Validity and Reliability of the Scale to Report Emotional Stress Signs–Multiple Sclerosis (STRESS-MS) in Assessing Abuse and Neglect of Adults With Multiple Sclerosis

Background:

Approximately 30% of people with multiple sclerosis (MS) require caregiving, with unknown prevalence of abuse and neglect. To explore these issues, we created the Scale to Report Emotional Stress Signs–Multiple Sclerosis (STRESS-MS). The objective was to develop, validate, and field-test a self-report questionnaire for screening people with MS for mistreatment.

Methods:

We developed the STRESS-MS questionnaire and administered it to 102 adults with advanced MS-related disability and 97 primary informal caregivers, correlating responses with direct observation of mistreatment, conducting an item analysis, and evaluating validity using a Longitudinal, Expert, All Data (LEAD) panel.

Results:

Most STRESS-MS subscales correlated highly with criterion-standard LEAD panel evaluations of mistreatment, with strong concurrent and discriminant validity. Nearly 53% of participants with MS reported experiencing psychological abuse; 9.8%, financial exploitation; 6.9%, physical abuse; 4.9%, neglect; and 3.9%, sexual abuse. Protective factors for people with MS included social support and older age; risk factors included depression and aggressiveness. The greatest risk factor was an informal caregiver who spent 20 or more hours per week caring for the person with MS.

Conclusions:

The STRESS-MS questionnaire is reasonably reliable and valid for detecting caregiver mistreatment in adults with MS. Although most informal caregivers are not abusive, this study highlights an underrecognized need to detect and prevent abuse and neglect of people with MS.

How the COVID-19 Pandemic has changed multiple sclerosis clinical practice: Results of a nationwide provider survey

Background

The COVID-19 crisis has created unanticipated changes in health care delivery for people living with multiple sclerosis (MS). The pandemic's rapid evolution has resulted in a knowledge gap in how COVID-19 has affected MS clinical practice. Our objective was to understand how the COVID-19 pandemic has affected clinical practice patterns in a nationwide cohort of MS clinicians across the United States.

Methods

In collaboration with the National Multiple Sclerosis Society (NMSS), we developed a 28-item SurveyMonkey^TM electronic questionnaire exploring MS specialists’ perceptions of how COVID-19 has altered how they prescribe MS disease-modifying therapies (DMTs), provide telehealth and other services, and view issues affecting their own well-being including re-deployment to the front lines of COVID-19 care and availability of personal protective equipment (PPE). NMSS staff sent a recruitment email containing the electronic survey link to 188 clinicians who serve on regional NMSS Healthcare Provider Councils across the US, 86 (45.7%) of whom were MS specialist physicians.

Results

Eighty-six of 188 potential respondents (45.7%) from 32 US states completed the survey including 45 physicians (41 neurologists, 3 physiatrists and 1 family physician), 18 rehabilitation therapists, 7 psychologists, 6 nurse practitioners, 4 social workers, 2 physician assistants, 2 nurses and 2 health professionals from other disciplines. More than 80% of all respondents working on-site in a health care setting believed they had adequate PPE. More than 41% were able to distance safely from others at work. Nearly 10% of respondents reported they had been re-deployed to the front lines of COVID-19 patient care, and an additional 16.9% anticipated being re-deployed. Among the MS specialist physician subgroup, nearly one-third reported using telemedicine to provide over 75% of their clinical care. Only 16.7% believed COVID-19 had not changed how they prescribe DMTs. Therapies prescribed more often during the pandemic included β-IFNs (28.6% of prescribers), natalizumab (23.8%), glatiramer acetate (21.4%) and teriflunomide (19%). DMTs prescribed less often included alemtuzumab (64.3% of prescribers), cladribine (54.8%), ocrelizumab and rituximab (50%), and fingolimod and siponimod (40.5%). For at least some of their patients during the pandemic, some MS specialists reported suspending certain DMTs including alemtuzumab (21.4% of prescribers), ocrelizumab and rituximab (16.7%) and cladribine (11.9%). Others reported extending DMT dosing intervals for natalizumab (38.1%), fingolimod and siponimod (11.9%).

