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Background The educational beliefs of medical educators influence their teaching practices. Insight into these beliefs is important for medical schools to improve the quality of education they provide students and to guide faculty development. Several studies in the field of higher education have explored the educational beliefs of educators, resulting in classifications that provide a structural basis for diverse beliefs. However, few classification studies have been conducted in the field of medical education. We propose a framework that describes faculty beliefs about teaching, learning, and knowledge which is specifically adapted to the medical education context. The proposed framework describes a matrix in which educational beliefs are organised two dimensionally into belief orientations and belief dimensions. The belief orientations range from teaching-centred to learning-centred; the belief dimensions represent qualitatively distinct aspects of beliefs, such as ‘desired learning outcomes’ and ‘students’ motivation’. Methods We conducted in-depth semi-structured interviews with 26 faculty members, all of whom were deeply involved in teaching, from two prominent medical schools. We used the original framework of Samuelowicz and Bain as a starting point for context-specific adaptation. The qualitative analysis consisted of relating relevant interview fragments to the Samuelowicz and Bain framework, while remaining open to potentially new beliefs identified during the interviews. A range of strategies were employed to ensure the quality of the results. Results We identified a new belief dimension and adapted or refined other dimensions to apply in the context of medical education. The belief orientations that have counterparts in the original Samuelowicz and Bain framework are described more precisely in the new framework. The new framework sharpens the boundary between teaching-centred and learning-centred belief orientations. Conclusions Our findings confirm the relevance of the structure of the original Samuelowicz and Bain beliefs framework. However, multiple adaptations and refinements were necessary to align the framework to the context of medical education. The refined belief dimensions and belief orientations enable a comprehensive description of the educational beliefs of medical educators. With these adaptations, the new framework provides a contemporary instrument to improve medical education and potentially assist in faculty development of medical educators.

Background: The educational beliefs of medical academics influence how they act in class and thus influence student learning. One component of these are beliefs academics hold about the qualities of teachers themselves. These teacher qualities range from behaviours and competencies to more personal attributes such as the teacher's identity and mission. However, it is unclear what medical academics believe to be key teacher qualities. Therefore, this study explored the variety of medical academics' beliefs about 'teacher qualities', aiming to identify and characterise profiles of academics with similar beliefs.Methods: We interviewed 26 expert academics from two medical schools to explore their beliefs about teacher qualities. A concentric onion-model focusing on teacher qualities was used to analyse and categorise the data deductively. Within each theme we developed subthemes inductively. To gain insight into the variety of beliefs we then clustered the participants into teacher profiles according to the themes. To better understand each of the profiles we carried out a quantitative study of the differences between profiles regarding subthemes, contextual and personal factors, and analysed statistical significance using Fisher's exact- and Student's t-tests for categorical and continuous data, respectively.Results: Four profiles of medical academics were identified, corresponding to the most central theme that each participant had reflected on: the 'Inspirer', 'Role-model', 'Practitioner', and 'Critic'. The focus of the profiles varied from external constraining factors within the 'Critic' profile to affective personal qualities within the 'Role-model' and 'Inspirer' profiles. The profiles could be regarded as hierarchically ordered by inclusiveness. Educational institute was the only significant factor related to the profiles.Conclusions: Besides the relevance of affective teacher qualities, the 'Inspirer' profile demonstrates the importance of developing a clear mission as a teaching academic, centred around student learning and professional development. In our view, academics who inspire their students continue to be inspired themselves.The practical implications are described for faculty development programmes, and for the potential value of using these profiles within medical schools. In the discourse on educational beliefs, the authors argue that more attention should be paid to affective qualities, in particular to explicating the educational mission of academics.

Approximately two out of three adult Americans are overweight or obese. Despite widespread recognition of this disorder, there has been little progress in the past 20 years in finding effective noninvasive treatments for weight loss. The consequences of obesity are increasingly well recognized and include increases in blood pressure, plasma lipids, the onset of type 2 diabetes, sleep apnea, asthma, osteoarthritis and a variety of cancers. Obesity can increase the rate of pregnancy complications and fetal malformations in normoglycemic women. Current medical approaches to obesity, including intensive lifestyle interventions and drug therapies, have been successful in achieving modest weight loss of 4–7%, less than the 1998 NIH Guidelines target of 10%. Surgical approaches, including laparoscopic adjustable gastric banding, vertical banded gastroplasty and Roux-en-Y gastric bypass, are much more successful, achieving weight loss of 15–50%. A treatment gap therefore exists in the management of obese and overweight patients, because many patients desire and would receive great health benefits by achieving weight loss of 7–15%. This review will discuss the dilemma of the treatment gap and explore possible ways by which it may be filled in the future by the use of innovative approaches.

