Photograph as Skin, Skin as Wax: Indexicality and the Visualisation of Syphilis in Fin-de-Siècle France The William Bynum Prize Essay

In early twentieth-century France, syphilis and its controversial status as a hereditary disease reigned as a chief concern for physicians and public health officials. As syphilis primarily presented visually on the surface of the skin, its study fell within the realms of both dermatologists and venereologists, who relied heavily on visual evidence in their detection, diagnosis, and treatment of the disease. Thus, in educational textbooks, atlases, and medical models, accurately reproducing the visible signposts of syphilis - the colour, texture, and patterns of primary chancres or secondary rashes - was of preeminent importance. Photography, with its potential claims to mechanical objectivity, would seem to provide the logical tool for such representations. Yet photography's relationship to syphilographie warrants further unpacking. Despite the rise of a desire for mechanical objectivity charted in the late nineteenth century, artist-produced, three-dimensional, wax-cast moulages coexisted with photographs as significant educational tools for dermatologists; at times, these models were further mediated through photographic reproduction in texts. Additionally, the rise of phototherapy complicated this relationship by fostering the clinical equation of the light-sensitive photographic plate with the patient's skin, which became the photographic record of disease and successful treatment. This paper explores these complexities to delineate a more nuanced understanding of objectivity vis-à-vis photography and syphilis. Rather than a desire to produce an unbiased image, fin-de-siècle dermatologists marshalled the photographic to exploit the verbal and visual rhetoric of objectivity, authority, and persuasion inextricably linked to culturally constructed understandings of the photograph. This rhetoric was often couched in the Peircean concept of indexicality, which physicians formulated through the language of witness, testimony, and direct connection.

Venereology at the polyclinic: postgraduate medical education among general practitioners in England, 1899-1914

In 1899 the British Medical Journal enthusiastically announced that a new postgraduate teaching college was to open in London. The aim of the Medical Graduates' College and Polyclinic (MGC) was to provide continuing education to general practitioners. It drew upon emerging specialisms and in so doing built upon the generalist training received at an undergraduate level. Courses were intended to refresh knowledge and to introduce general practitioners to new knowledge claims and clinical practices. The establishment of postgraduate institutions such as the MGC marked an important stage in the development of medical education in England. Yet these institutions, and the emergence of postgraduate medical education more broadly, have been largely overlooked by historians. Moreover the history of venereological training among medical undergraduates and postgraduates alike has been overlooked. The study of such special subjects characterised postgraduate study. This article examines the dissemination of venereological knowledge among subscribers to MGC as an important case study for the development of institutionalised postgraduate medical education in England at the turn of the twentieth century.

Evaluation of an interactive case simulation system in dermatology and venereology for medical students

BACKGROUND

Most of the many computer resources used in clinical teaching of dermatology and venereology for medical undergraduates are information-oriented and focus mostly on finding a "correct" multiple-choice alternative or free-text answer. We wanted to create an interactive computer program, which facilitates not only factual recall but also clinical reasoning.

METHODS

Through continuous interaction with students, a new computerised interactive case simulation system, NUDOV, was developed. It is based on authentic cases and contains images of real patients, actors and healthcare providers. The student selects a patient and proposes questions for medical history, examines the skin, and suggests investigations, diagnosis, differential diagnoses and further management. Feedback is given by comparing the user's own suggestions with those of a specialist. In addition, a log file of the student's actions is recorded. The program includes a large number of images, video clips and Internet links. It was evaluated with a student questionnaire and by randomising medical students to conventional teaching (n = 85) or conventional teaching plus NUDOV (n = 31) and comparing the results of the two groups in a final written examination.

RESULTS

The questionnaire showed that 90% of the NUDOV students stated that the program facilitated their learning to a large/very large extent, and 71% reported that extensive working with authentic computerised cases made it easier to understand and learn about diseases and their management. The layout, user-friendliness and feedback concept were judged as good/very good by 87%, 97%, and 100%, respectively. Log files revealed that the students, in general, worked with each case for 60-90 min. However, the intervention group did not score significantly better than the control group in the written examination.

CONCLUSION

We created a computerised case simulation program allowing students to manage patients in a non-linear format supporting the clinical reasoning process. The student gets feedback through comparison with a specialist, eliminating the need for external scoring or correction. The model also permits discussion of case processing, since all transactions are stored in a log file. The program was highly appreciated by the students, but did not significantly improve their performance in the written final examination.