Conclusions

In this nationwide survey, MS specialist physicians and other clinicians serving on regional NMSS Healthcare Provider Councils across the US reported profound changes in how they are delivering MS care during the COVID-19 pandemic.

Abuse and neglect of people with multiple sclerosis: A survey with the North American Research Committee on Multiple Sclerosis (NARCOMS)

BACKGROUND

An estimated 100,000 Americans with advanced multiple sclerosis (MS) are at risk of mistreatment, yet we lack national prevalence data on abuse and neglect. Our objective was to determine the incidence and prevalence of caregiver abuse and neglect among U.S. adults with advanced MS.

METHODS

Through an anonymous telephone survey with the North American Research Committee on Multiple Sclerosis (NARCOMS), we administered the validated Scale to Report Emotional Stress Signs - Multiple Sclerosis (STRESS-MS) and other study measures to 206 U.S. adults who had unpaid caregivers because of MS-related disability.

RESULTS

54.9% of respondents disclosed undergoing some form of mistreatment since first requiring caregiving by a family member or friend, including psychological abuse (44.2%), financial abuse (25.2%), neglect (16.5%), physical abuse (11.2%) or sexual abuse (8.3%). Many had experienced multiple forms of mistreatment. Mistreated respondents reported less social support, more alcohol use, and higher levels of fatigue and cognitive impairment. Daily caregiving increased mistreatment risk. Caregivers with mental illness were 13 times more likely to be abusive or neglectful. Poor premorbid relationships with caregivers nearly tripled mistreatment risk, while any significant alcohol use history by people with MS or caregivers doubled risk.

CONCLUSIONS

In a nationwide survey, over 50% of American adults with advanced MS reported mistreatment by caregivers.

Changing trends in residents-as-teachers across graduate medical education

BACKGROUND

Teaching residents how to teach is a critical part of residents' training in graduate medical education (GME). The purpose of this study was to assess the change in resident-as-teacher (RaT) instruction in GME over the past 15 years in the US.

METHODS

We used a quantitative and qualitative survey of all program directors (PDs) across specialties. We compared our findings with a previous work from 2000-2001 that studied the same matter. Finally, we qualitatively analyzed PDs' responses regarding the reasons for implementing and not implementing RaT instruction.

RESULTS

Two hundred and twenty-one PDs completed the survey, which yields a response rate of 12.6%. Over 80% of PDs implement RaT, an increase of 26.34% compared to 2000-2001. RaT instruction uses multiple methods with didactic lectures reported as the most common, followed by role playing in simulated environments, then observing and giving feedback. Residents giving feedback, clinical supervision, and bedside teaching were the top three targeted skills. Through our qualitative analysis we identified five main reasons for implementing RaT: teaching is part of the residents' role; learners desire formal RaT training; regulatory bodies require RaT training; RaT improves residents' education; and RaT prepares residents for their current and future roles.

CONCLUSION

The use of RaT instruction has increased significantly in GME. More and more PDs are realizing its importance in the residents' formative training experience. Future studies should examine the effectiveness of each method for RaT instruction.

The impact of an objective structured teaching evaluation on faculty teaching skills

BACKGROUND

Objective structured teaching evaluations (OSTEs) have been utilized to evaluate educational curricula and for resident and faculty development.

PURPOSE

This study examines the impact of an OSTE on faculty teaching effectiveness and faculty satisfaction.

METHODS

From 2004 to 2007, 46 faculty members participated in the OSTE. Faculty assessed their teaching abilities with a retrospective pre-post-test analysis. Faculty teaching evaluations for the 6 months before and after the OSTE were compared. Faculty participants completed satisfaction questionnaires regarding their OSTE experience and made teaching plans for the future.

RESULTS

After the OSTE, faculty reported statistically significant improvements in all self-assessed teaching skills. There was, however, no improvement in their teaching evaluations. Faculty satisfaction with the OSTE experience was high. They indicated teaching plans incorporating lessons from the OSTE.