OBJECTIVES The development of patient-centred attitudes by health care providers is critical to improving health care quality. A prior study showed that medical students with more patient-centred attitudes scored higher in communication skills as judged by standardised patients (SPs) than students with less patient-centred attitudes. We designed this multicentre study to examine the relationships among students' demographic characteristics, patient-centredness and communication scores on an SP examination. METHODS Early Year 4 medical students at three US schools completed a 12-item survey during an SP examination. Survey items addressed demographics (gender, ethnicity, primary childhood language) and patient-centredness. Factor analysis on the patient-centredness items defined specific patient-centred attitudes. We used multiple regression analysis incorporating demographic characteristics, school and patient-centredness items and examined the effect of these variables on the outcome variable of communication score. RESULTS A total of 351 students took the SP examination and 329 (94%) completed the patient-centredness questionnaire. Responses indicated generally high patient-centredness. Student ethnicity and medical school were significantly associated with communication scores; gender and primary childhood language were not. Two attitudinal factors were identified: patient perspective and impersonal attitude. Multiple regression analysis revealed that school and scores on the impersonal factor were associated with communication scores. The effect size was modest. CONCLUSIONS In a medical student SP examination, modest differences in communication scores based on ethnicity were observed and can be partially explained by student attitudes regarding patient-centredness. Curricular interventions to enhance clinical experiences, teaching and feedback are needed to address key elements of a patient-centred approach to care.

For more than 40 years, the faculties of Duke University School of Medicine (SOM) and Stanford University SOM have encouraged or required students to engage in scholarship as a way to broaden their education and attract them to careers in academic medicine. A dedicated period of research was first integrated into the Duke curriculum in 1959 to provide an opportunity for students to develop into physician leaders through a rigorous scholarly experience in biomedically related research. Originally designed to foster experience in laboratory-based basic research, the third-year program has evolved in response to the changing landscape of medicine and shifting needs and career interests of the medical student population. Stanford University SOM also has a long-standing commitment to biomedical research and currently requires each student to complete an in-depth, mentored "scholarly concentration." In contrast to Duke, where most of the scholarly research experiences take place in an immersive third year, the Stanford program encourages a longitudinal, multiyear exposure over all four (or five) years of medical school. Although the enduring effects of embedding a rigorous research program are not yet fully known, preliminary data suggest that these experiences instill an appreciation for research, impart research rigor and methodologies, and may motivate students to pursue careers in academic medicine. The authors discuss the histories, evolution, logistics, and ongoing challenges of the research programs at Duke University SOM and Stanford University SOM.

Abraham Flexner's 1910 report is credited with promoting critical reforms in medical education. Because Flexner advocated scientific rigor and standardization in medical education, his report has been perceived to place little emphasis on the importance of public health in clinical education and training. However, a review of the report reveals that Flexner presciently identified at least three public-health-oriented principles that contributed to his arguments for medical education reform: (1) The training, quality, and quantity of physicians should meet the health needs of the public, (2) physicians have societal obligations to prevent disease and promote health, and medical training should include the breadth of knowledge necessary to meet these obligations, and (3) collaborations between the academic medicine and public health communities result in benefits to both parties. In this article, commemorating the Flexner Centenary, the authors review the progress of U.S. and Canadian medical schools in addressing these principles in the context of contemporary societal health needs, provide an update on recent efforts to address what has long been perceived as a deficit in medical education (inadequate grounding of medical students in public health), and provide new recommendations on how to create important linkages between medical education and public health. Contemporary health challenges that require a public health approach in addition to one-on-one clinical skills include containing epidemics of preventable chronic diseases, reforming the health care system to provide equitable high-quality care to populations, and responding to potential disasters in an increasingly interconnected world. The quantitative skills and contextual knowledge that will prepare physicians to address these and other population health problems constitute the basics of public health and should be included throughout the continuum of medical education.

Web-based clinical cases ("virtual patients", VPs) provide the potential for valid, cost-effective teaching and assessment of clinical skills, especially clinical reasoning skills, of medical students. However, medical students must embrace this teaching and assessment modality for it to be adopted widely.We examined student acceptance of a web-based VP system, Web-SP, developed for teaching and assessment purposes, in a group of 15 second-year and 12 fourth-year medical students.Student acceptance of this web-based method was high, with greater acceptance in pre-clinical (second-year) compared with clinical (fourth-year) medical students. Students rated VPs as realistic and appropriately challenging; they particularly liked the ability of VPs to show physical abnormalities (such as abnormal heart and lung sounds, skin lesions, and neurological findings), a feature that is absent in standardized patients.These results document high acceptance of web-based instruction and assessment by medical students. VPs of the complexity used in this study appear to be particularly well suited for learning and assessment purposes in early medical students who have not yet had significant clinical contact.

