-communicative brain-injured patients.

The time course of visual word recognition as revealed by linear regression analysis of ERP data

EEG correlates of a range of psycholinguistic word properties were used to investigate the time course of access to psycholinguistic information during visual word recognition. Neurophysiological responses recorded in a visual lexical decision task were submitted to linear regression analysis. First, 10 psycholinguistic features of each of 300 stimulus words were submitted to a principal component analysis, which yielded four orthogonal variables likely to reflect separable processes in visual word recognition: Word length, Letter n-gram frequency, Lexical frequency and Semantic coherence of a word's morphological family. Since the lexical decision task required subjects to distinguish between words and pseudowords, the binary variable Lexicality was also investigated using a factorial design. Word-pseudoword differences in the event-related potential first appeared at 160 ms after word onset. However, regression analysis of EEG data documented a much earlier effect of both Word length and Letter n-gram frequency around 90 ms. Lexical frequency showed its earliest effect slightly later, at 110 ms, and Semantic coherence significantly correlated with neurophysiological measures around 160 ms, simultaneously with the lexicality effect. Source estimates indicated parieto-temporo-occipital generators for the factors Length, Letter n-gram frequency and Word frequency, but widespread activation with foci in left anterior temporal lobe and inferior frontal cortex related to Semantic coherence. At later stages (>200 ms), all variables exhibited simultaneous EEG correlates. These results indicate that information about surface form and meaning of a lexical item is first accessed at different times in different brain systems and then processed simultaneously, thus supporting cascaded interactive processing models.

AMEE Medical Education Guide No. 24: Portfolios as a method of student assessment

This guide is intended to inform medical teachers about the use of portfolios for student assessment. It provides a background to the topic, reviews the range of assessment purposes for which portfolios have been used, identifies possible portfolio contents and outlines the advantages of portfolio assessment with particular focus on assessing professionalism. The experience of one medical school, the University of Dundee, is presented as a case study. The current state of understanding of the technical, psychometric issues relating to portfolio assessment is clarified. The final part of the paper provides a practical guide for those wishing to design and implement portfolio assessment in their own institutions. Five steps in the portfolio assessment process are identified: documentation, reflection, evaluation, defence and decision. It is concluded that portfolio assessment is an important addition to the assessor's toolkit. Reasons for using portfolios for assessment purposes include the impact that they have in driving student learning and their ability to measure outcomes such as professionalism that are difficult to assess using traditional methods.

Portfolio assessment in medical students' final examinations

The introduction of an outcome-based approach to education at Dundee Medical School in Scotland instigated a search for assessment methods that would appropriately assess the students' achievements in terms of the learning outcomes. Portfolio assessment has been developed for this purpose and has been adopted for the summative assessment of students in their final examination in Dundee. The contents of the portfolio and the assessment process have been defined and the first cohort of students to be assessed in this way has been studied. The evaluation of the approach demonstrated strong staff support. Students were also positive although with some reservations. It is concluded that portfolio assessment is a powerful approach to assessing a range of curriculum outcomes not easily assessed by other methods and is worthy of inclusion in the assessor's toolkit.

Susceptibility-induced loss of signal: comparing PET and fMRI on a semantic task

Functional magnetic resonance imaging (fMRI) has become a popular tool for investigations into the neural correlates of cognitive activity. One limitation of fMRI, however, is that it has difficulty imaging regions near tissue interfaces due to distortions from macroscopic susceptibility effects which become more severe at higher magnetic field strengths. This difficulty can be particularly problematic for language tasks that engage regions of the temporal lobes near the air-filled sinuses. This paper investigates susceptibility-induced signal loss in the temporal lobes and proposes that by defining a priori regions of interest and using the small-volume statistical correction of K. J. Worsley, S. Marrett, P. Neelin, A. C. Vandal, K. J. Friston, and A. C. Evans (1996, Hum. Brain Mapp. 4: 58-83), activations in these areas can sometimes be detected by increasing the statistical power of the analysis. We conducted two experiments, one with PET and the other with fMRI, using almost identical semantic categorization paradigms and comparable methods of analysis. There were areas of overlap as well as differences between the PET and fMRI results. One anticipated difference was a lack of activation in two regions in the temporal lobe on initial analyses in the fMRI data set. With a specific region of interest, however, activation in one of the regions was detected. These experiments demonstrate three points: first, even for almost identical cognitive tasks such as those in this study, PET and fMRI may not produce identical results; second, differences between the two methods due to macroscopic susceptibility artifacts in fMRI can be overcome with appropriate statistical corrections, but only partially; and third, new data acquisition paradigms are necessary to fully deal with susceptibility-induced signal loss if the sensitivity of the fMRI experiment to temporal lobe activations is to be enhanced.