CONCLUSIONS

Faculty felt the OSTE was a rewarding experience and reported improvement in their teaching abilities; however, faculty teaching evaluations did not improve.

Outpatient oral misoprostol for prolonged pregnancies: a pilot investigation

We evaluated the effectiveness of oral misoprostol for outpatient cervical ripening and labor induction in prolonged pregnancies. We performed a randomized, double-blind, placebo-controlled study of women at 40 to 42 weeks' gestation with well-dated pregnancies, singleton gestations, Bishop scores less than 6, vertex presentations, and intact membranes. Subjects received either oral misoprostol 100 microg or placebo daily for 3 days unless the subject developed significant cervical change or began labor spontaneously. Study drug was repeated every 24 hours for a maximum of three doses if subjects did not develop significant cervical change or enter labor. Induction of labor was not allowed while the subject was enrolled in the study. Forty-three subjects were randomized to receive misoprostol and 44 randomized to receive placebo. A significant difference was noted in reduction of time from study entry to both active phase (p < 0.001) and delivery (p < 0.001) in the misoprostol group. Fewer women remained undelivered after the 72-hour study period in the misoprostol group. There were no differences in route of delivery or neonatal outcomes between groups.

CONCLUSION

Daily administration of oral misoprostol over 3 days to women with prolonged pregnancies shortened time intervals from dosing to entry into active labor and delivery compared with placebo.

Attributes of effective community preceptors for pre-clerkship medical students

BACKGROUND

Attributes of effective precepting of pre-clerkship medical students in community settings are not adequately described. As part of preceptor needs assessment, we conducted site visits over three consecutive years. We also measured the preceptorships' educational quality, using students' post-rotation data, to identify priority areas for faculty development, corroborate site visit findings, and assess functions of the site visit.

METHODS

Three university faculty directly observed teaching encounters in 83 community preceptors' offices during a 12-18-week second year (pre-clerkship) medical student rotation. Data were collected on practice demographics, teaching content, and educational quality, using multiple measures. Narrative responses to interview questions were coded for prevalent themes. Student post-rotation assessments were obtained by anonymous online evaluations.

RESULTS

Good precepting attributes and suggestions for improvement were identified from both narrative analysis and student post-rotation evaluations in these key areas: independence in patient assessment, time spent teaching, giving feedback and orientation to the preceptor's practice. Student evaluations of preceptors' effectiveness significantly improved from year 1 to 2 and persisted into year 3. Appropriate faculty development strategies were derived from the combined results.

CONCLUSIONS

The site visit by university faculty allows real-time observation and may itself be an effective intervention for improving teaching and learning.

Primary care for adults with physical disabilities: perceptions from consumer and provider focus groups

BACKGROUND AND OBJECTIVES

Family physicians lack data on how best to address the needs of adults with physical disabilities. We undertook this study to understand how consumers, educators, and other professionals perceive primary care for people with disabilities.

METHODS

We conducted six focus groups, three with 27 health professionals in primary care practices affiliated with an urban university medical center and three with 19 local adults, ages 21-64 years, with physical disabilities. From transcribed recordings, three investigators conducted separate content analyses. Independent author reviews and participant review confirmed saturation and agreement for major themes.

RESULTS

All groups perceived that generalist physicians and other health professionals need more education about disability issues. Multiple barriers limit care, including physical access and transportation, funding, limitations in professionals' knowledge and attitudes, communication gaps, and health systems failures. Both consumers and professionals recommended reducing barriers by educating professionals and trainees about disabilities and resources, improving provider-patient communication, enhancing physical access (eg, high-low examination tables, wide automatic doors, high-contrast signs and lighting, wheelchair scales), and increasing appointment times.

CONCLUSIONS

Primary care must address the unmet needs of people with disabilities. Family medicine educators can begin by teaching learners how to coordinate care, access resources, and communicate about disability issues.