[The new German educational law for medical schools: the Hamburg concept in dermatology and venereology]

Medical school graduates are required to deal with complex situations in their future work which require profound theoretical knowledge as well as many practical skills. The University of Hamburg used a new educational law (AappO 2002) as catalyst to define learning objectives relevant for practice and to guarantee a close connection between theory and practice. A newly founded curriculum committee with twelve members developed a strategy and structure for the new clinical curriculum (KliniCuM) in weekly sessions. The subject dermatology and venereology is taught in the thematic block "The Internal and External Human Being" in integrated courses with the subjects internal medicine, pathology and pharmacology. The teaching modules (introductory lectures, symptom-oriented lectures, problem-based tutorials and bedside-teaching) are practice oriented and teach diseases and skills of dermatology which are important for "general medicine". Written and practical exams take place at the end of the block. Although there is more required attendance and increased demands on students' time, dermatology has received very positive evaluation results. Students consider their gain in knowledge and skills as very high. The new curriculum in Hamburg could provide helpful orientation for other medical faculties in changing their curricula for the subject "dermatology and venereology" according to the new educational law.

Level 2 genitourinary medicine training and ongoing supervision -- how we can all benefit

An innovative six-month, two sessions a week, funded clinical attachment programme was devised and introduced for practical training and experience to meet the demands and requirements of those wishing practical experience and training in genitourinary medicine. This has been generated by interest from previous theoretical teaching and as a desire to provide Level 2 services in the community. To date four doctors have completed this training with excellent mutual evaluation and a recognition by all involved, including commissioners, of the importance of maintaining a regular formal session while providing Level 2 community sexual health services. To be formally recognized improved evaluation, standardization and certification are required. However, if pursued, this package with continuing specialist links should prove beneficial to all involved and with the current epidemic of sexually transmitted infections will improve and enhance available services.

[The German Society for Control of Sexually Transmitted Diseases (DGBG/GBGK) 1945-1984]

The Deutsche Gesellschaft zur Bekämpfung der Geschlechtskrankheiten (German Society for Control of Sexually Transmitted Diseases) was founded in 1902. After World War II, many regional groups existed. The drafting of the Gesetz zur Bekämpfung der Geschlechtskrankheiten (Laws regarding Control of Sexually Transmitted Diseases), public education regarding the increasing rates of STDs, continuing medical education especially regarding the use of penicillin in syphilis and gonorrhea, and the major scientific advances in this field stimulated the re-formation of a national organization. Members of the new organization were important in the development of more sophisticated tests for syphilis in the 1960s, for the decrease in incidence of gonorrhea in the 1970s, and for advances in the diagnosis and treatment of mycoplasma, Chlamydia trachomatis, herpes genitalis and human papilloma viruses. This new information was also disseminated via a variety of continuing medical education activities. The hopes of the general public and physicians that such therapeutic advances would make scientific research in the area of STDs unattractive or even unnecessary proved to be overly optimistic. The worldwide epidemic of HIV/AIDS confronted the society with a new major challenge in the early 1980s.

Medical student awareness of sexual health is poor

The aim of the study was to assess sexual health knowledge of medical students. Participants from the student population of an English Medical School (University of Bristol) were asked to fill in a questionnaire on the Internet about sexual health issues. The number of correct responses to each question was analysed according to participants' gender and medical school year. While certain issues relating to sexually transmitted infections, contraception and confidentiality in HIV testing were well understood, there was poor knowledge about the failure rate of condoms, abortion rates and prevalence of chlamydia. Women knew more about the contraceptive pill than men. Although increased years of medical training had some benefit in improving the accuracy of knowledge, this effect was surprisingly small. Most medical students have inaccurate factual knowledge about certain important sexual health issues. We consider this to reflect poorly on sexual health awareness in young people in general. There is need for greater sexual health education for future doctors and for the general public.

The historical role and education of nurses for the care and management of sexually transmitted infections in the United Kingdom: 2 education and training

The beginning of the 20th century saw the first attempts to educate nurses about sexually transmitted infections (STIs) in the United Kingdom. Throughout the century, numerous individuals and organisations campaigned for improved STI awareness education for nurses. Education initiatives gradually moved from the more generic nurse training programmes to the specialist courses for genitourinary medicine (GUM) nurses. Even so, it wasn't until the 1970s that these specialist courses were successfully implemented and sustained. Following a detailed review of nursing education and STIs over the past century, this paper speculates why programmes of STI education have never been sustained for the general nursing workforce. It then considers possible developments for future education agendas that will ultimately enable nurses to contribute more readily to the challenges that national sexual health and nursing strategies currently propose.

A randomised controlled trial of the effectiveness of combining video role play with traditional methods of delivering undergraduate medical education

OBJECTIVE

To determine the effectiveness of video role play with structured feedback in improving undergraduate communication skills and application of knowledge in genitourinary medicine.