Task-based learning: the answer to integration and problem-based learning in the clinical years

INTRODUCTION

Integrated teaching and problem-based learning (PBL) are powerful educational strategies. Difficulties arise, however, in their application in the later years of the undergraduate medical curriculum, particularly in clinical attachments. Two solutions have been proposed - the use of integrated clinical teaching teams and time allocated during the week for PBL separate from the clinical work. Both approaches have significant disadvantages. Task-based learning (TBL) is a preferred strategy. In TBL, a range of tasks undertaken by a doctor are identified, e.g. management of a patient with abdominal pain, and these are used as the focus for learning. Students have responsibility for integrating their learning round the tasks as they move through a range of clinical attachments in different disciplines. They are assisted in this process by study guides.

METHOD

The implementation of TBL is described in one medical school. One hundred and thirteen tasks, arranged in 16 groups, serve to integrate the student learning as they rotate through 10 clinical attachments.

RESULTS

This trans-disciplinary approach to integration, which incorporates the principles of PBL offers advantages to both teachers and students. It recognizes that clinical attachments in individual disciplines can offer rich learning opportunities and that such attachments can play a role in an integrated, as well as in a traditional, curriculum. In TBL, the contributions of the clinical attachments to the curriculum learning outcomes must be clearly defined and tasks selected which will serve as a focus for the integration of the students' learning over the range of attachments.

An evaluation of CASES--an educational audit programme for orthodontists

A regional approach to a national clinical audit programme in orthodontics in the UK is described and evaluated. The programme was designed using the CRISIS criteria for effective continuing education. Programme participants completed duplicate questionnaires on 6 simulated patient scenarios, chosen for their relevance to everyday practice while posing important clinical dilemmas. The participation rate was 77% from hospital-based practitioners and 29% from specialist practitioners. Feedback to programme participants was given in the form of histograms, and provided a snapshot of national approaches to patient investigation, treatment and expected outcomes. A commentary on the data and references to appropriate articles in the literature were included. Evaluation of the programme by questionnaire survey showed that it was extensively used by hospital-based practitioners. It is concluded that the model used provided an effective and efficient framework for conducting clinical audit and delivering continuing education to the hospital-based group.

Approaches to eliminating sociocultural disparities in health

The recent flurry of studies documenting the presence of racial, ethnic, and socioeconomic disparities in health care and health have outpaced articles that describe effective strategies to eliminate disparities. Through literature review and informal interviews with research, policy, and program experts, we developed a framework of programs that address disparities through targeting clinicians, patients and communities, and health systems. We found that the lack of technical expertise, resources, and sensitive tools are all common barriers to evaluating programs. To stimulate more effective programs and rigorous evaluations, we describe specialized implementation and evaluation techniques programs can use, and make recommendations for future efforts.

Empathy, expectations, and situational preferences: personality influences on the decision to participate in volunteer helping behaviors

Although considerable evidence indicates that dispositional empathy is associated with the degree of help that observers will offer needy targets, little is known about the effect of empathy on one's initial willingness to enter situations in which such needy targets might be found. Three studies were conducted to evaluate two related propositions: (1) that dispositional empathy influences such situational preferences, and (2) that this influence is mediated by the expectancies one holds regarding the emotions likely to occur in those situations. Using hypothetical judgments, Study 1 found support for both propositions. Study 2, in which participants believed that their responses actually committed them to encountering needy targets, provided further support for the model, as did Study 3, which examined the experiences of actual community volunteers. The theoretical and practical implications of these findings are discussed.