Student perceptions of the one minute preceptor and traditional preceptor models

BACKGROUND

The one-minute preceptor (OMP) model was developed to effectively and efficiently teach learners while simultaneously addressing patient needs. This study was conducted to determine if third- and fourth-year medical students prefer the OMP model over the traditional precepting model and what teaching points they needed from the clinical encounters.

METHODS

Third- and fourth-year students (N = 164) at two medical schools completed a questionnaire and prompts on teaching points in response to viewing two videotaped precepting encounters. Differences between OMP and traditional precepting scores were computed using a factorial repeated measures analysis of co-variance (ANCOVA). Teaching points were coded and counted.

RESULTS

Students preferred the OMP precepting model to the traditional teaching model (p = 0.001). While the desired teaching points changed as the case presentation/discussion progressed, students were most interested in learning about the clinical presentation or natural progression of the disease regardless of teaching model used.

CONCLUSIONS

Students rate the OMP as a more effective model of teaching than the traditional model. The teaching points desired by students change as the case presentation/discussion unfolds. Work carried out at: University of California, San Francisco, Office of Medical Education and University of California, Irvine, Department of Family Medicine.

Facilitating collaboration among academic generalist disciplines: a call to action

To meet its population's health needs, the United States must have a coherent system to train and support primary care physicians. This goal can be achieved only though genuine collaboration between academic generalist disciplines. Academic general pediatrics, general internal medicine, and family medicine may be hampering this effort and their own futures by lack of collaboration. This essay addresses the necessity of collaboration among generalist physicians in research, medical education, clinical care, and advocacy. Academic generalists should collaborate by (1) making a clear decision to collaborate, (2) proactively discussing the flow of money, (3) rewarding collaboration, (4) initiating regular generalist meetings, (5) refusing to tolerate denigration of other generalist disciplines, (6) facilitating strategic planning for collaboration among generalist disciplines, and (7) learning from previous collaborative successes and failures. Collaboration among academic generalists will enhance opportunities for trainees, primary care research, and advocacy; conserve resources; and improve patient care.

Resident doctors' understanding of their roles as clinical teachers

INTRODUCTION

Limited data illuminate how resident doctors view their important roles as teachers, supervisors and role models. Analysing qualitative data about resident teachers' self-perceptions can offer helpful insights.

METHODS

One year after a randomised trial of a residents-as-teachers curriculum at a university medical centre, we invited its 23 resident participants to participate in semistructured interviews. We interviewed 21 third year residents from internal medicine, family medicine and paediatrics, including 12 intervention residents who had been randomly assigned to receive a 13-hour teacher training programme and 9 control residents who had received no training. We used grounded theory techniques. Two investigators independently content-analysed the transcribed interviews for emerging themes and we then developed a schema for a third investigator to code the transcripts.

RESULTS

Three key themes consistently emerged: enthusiasm for teaching (current and future), learner-centredness, and self-knowledge about teaching. Compared with control residents, the intervention residents expressed greater enthusiasm for teaching, more learner-centred and empathic approaches, and a richer understanding of teaching principles and skills. Most intervention residents wanted to continue teaching during and after training. Fewer control residents enjoyed their current teaching, and fewer still wanted to teach in the future. The control residents seemed easily frustrated by time constraints and they often expressed cynicism and blame toward learners.

DISCUSSION

One year after participating in a randomised trial of a residents-as-teachers curriculum, generalist residents revealed fairly consistent perceptions of their teaching roles. Teacher training may offer residents lasting benefits, including improved teaching skills and satisfaction.

The on-line Clinical Teaching Perception Inventory: a "snapshot" of medical teachers

BACKGROUND AND OBJECTIVES

Medical educators need practical and accurate instruments for evaluating clinical teaching. Our purpose was to develop norms for the Clinical Teaching Perception Inventory (CTPI) on a multidisciplinary group of North American faculty and resident teachers.

METHODS

A no-cost, on-line inventory (www.residentteachers.com) measured participants' comfort with teaching. Respondents recruited through surveys and professional organizations completed two identical Q-sorts, ranking 28 descriptors first for "my ideal teacher" and then for "myself as a teacher."