DESIGN

A blind, randomised, controlled trial.

SUBJECTS AND SETTING

Fourth year undergraduates attending a 5 week attachment in genitourinary medicine during 1997 at a London medical school.

INTERVENTION

A randomly selected sample group of undergraduates were filmed in the role of a doctor interviewing a patient (played by an actor) presenting with a genitourinary (GU) problem. Structured feedback by a GU physician and an educational psychologist was given a week later. The control group of undergraduates did not receive this training intervention.

OUTCOME MEASURES

Student performance in two stations of an objective structured clinical examination (OSCE), administered at the end of their attachment. This tested communication skills and knowledge in GU settings.

RESULTS

132 undergraduates were assessed in the OSCE. 40 of these were in the sample group who received training using video role play with feedback and 92 were in the control group. The sample group scored significantly higher marks than the control group (p<0.001).

CONCLUSIONS

Video role play with structured feedback is effective in improving undergraduate communication skills and application of knowledge in GU medicine settings.

Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy

BACKGROUND

Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care.

OBJECTIVE

To examine the relationship between choice of appropriate antiretroviral therapy (ART) to physician specialty and HIV/AIDS experience.

DESIGN

Self-administered physician survey.

PARTICIPANTS

Random sample of 2,478 internal medicine (IM) and infectious disease (ID) physicians.

MEASUREMENTS

Choice of guideline-recommended ART.

RESULTS

Two patients with HIV disease, differing only by CD4+ count and HIV RNA load, were presented. Respondents were asked whether ART was indicated, and if so, what ART regimen they would choose. Respondents' ART choices were categorized as "recommended" or not by Department of Health and Human Services guidelines. Respondents' HIV/AIDS experience was categorized as moderate to high (MOD/HI) or none to low (NO/LO). For Case 1, 72.9% of responding physicians chose recommended ART. Recommended ART was more likely (P <.01) to be chosen by ID physicians (88.2%) than by IM physicians (57.1%). Physicians with MOD/HI experience were also more likely (P <.01) to choose recommended ART than those with NO/LO experience. Finally, choice of ART was examined using logistic regression: specialty and HIV experience were found to be independent predictors of choosing recommended ART (for ID physicians, odds ratio [OR], 4.66; 95% confidence interval [95% CI], 3.15 to 6.90; and for MOD/HI experience, OR, 2.05; 95% CI, 1.33 to 3.16). Results for Case 2 were similar. When the analysis was repeated excluding physicians who indicated they would refer the HIV "patient," specialty and HIV experience were not significant predictors of choosing recommended ART.

CONCLUSIONS

Guideline-recommended ART appears to be less likely to be chosen by generalists and physicians with less HIV/AIDS experience, although many of these physicians report they would refer these patients in clinical practice. These results lend support to current recommendations for routine expert consultant input in the management of those with HIV/AIDS.

Professional development in reproductive and sexual health--a pilot study from Suffolk, UK

Staff from two neighbouring trusts working in the fields of family planning and sexual health worked together to develop joint guidelines and from this evolved a training initiative. It was acknowledged that staff were either primarily trained in family planning or in the management of sexually transmitted infections (ST1) and therefore the training would be interdisciplinary. In line with current educational thinking it was also decided to make it multiprofessional. A pilot training project was therefore set up to answer the question 'can self directed learning combined with facilitated small group study sessions provide theoretical updating for a range of health professionals within the field of reproductive and sexual health'. The project aimed to increase theoretical knowledge of contraception, sexually transmitted infections and termination of pregnancy for all relevant nursing and medical staff working within the two trusts. The stated outcome of the project was for all staff to achieve a wider core knowledge of the identified topics, regardless of whether their primary training and knowledge base was in family planning or sexually transmitted infection. The project spanned five months and offered professional development packages in hormonal contraception, non-hormonal contraception, termination of pregnancy, bacterial and minor STIs and viral STIs. The pilot project was well received and the process was shown to be an effective way of increasing the knowledge base. The knowledge shift was greatest in the opposing discipline to the primary discipline of each participant. There were added advantages in team building for staff within the same trust and networking across trusts. The strengths and weaknesses of the process were identified and used to develop ideas for future professional development initiatives.

Syndromic management of STDs in pharmacies: evaluation and randomised intervention trial

BACKGROUND

Improved clinic based syndromic management of sexually transmitted diseases (STDs) in Tanzania reduced HIV transmission. However, in many developing countries, people seek STD treatment in pharmacies. This study used standardised simulated patients (SSP) to assess STD syndromic management in pharmacies and evaluate the impact of an educational intervention.