AMEE Medical Education Guide No. 15: Problem-based learning: a practical guide

This practical guide for health professions teachers provides a perspective of one of the most important educational developments in the past 30 years.Problem-based learning (PBL) is a continuum of approaches rather than one immutable process. It is a teaching method that can be included in the teacher's tool-kit along with other teaching methods rather than used as the sole educational strategy.PBL reverses the traditional approach to teaching and learning. It starts with individual examples or problem scenarios which stimulate student learning. In so doing, students arrive at general principles and concepts which they then generalize to other situations. PBL has many advantages. It facilitates the acquisition of generic competences, encourages a deep approach to learning and prepares students for the adult learning approach they need for a lifetime of learning in the health care professions. It is also fun. PBL helps in curriculum planning by defining core, ensuring relevance of content, integrating student learning and providing prototype cases. There are also drawbacks associated with PBL. Students may fail to develop an organized framework for their knowledge. The PBL process may inhibit good teachers sharing their enthusiasm for their topic with students and student identification with good teachers.Teachers may not have the skills to facilitate PBL.The problem scenario is of crucial significance. It should engage the students' interest and be skilfully written. While the medium selected for presentation of the scenario is usually print, other media may be used.The clinical tasks carried out by the student may replace the problem scenario as the focus for learning.Students are supported during the PBL process by tutors and/or study guides.The amount of support required is inversely related to the students' prior learning and understanding of the PBL process. A range of additional learning resources and opportunities may be made available to the students, including textbooks, videotapes, computer-based material, lectures and clinical sessions. Tutors require group facilitation skills, an understanding of the PBL process and knowledge of the course and of the curriculum in general.They need special personal qualities and it is preferable if they have expertise in the content area.While special assessment processes have been developed to assess students learning by the PBL method, the general principles of assessment apply to PBL courses and a mixed menu of assessment methods needs to be employed. Curriculum design involves a skilful blend of educational strategies designed to help students achieve the curriculum outcomes. PBL may make a valuable contribution to this blend but attention needs to be paid to how it is implemented.

AMEE Guide No. 14: Outcome-based education: Part 5-From competency to meta-competency: a model for the specification of learning outcomes

Increased attention is being paid to the specification of learning outcomes.This paper provides a framework based on the three-circle model: what the doctor should be able to do ('doing the right thing'), the approaches to doing it ('doing the thing right') and the development of the individual as a professional ('the right person doing it').Twelve learning outcomes are specified, and these are further subdivided.The different outcomes have been defined at an appropriate level of generality to allow adaptability to the phases of the curriculum, to the subject matter, to the instructional methodology and to the students' learning needs. Outcomes in each of the three areas have distinct underlying characteristics.They move from technical competences or intelligences to meta-competences including academic, emotional, analytical, creative and personal intelligences. The Dundee outcome model offers an intuitive, user-friendly and transparent approach to communicating learning outcomes. It encourages a holistic and integrated approach to medical education and helps to avoid tension between vocational and academic perspectives.The framework can be easily adapted to local needs. It emphasizes the relevance and validity of outcomes to medical practice.The model is relevant to all phases of education and can facilitate the continuum between the different phases. It has the potential of facilitating a comparison between different training programmes in medicine and between different professions engaged in health care delivery.

AMEE Guide No. 14: Outcome-based education: Part 5-From competency to meta-competency: a model for the specification of learning outcomes

Increased attention is being paid to the specification of learning outcomes.This paper provides a framework based on the three-circle model: what the doctor should be able to do ('doing the right thing'), the approaches to doing it ('doing the thing right') and the development of the individual as a professional ('the right person doing it').Twelve learning outcomes are specified, and these are further subdivided.The different outcomes have been defined at an appropriate level of generality to allow adaptability to the phases of the curriculum, to the subject matter, to the instructional methodology and to the students' learning needs. Outcomes in each of the three areas have distinct underlying characteristics.They move from technical competences or intelligences to meta-competences including academic, emotional, analytical, creative and personal intelligences. The Dundee outcome model offers an intuitive, user-friendly and transparent approach to communicating learning outcomes. It encourages a holistic and integrated approach to medical education and helps to avoid tension between vocational and academic perspectives.The framework can be easily adapted to local needs. It emphasizes the relevance and validity of outcomes to medical practice.The model is relevant to all phases of education and can facilitate the continuum between the different phases. It has the potential of facilitating a comparison between different training programmes in medicine and between different professions engaged in health care delivery.