Context Achieving competence in ‘practice-based learning’ implies that doctors can accurately self- assess their clinical skills to identify behaviours that need improvement. This study examines the impact of receiving feedback via performance benchmarks on medical students' self-assessment after a clinical performance examination (CPX). Methods The authors developed a practice-based learning exercise at 3 institutions following a required 8-station CPX for medical students at the end of Year 3. Standardised patients (SPs) scored students after each station using checklists developed by experts. Students assessed their own performance immediately after the CPX (Phase 1). One month later, students watched their videotaped performance and reassessed (Phase 2). Some students received performance benchmarks (their scores, plus normative class data) before the video review. Pearson's correlations between self-ratings and SP ratings were calculated for overall performance and specific skill areas (history taking, physical examination, doctor−patient communication) for Phase 1 and Phase 2. The 2 correlations were then compared for each student group (i.e. those who received and those who did not receive feedback). Results A total of 280 students completed both study phases. Mean CPX scores ranged from 51% to 71% of items correct overall and for each skill area. Phase 1 self-assessment correlated weakly with SP ratings of student performance (r = 0.01–0.16). Without feedback, Phase 2 correlations remained weak (r = 0.13–0.18; n = 109). With feedback, Phase 2 correlations improved significantly (r = 0.26–0.47; n = 171). Low-performing students showed the greatest improvement after receiving feedback. Conclusions The accuracy of student self-assessment was poor after a CPX, but improved significantly with performance feedback (scores and benchmarks). Videotape review alone (without feedback) did not improve self-assessment accuracy. Practice-based learning exercises that incorporate feedback to medical students hold promise to improve self-assessment skills.

Undergraduate (i.e., baccalaureate) premedical students have limited exposure to clinical practice before applying to medical school-a shortcoming, given the personal and financial resources required to complete medical training.The Stanford Immersion in Medicine Series (SIMS) is a program that streamlines the completion of regulatory requirements for premedical students and allows them to develop one-on-one mentor-mentee relationships with practicing physicians. The program, offered quarterly since 2007, is an elective available for Stanford University sophomores, juniors, and seniors. Participants apply to the program and, if accepted, receive patient rights and professionalism training. Students shadow the physician they are paired with at least four times and submit a reflective essay about their experience.SIMS program coordinators administered surveys before and after shadowing to assess changes in students' perceptions and understanding of medical careers.The authors observed, in the 61 Stanford premedical students who participated in SIMS between March and June 2010 and completed both pre- and postprogram questionnaires, significant increases in familiarity with physician responsibilities and in understanding physician-patient interactions. The authors detected no significant changes in student commitment to pursuing medicine. Student perceptions of the value of shadowing-high both pre- and post shadowing-did not change.Physician shadowing by premedical baccalaureate students appears to promote an understanding of physician roles and workplace challenges. Future studies should identify the ideal timing, format, and duration of shadowing to optimize the experience and allow students to make informed decisions about whether to pursue a medical career.

Background Erectile dysfunction in men is common. We evaluated a system by which alprostadil (prostaglandin E1) is delivered transurethrally to treat this disorder. Methods Alprostadil was delivered transurethrally in a double-blind, placebo-controlled study of 1511 men, 27 to 88 years of age, who had chronic erectile dysfunction from various organic causes. The men were first tested in the clinic with up to four doses of the drug (125, 250, 500, and 1000 μg); those who had sufficient responses were randomly assigned to treatment with either the effective dose of alprostadil or placebo for three months at home. Results During in-clinic testing, 996 men (65.9 percent) had erections sufficient for intercourse. Of these men, 961 reported the results of at least one home treatment; 299 of the 461 treated with alprostadil (64.9 percent) had intercourse successfully at least once, as compared with 93 of the 500 who received placebo (18.6 percent, P

Background Short stature in children who are not deficient in growth hormone (GH) is probably caused by a variety of defects. Some children with idiopathic short stature have low serum concentrations of GH-binding protein, which is derived from the GH receptor. The possibility that low serum concentrations of GH-binding protein might indicate partial insensitivity to GH led us to investigate possible defects in the gene for the GH receptor in children with idiopathic short stature and low serum concentrations of GH-binding protein. Methods We studied 14 children with idiopathic short stature who were selected on the basis of normal GH secretion and low serum concentrations of GH-binding protein. Analysis of single-strand conformation polymorphisms and DNA sequencing were both used to identify mutations in the GH-receptor gene. Results Mutations in the region of the GH-receptor gene that codes for the extracellular domain of the receptor were found in 4 of the 14 children, but in none of 24 normal subjects...