RESULTS

An international sample of 255 residents and 256 faculty members--including 143 respondents from family medicine--completed the on-line CTPI from April 2001 to March 2003. Resident and faculty teachers agreed on top descriptors for ideal clinical teachers: stimulating, encouraging, competent, communicates, and well-read. Resident teachers revealed larger discrepancies between "self" and "ideal" scores than faculty participants did. Many respondents wished to be more stimulating and well-read, highlighting perceived needs for teaching skills development. Between the subsamples of 143 family medicine teachers and 368 non-family medicine teachers, scores were virtually indistinguishable.

CONCLUSIONS

A multidisciplinary sample of 511 faculty and resident teachers agreed on key characteristics of ideal clinical teachers. Generalist educators and others can use the on-line CTPI at no cost to assess their self-perceptions as clinical teachers.

The effect of a 13-hour curriculum to improve residents' teaching skills: a randomized trial

BACKGROUND

Although resident physicians often teach, few trials have tested interventions to improve residents' teaching skills. A pilot trial in 2001-2002 found that 13 trained resident teachers taught better than did untrained control residents.

OBJECTIVE

To determine whether a longitudinal residents-as-teachers curriculum improves residents' teaching skills.

DESIGN

Randomized, controlled trial from May 2001 to February 2002 (pilot trial) and March 2002 to April 2003.

SETTING

4 generalist residencies affiliated with an urban academic medical center.

PARTICIPANTS

62 second-year residents: 23 in the 2001-2002 pilot trial and 39 more in 2002-2003; 27 of the 39 participants were medicine residents required to learn teaching skills.

INTERVENTION

A 13-hour curriculum in which residents practiced teaching and received feedback during 1-hour small-group sessions taught twice monthly for 6 months.

MEASUREMENTS

A 3.5-hour, 8-station, objective structured teaching examination that was enacted and rated by 50 medical students before and after the intervention. Two trained, blinded raters independently assessed each station (inter-rater reliability, 0.75).

RESULTS

In the combined results for 2001-2003, the intervention group (n = 33) and control group (n = 29) were similar in sex, specialty, and academic performance. On a 1 to 5 Likert scale, intervention residents outscored controls on overall improvement score (post-test-pretest difference, 0.74 vs. 0.07; difference between intervention and control groups, 0.68 [95% CI, 0.55 to 0.81]; P < 0.001) by a magnitude of 2.8 standard deviations and on all 8 individual stations. The intervention residents improved 28.5% overall, whereas the scores of control residents did not increase significantly (2.7%). In 2002-2003, 19 intervention residents similarly outscored 19 controls (post-test-pretest difference, 0.83 vs. 0.14; difference between intervention and control groups, 0.69 [CI, 0.53 to 0.84]; P < 0.001). Twenty-seven medicine residents required to learn teaching skills achieved scores similar to those of volunteers.

LIMITATIONS

The study was conducted at a single institution. No "real life" assessment with which to compare the results of the objective structured teaching examination was available.

CONCLUSIONS

Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved teaching skills, as judged by medical student raters. Residents required to participate improved as much as volunteers did.

Evaluating a 'service elective' in clinical teaching for medical students

Many medical students wish to begin developing clinical teaching skills before residency. Faculty at the University of California, Irvine developed a 60-hour, longitudinal 'service elective' in teaching skills, which 50 third-year and fourth-year students have completed since 2001. Students learned to enact and rate eight stations of an objective structured teaching examination (OSTE) for generalist resident physicians, broadening this practical training with in-class exercises. To evaluate the elective, structured, written questionnaires were administered. Participating students gave the elective a mean rating of 5.24 on a seven-point Likert-type scale, which fell between 'very good' (5) and 'excellent' (6). Narrative comments showed that students believed the elective--and in particular the OSTE training--prepared them well for teaching as residents.

A pilot randomized, controlled trial of a longitudinal residents-as-teachers curriculum

PURPOSE

To determine whether a longitudinal residents-as-teachers curriculum improves generalist residents' teaching skills.