An adult with a severe Class II division 1 malocclusion: Frances' case

This article describes treatment options for an adult with a severe Class II division 1 malocclusion. The opinions of British orthodontists, as obtained through the CASES project, are summarized and the patient's actual treatment is discussed.

Relationship-specific and global perceptions of social support: associations with well-being and attachment

Is one's global sense of social support largely a summation of the support perceived to exist within current social relationships, or is it a trait-like construct independent of current support levels? To address this issue, 183 college students completed measures of global support, support from four different social domains, attachment style, and several measures of well-being. Hierarchical regression analyses revealed that for two well-being measures (global and social loneliness), both global and domain support displayed significant unique associations; for emotional loneliness, only domain support had a significant unique influence. For the well-being measure reflecting generalized negative affect, only global support displayed such a unique association. Thus, global and domain support appear to be, to a considerable degree, independent constructs, each with its own sphere of influence in affecting well-being.

An adolescent with a Class II division 2 malocclusion complicated by unerupted palatal canines: Linda's case

This article describes treatment options for a teenager with a class II division 2 malocclusion complicated by unerupted and palatally displaced upper canines. The opinions of British orthodontists, as obtained through the CASES project, are summarized and the patient's actual treatment is discussed.

Relationship-specific and global perceptions of social support: associations with well-being and attachment

Is one's global sense of social support largely a summation of the support perceived to exist within current social relationships, or is it a trait-like construct independent of current support levels? To address this issue, 183 college students completed measures of global support, support from four different social domains, attachment style, and several measures of well-being. Hierarchical regression analyses revealed that for two well-being measures (global and social loneliness), both global and domain support displayed significant unique associations; for emotional loneliness, only domain support had a significant unique influence. For the well-being measure reflecting generalized negative affect, only global support displayed such a unique association. Thus, global and domain support appear to be, to a considerable degree, independent constructs, each with its own sphere of influence in affecting well-being.

Surgery, growth modification or orthodontic camouflage? Brian's case

A skeletal class II malocclusion can be dealt with in a number of ways. The preferred option is to use orthodontic treatment and growth modification if at all possible, but in cases where this is not possible the problem might be camouflaged or treated by surgery. In the case reported here the options are fully discussed and the opinions of the orthodontists expressed in the CASES project made clear. The actual treatment undertaken is also described.

An extraction dilemma: Cheryl's case

This article describes treatment options for a teenager with a mild, although aesthetically unpleasing, malocclusion. The opinions of British orthodontists, as obtained through the CASES project, are summarized and the patient's actual treatment is discussed.

Hypodontia: George's case

Five questions are posed regarding the treatment of a patient with hypodontia. The treatment options are discussed, and the actual treatment carried out demonstrated. The treatment preferences of British Orthodontists, elicited through the CASES project, are also included.

Early treatment of Class III malocclusion? Colin's case

This is the first of six simulated case reports accompanying the questionnaire detailed in the article 'How to Do It: Making Clinical Audit Work' found earlier in this issue. You will find comprehensive discussion of the problem of making a decision about the early treatment of Class III malocclusion.

How to do it: making audit work

The orthodontic Audit Working Party of the Faculty of Dental Surgery, Royal College of Surgeons of England, in collaboration with the Centre for Medical Education, Ninewells Hospital and Medical School, Dundee developed an audit project entitled 'Clinical Audit: Scenarios for Evaluation and Study'. The aim of the project was to contribute to the construction of clinical guidelines for orthodontists. This article, the first of a short series, describes the background to and general results of the study. Further articles will study individual aspects of the project.

CASES--clinical audit; scenarios for evaluation and study

CASES, an audit and continuing education programme, evaluated aspects of current orthodontic practice and allowed orthodontists to identify areas where their practice differed from regional and national results. Evaluation of the CASES programme verified its value in audit and continuing education and the authors hope it will encourage similar projects in other disciplines too.