The actions of recombinant human insulin-like growth factor-I (rhIGF-I) and insulin were compared in 21 healthy young (24 +/- 1 yr) and 14 healthy middle-aged (48 +/- 2 yr) subjects during 3-h paired euglycemic clamp studies using one of three doses (rhIGF-I 0.2, 0.4, and 0.8 micrograms/kg.min and insulin 0.2, 0.4, and 0.8 mU/kg.min, doses chosen to produce equivalent increases in glucose uptake). In younger subjects, rhIGF-I infusions suppressed insulin by 19-33%, C-peptide by 47-59% and glucagon by 33-47% (all, P < 0.02). The suppression of C-peptide was less pronounced with insulin than with rhIGF-I (P < 0.007). The metabolic responses to rhIGF-I and insulin were remarkably similar: not only did both hormones increase glucose uptake and oxidation in a nearly identical fashion, but they also produced similar suppression of glucose production, free fatty acid levels, and fat oxidation rates. In contrast, rhIGF-I had a more pronounced amino acid-lowering effect than did insulin (P < 0.004). In middle-aged subjects, basal IGF-I levels were 44% lower (P < 0.0001) whereas basal insulin and C-peptide were 20-25% higher than in younger subjects. Age did not alter the response to rhIGF-I. However, insulin-induced stimulation of glucose uptake was blunted in older subjects (P = 0.05). Our data suggest that absolute IGF-I and relative insulin deficiency contribute to adverse metabolic changes seen in middle age.

Medical schools continually evolve their curricula to keep students abreast of advances in basic, translational, and clinical sciences. To provide feedback to educators, critical evaluation of the effectiveness of these curricular changes is necessary. This article describes a method of curriculum evaluation, called "empowerment evaluation," that is new to medical education. It mirrors the increasingly collaborative culture of medical education and offers tools to enhance the faculty's teaching experience and students' learning environments. Empowerment evaluation provides a method for gathering, analyzing, and sharing data about a program and its outcomes and encourages faculty, students, and support personnel to actively participate in system changes. It assumes that the more closely stakeholders are involved in reflecting on evaluation findings, the more likely they are to take ownership of the results and to guide curricular decision making and reform. The steps of empowerment evaluation include collecting evaluation data, designating a "critical friend" to communicate areas of potential improvement, establishing a culture of evidence, encouraging a cycle of reflection and action, cultivating a community of learners, and developing reflective educational practitioners. This article illustrates how stakeholders used the principles of empowerment evaluation to facilitate yearly cycles of improvement at the Stanford University School of Medicine, which implemented a major curriculum reform in 2003-2004. The use of empowerment evaluation concepts and tools fostered greater institutional self-reflection, led to an evidence-based model of decision making, and expanded opportunities for students, faculty, and support staff to work collaboratively to improve and refine the medical school's curriculum.

The authors describe the population health curriculum at the Stanford University School of Medicine from 2003 to 2007 that includes a requirement for first-year medical students to engage in community-based population health projects. The new curriculum in population health comprises classroom and experiential teaching methods. Population health projects, a key component of the curriculum, are described and classified by topic and topic area (e.g., health education; health services) and the intended outcome of the intervention (e.g., establishing new policies; advocacy). During the past four years, 344 students have entered the curriculum and have participated in 68 population health projects. The projects were determined both by students' interests and community needs, and they represented diverse topics: 51% of the 68 projects addressed topics in the area of disease prevention and health promotion; 28% addressed health care access; 15% addressed health services; 4% addressed emergency preparedness; and 1% addressed ethical issues in health. Each project had one of three targets for intervention: community capacity building, establishing policies and engaging in advocacy, and bringing about change or improvement in an aspect of the health care system. Projects represented diverse stages in the evolution of a community-campus partnership, from needs assessment to planning, implementation, and evaluation of project outcomes. Experience to date shows that classroom-based sessions and experiential learning in the area of population health can be successfully integrated in a medical school curriculum. When contextualized in a population health curriculum, population health projects can provide future physicians with an experiential counterpart to their classroom learning.