METHODS

SSP presented syndromes of urethral discharge, genital ulcer, vaginal discharge, and pelvic inflammatory disease (PID) at 180 randomly selected pharmacies in Lima, Peru. These pharmacies were then randomised to receive or not receive education on STD recognition, management, and prevention counselling, and were again visited by SSP.

RESULTS

At 360 pharmacy visits before the intervention, syndromes most often recognised as STD related were genital ulcer (81%) and urethral discharge (73%) in men, followed by vaginal discharge (43%) and PID (6%) in women. Treatments offered to 82.5% of SSP rarely conformed to international or national guidelines (for urethral discharge, 1.5%; genital ulcer, 1%; vaginal discharge, 4%; and PID, none). Only 20.5% of SSP were referred to a physician and 30% received any counselling. The intervention reached 55% of pharmacies, and produced a small but significant increase in counselling; by "intent to intervene" analysis, intervention pharmacies provided post-counselling more often than did controls (40% v 27%, p = 0.01).

CONCLUSION

Pharmacies usually failed to recognise STD syndromes in women, and usually provided treatment, most often with ineffective regimens. Educational interventions improved counselling. More effective interventions are needed to improve STD recognition, treatment, and referral practices.

Adapting an effective primary care provider STD/HIV prevention training programme

Sexually acquired human immunodeficiency virus (HIV) infection continues to be the major source of HIV infection in the USA. Preventing sexual transmission of HIV can be accomplished through patient behaviour change. Such behaviour change can also decrease risk of other sexually transmitted diseases (STDs) and unwanted pregnancies, both far more common problems than HIV infection. Primary care physicians and other providers can increase patients' safe sex practices by conducting effective sexual risk assessment (RA) and risk reduction (RR) counselling, but physicians both infrequently and incompletely do sexual RA and RR. A programme was developed to improve primary care physicians' prevention practice using Simulated Patient Instructors (SPIs) and mailed educational materials. Programme evaluations showed improved sexual RA and RR practice both by self-report as well as by observation by Simulated Patient Evaluators (SPEs). This paper briefly reviews these findings and then presents adaptations made to improve the programme's content, decrease its cost and increase its availability for training many other care providers. Evaluation of the adapted programme indicates that content and training methods are highly regarded by a diverse array of trainees. To disseminate the modified programme beyond the local area, a Train-the-Trainer programme and manual have been developed, including discussion of recruiting, training and using SPIs for sexual risk reduction. Wider use of this training, as well as more effective and more readily available STD/HIV prevention training, are needed to attain national goals of provider clinical prevention practice.

Venus and Freud: an educational opportunity?

OBJECTIVE

To discuss the importance of genitourinary medicine as a core component for a new problem based medical undergraduate curriculum and to describe the advantages of consensus group method as a means of identifying learning objectives for an integrated course.

METHODS

A group of experts in the field of sexual health was convened around the module on sexual health. It was led by a genitourinary specialist and aided by a curriculum facilitator. Group contributors represented a wide variety of disciplines and included a medical student. The group met on three occasions for 1.5 hours.

RESULTS

The identified learning objectives are presented under the course themes. The values and relevance of the individual objectives are discussed with particular reference to an integrated curriculum which combines clinical and basic science in a problem based learning (PBL) format. The communication skills and attitudes necessary to take a competent sexual history are stressed. Links with other relevant modules in the PBL curriculum are described to show how the topic of sexual health develops throughout the course. Learning methods, resources and assessment procedures are also outlined.

CONCLUSION

The educational potential of sexual health and behaviour as a core topic for a novel integrated course is considerable and merits a greater importance than it appears to receive in current undergraduate courses.

[Teaching of dermatology and venereology in Warsaw before the establishment of the first departments of these specialties in Poland]

Teaching and scientific activities were discussed of the outstanding surgeons and internists lecturing on dermatology and venereology at the Academic Faculty of Medicine existing in the years 1809-1816 and at the Faculty of Medicine of The Warsaw University closed by the tsarist authorities after the November Insurrection in 1831. The academic school of medicine could begin its work after a pause of 25 years in 1857 as The Medical-Surgical Academy transformed in 1862 into The Medical Faculty of The Central School closed definitely in 1869 when a Russian university was founded in its place. Those who rendered the greatest services in the development of dermatology and venereology in Warsaw were, among others, Józef Czekierski, Andrzej Janikowski, Antoni Le Brun, and Polikarp Girsztowt, and in the first place Bronisław Chojnowski who raised it to the rank of a clinical discipline. After closing of The Central School the main center for the Polish dermatologists and venereologists was The St. Lazarus Hospital.