The new Dundee medical curriculum: a whole that is greater than the sum of the parts

The medical undergraduate curriculum at the University of Dundee has evolved in response to changing needs. The new curriculum, introduced in 1995, combines idealism and pragmatism. Underpinning it is the concept that the curriculum is an educational programme where the whole is greater than the sum of the parts. The concepts contributing to this are: the spiral nature of the curriculum, with its three interlocking phases; a body-system-based approach, with themes running through the curriculum, providing a focus for the students' learning; a core curriculum with special study modules or options; the educational strategies adopted, including elements of problem-based and community-based learning and approaches to teaching and learning that encourage the students to take more responsibility for their own learning; an approach to assessment which emphasizes the overall objectives of the course; an organization and management of the curriculum; and an allocation of resources designed to support the educational philosophy.

A physics-based coordinate transformation for 3-D image matching

Many image matching schemes are based on mapping coordinate locations, such as the locations of landmarks, in one image to corresponding locations in a second image. A new approach to this mapping (coordinate transformation), called the elastic body spline (EBS), is described. The spline is based on a physical model of a homogeneous, isotropic three-dimensional (3-D) elastic body. The model can approximate the way that some physical objects deform. The EBS as well as the affine transformation, the thin plate spline [1], [2] and the volume spline [3] are used to match 3-D magnetic resonance images (MRI's) of the breast that are used in the diagnosis and evaluation of breast cancer. These coordinate transformations are evaluated with different types of deformations and different numbers of corresponding (paired) coordinate locations. In all but one of the cases considered, using the EBS yields more similar images than the other methods.

Electroconvulsive therapy in the very old

At least one study has questioned the safety of electroconvulsive therapy (ECT) in the very old. In this study, the authors reviewed a 5-year experience with ECT at two university psychiatric services for patients 75 years of age or older. Both outcomes and complications were reviewed. Nineteen of 22 patients (86.3%) were ECT responders. Five patients (22.7%) suffered complications which varied from minor to substantial. ECT was found to be an effective and reasonably safe treatment for depression in the very old.

Effect of perspective taking on the cognitive representation of persons: a merging of self and other

Two experiments examined the possibility that perspective taking leads observers to create cognitive representation of others that substantially overlap with the observers' own self-representations. In Experiment 1 observers receiving role-taking instructions were more likely to ascribe traits to a novel target that they (observers) had earlier indicated were self-descriptive. This pattern was most pronounced, however for positively valenced traits. In Experiment 2 some participants received role-taking instructions but were also given a distracting memory task. In the absence of this task, role taking again produced greater overlap--primarily for positive traits--between self- and target representations. In the presence of the memory task, the degree of self-target overlap was significantly reduced for all traits, regardless of valence. Possible explanations for these findings are discussed.

Profile of persons with disabilities in Medicare and Medicaid

This DataView presents descriptive information on beneficiaries with disabilities in Medicare and Medicaid. Medicare data show that persons with disabilities have more functional limitations, poorer health status, lower incomes, and experience more barriers to health care than aged Medicare beneficiaries. Medicaid data reveal that significant growth in the Medicaid disabled population has led to the disabled outnumbering the Medicaid-eligible elderly. Additionally, Medicaid serves an increasingly younger disabled population and more persons with mental impairments.

Role of ambulatory care for student-patient interaction: the EPITOME model

In undergraduate medical education, a shift away from in-patient teaching towards greater use of the ambulatory care setting is occurring. This paper looks at what effect this change in emphasis might have on students' clinical competence. A log-book approach was used to study final-year orthopaedic students' opportunities to interact with patients in the wards and out-patient clinics at the University of Dundee Medical School. Students perceived that similar opportunities to interact with patients to develop and improve their clinical skills were provided by both settings. The study showed that much greater use could be made of both settings for clinical skills teaching. While students were not enthusiastic about the log-book approach, it stimulated their thinking. It is concluded that student opportunities to develop clinical skills will not be adversely affected by the trend towards ambulatory care teaching. There should be more clinical teaching in the out-patient setting.

Three decades of Medicare: what the numbers tell us

The Medicare program was first implemented to meet a critical need in American society, and over its thirty-year history it has evolved into an integral part of the U.S. health care system. This DataWatch provides a broad overview of the program, outlining both historical and current trends in coverage, financing, payment mechanisms, beneficiary status, benefits, and spending.