✓ The purpose of this study was to determine the effect of insulin-like growth factor-I (IGF-I) on the catabolic state and clinical outcome of head-injured patients. Thirty-three patients between the ages of 18 and 59 years with isolated traumatic head injury and Glasgow Coma Scale (GCS) scores of 4 to 10 were randomized to one of two groups. All patients received standard neurosurgical intensive care plus aggressive nutritional support; the patients in the treatment group also received intravenous therapy with continuous IGF-I (0.01 mg/kg/hour). During the 14-day dosing period, the control patients lost weight, whereas treated patients gained weight despite a significantly higher measured energy expenditure and lower caloric intake (p = 0.02). Daily glucose concentrations and nitrogen outputs were greater in control patients (p = 0.03) throughout the study period. During Week 1, only treated patients achieved positive nitrogen balance. Fifteen of 17 treated and 13 of 16 control patients survived the 1st week. No deaths occurred in patients whose serum IGF-I concentrations were higher than 350 ng/ml. Dichotomized Glasgow Outcome Scale scores for patients with baseline GCS scores of 5 to 7 improved from poor to good for eight of 12 treated patients but for only three of 11 control patients (p = 0.06). Eight of 11 treated patients with serum IGF-I concentrations that were at least 350 ng/ml achieved moderate-to-good outcome scores at 6 months, compared to only one of five patients with lower concentrations (p < 0.05). These findings indicate that pharmacological concentrations of IGF-I may improve clinical outcome and nitrogen utilization in patients with moderate-to-severe head injury.

Objective : To increase lean body mass and improve health status in patients with wasting associated with the acquired immunodeficiency syndrome (AIDS) by treatment with recombinant human growth hormone (rhGH), recombinant human insulin-like growth factor 1 (rhIGF-1), or both. Design : Randomized, double-blind, placebo-controlled clinical trial. Setting : University of New Mexico Clinical Research Center and University of Texas Southwestern Medical Center. Patients : 60 patients with AIDS and wasting as defined by the Centers for Disease Control and Prevention. Patients were divided into four groups of 15 patients each. Intervention : Group 1 received 1.4 mg of rhGH once daily plus placebo twice daily ; group 2 received 5 mg of rhIGF-1 twice daily plus placebo once daily ; group 3 received 5 mg of rhIGF-1 twice daily plus 1.4 mg of rhGH once daily ; and group 4 received placebo three times daily. Measurements : Body weight, body composition, muscle strength, protein catabolism, quality of life, and immune status were assessed at baseline, and changes in these variables were measured at 6 and 12 weeks. Results : At 6 weeks, lean body mass had increased and total fat mass had decreased in the groups receiving rhGH, rhIGF-1, or both. Group 3 had the greatest changes in lean body mass (mean ± SE, 3.2 ± 0.59 kg ; P < 0.001) ; only in this group were changes in body mass maintained at 12 weeks. Only patients in group 1 had improvement in muscular strength of the knees and upper body (P = 0.04) and quality of life (P = 0.01). Immunologic function did not improve in any group. Conclusions : Growth factor therapy had significantly increased lean body mass and decreased fat mass by 6 weeks, but these improvements persisted for 12 weeks only in group 3. Growth factor therapy at the dosages used in this study is not recommended because the magnitude of weight gain was modest and improvements in quality-of-life measures varied.

Multiple cDNAs belonging to the c-erbA gene family encode proteins that bind T3 with high affinity. However, the biological functions of these multiple thyroid hormone receptors have not yet been clarified. Generalized thyroid hormone resistance (GTHR) refers to a human syndrome characterized by tissue refractoriness to the action of thyroid hormones; several studies have suggested quantitative or qualitative defects in T3 binding to nuclear receptors in certain kindreds. To investigate the biological functions of the c-erbA genes, c-erbA alpha and c-erbA beta, we tested the hypothesis that an abnormal c-erbA gene product is present in GTHR by examining these genes in members of one kindred. Restriction enzyme analysis failed to identify an abnormal pattern in affected individuals suggesting no rearrangements or large deletions. However, we demonstrated that the gene conferring the GTHR phenotype is tightly linked to the c-erbA beta locus on chromosome 3. This linkage strongly suggests that the c-erbA beta gene is important in man as a thyroid hormone receptor and identifies a putative c-erbA beta mutant phenotype with central nervous system, pituitary, liver, metabolic, and growth abnormalities.

We now report successful preoperative lateralization by simultaneous bilateral inferior petrosal sinus sampling of the relevant pituitary hormones in two patients with non-ACTH-secreting microadenomas. The patients were a 23-year-old woman with a mixed pituitary tumor secreting TSH and causing hyperthyroidism and a 44-year-old man with acromegaly. Both had high-resolution CT scans without evidence of adenoma; the patient with acromegaly also had a normal MRI scan of the pituitary