Two social worlds: social correlates and stability of adolescent status groups

Adolescents' peer group status in high school was examined using self-report, peer nominations, and archival data collected during 2 consecutive school years. Higher status students (popular and controversial) had more close friends, engaged more frequently in peer activities, and self-disclosed more than lower status students (rejected and neglected). They were also more involved in extracurricular school activities and received more social honors from their schoolmates. Although the higher status students were more alike than different, controversial adolescents did report more self-disclosure and dating behavior than popular students. Lower status students were also highly similar, although rejected students reported lower grades. Regarding the temporal stability of these status groups, the adolescent sample exhibited slightly higher overall stability than that found in previous investigations of younger children.

Two social worlds: social correlates and stability of adolescent status groups

Adolescents' peer group status in high school was examined using self-report, peer nominations, and archival data collected during 2 consecutive school years. Higher status students (popular and controversial) had more close friends, engaged more frequently in peer activities, and self-disclosed more than lower status students (rejected and neglected). They were also more involved in extracurricular school activities and received more social honors from their schoolmates. Although the higher status students were more alike than different, controversial adolescents did report more self-disclosure and dating behavior than popular students. Lower status students were also highly similar, although rejected students reported lower grades. Regarding the temporal stability of these status groups, the adolescent sample exhibited slightly higher overall stability than that found in previous investigations of younger children.

Topics for general dental practioner continuing education: survey of Scottish views

The provision of continuing education for general dental practitioners is expanding with a bewildering range of presentation methods and variation in quality. The first stage in the development of any educational programme should be identification of target audience needs, but little has been published on this subject. To draw the attention of providers of continuing education material to the perceived needs of general dental practitioners in one geographical region, a questionnaire survey was employed. Scottish general dental practitioners were asked to identify topics on which they needed continuing education. Sixty-five per cent responded. Conservative dentistry and periodontology were requested most frequently. The reasons for this and the wide range of topics requested are discussed.

The heritability of characteristics associated with dispositional empathy

This investigation used data from Loehlin and Nichols's (1976) study of over 800 sets of twins to examine evidence for the heritability of three facets of empathy: empathic concern, personal distress, and perspective taking. Expert judges first identified sets of adjectives, included within Loehlin and Nichols's original data, which reflected each empathy construct; these items were then validated in an independent sample. Comparisons of the responses given to these items by identical and fraternal twins in the Loehlin and Nichols investigation revealed evidence of significant heritability for characteristics associated with the two affective facets of empathy--empathic concern and personal distress--but not for the nonaffective construct of perspective taking. This pattern is consistent with the view that temperamental emotionality may underlie the heritability of affective empathy.

Obsessive-compulsive disorder responsive to electroconvulsive therapy in an elderly woman

An elderly woman with a long history of obsessive-compulsive disorder (OCD) was treated with electroconvulsive therapy (ECT) after intractable depression developed. OCD had been well established for many years before onset of the depressive symptoms. After ECT, there was resolution of both OCD and depression. The patient eventually had relapse and was treated with maintenance ECT.

Comparison of student learning in the out-patient clinic and ward round

In undergraduate medical education there is a trend away from ward-based teaching towards out-patient and community-based teaching. To study the potential effects of this altered emphasis on student learning, a pilot group of final-year medical students at the University of Dundee was asked to keep individual structured log-books. These contained details of patients seen during their 3-week orthopaedic attachment in both a ward and out-patient setting. A comparison of perceived learning in the two settings showed that students learned more from attending an out-patient clinic than a ward round, but did not make full use of the learning potential of either. The setting did not particularly influence the balance of learning as categorized here but only the ward round supplied experience of surgical complications. The amount of learning taking place in an out-patient clinic was influenced by student ability, measured by examination performance, but not by clinic work-load. The implications of increased use of out-patient clinics and the advantages and disadvantages of the approach employed are discussed. It is concluded that in the situation studied student learning in the outpatient setting is as good as or superior to the ward setting but should not totally replace it.

The quality of the new birth certificate data: a validation study in North Carolina

A random sample of 395 December 1989 North Carolina birth certificates and the corresponding maternal hospital medical records were examined to validate selected items. Reporting was very accurate for birth-weight, Apgar score, and method of delivery; fair to good for tobacco use, prenatal care, weight gain during pregnancy, obstetrical procedures, and events of labor and delivery; and poor for medical history and alcohol use. This study suggests that many of the new birth certificate items will support valid aggregate analyses for maternal and child health research and evaluation.