METHOD

From May 2001 to February 2002, 23 second-year generalist residents in four residencies affiliated with the University of California, Irvine, College of Medicine, completed a randomized, controlled trial of a longitudinal residents-as-teachers program. Thirteen intervention residents underwent a 13-hour curriculum during one-hour noon conferences twice monthly for six months, practicing teaching skills and receiving checklist-guided feedback. In a 3.5-hour, eight-station objective structured teaching examination (OSTE) enacted and rated by 15 senior medical students before and after the curriculum, two trained, blinded raters independently assessed each station with detailed, case-specific rating scales (rating scale reliability = 0.96, inter-rater reliability = 0.78).

RESULTS

The intervention and control groups were similar in academic performance, specialty distribution, and gender (chi(2) = 0.434, p =.81). On a five-point Likert scale (5 = best teaching skills), intervention and control residents showed similar mean pretest OSTE scores (2.83 vs. 2.88, p =.736). The intervention group improved their mean overall OSTE scores 22.3% (more than two standard deviations) from 2.83 (pretest) to 3.46 (post-test; p <.0005; 95% CI 0.53 to 0.72). Intervention residents also improved significantly on six of eight OSTE stations. Within the control group, no pretest-to-post-test change achieved statistical significance. Mann-Whitney and Wilcoxon signed-rank tests confirmed these results.

CONCLUSIONS

Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved OSTE scores. Future research should clarify which aspects of residents-as-teachers curricula most effectively improve educational outcomes.

Primary care resident, faculty, and patient views of barriers to cultural competence, and the skills needed to overcome them

INTRODUCTION

Primary care residencies are expected to provide training in cultural competence. However, we have insufficient information about the perceptions of stakeholders actually involved in healthcare (i.e. residents, faculty and patients) regarding commonly encountered cross-cultural barriers and the skills required to overcome them.

METHOD

This study used a total of 10 focus groups to explore resident, faculty and patient attitudes and beliefs about what culturally competent doctor-patient communication means, what obstacles impede or prevent culturally competent communication, and what kinds of skills are helpful in achieving cultural competence. A content analysis was performed to identify major themes.

RESULTS

Residents and faculty defined culturally competent communication in terms of both generic and culture-specific elements, however, patients tended to emphasize only generic attitudes and skills. Residents and patients were liable to blame each other in explaining barriers; faculty were more likely to consider systemic influences contributing to resident-patient difficulties. All groups emphasized appropriate skill and attitude development in learners as the key to successful communication. However, residents were sceptical of sensitivity and communication skills training, and worried that didactic presentations would result in cultural stereotyping.

DISCUSSION

All stakeholders recognized the importance of effective doctor-patient communication. Of concern was the tendency of various stakeholders to engage in person-blame models.

Reach out and teach someone: generalist residents' needs for teaching skills development

BACKGROUND AND OBJECTIVES

Family practice residents and students receive substantial teaching from senior residents. Yet, we lack data about residents' needs for teaching skills development, particularly in generalist training. This multicenter, interdisciplinary study describes the learning needs of generalist residents for becoming more effective teachers.

METHODS

One hundred medical students, residents, and faculty infamily medicine, internal medicine, and pediatrics participated in 11 focus groups and 4 semi-structured key informant interviews at the University of California, Irvine and the University of California, Los Angeles in 2000-2001.

RESULTS

Participants agreed that resident teachers fulfill critical roles in medical education, providing powerful, skills-based teaching that can tangibly benefit both residents themselves and their junior learners. House staff often facilitate students' best learning experiences despite inherent risks in serving as teachers and professional role models. Residents need teaching skills training that prepares them to lead clinical teams and teach students essential skills that include history taking and physical examination, critical reasoning, charting, and procedures.

CONCLUSIONS

Generalist residents fulfill important roles as practical clinical teachers and role models for junior learners. Future research should address how resident teachers affect learners' clinical skills, academic performance, and professionalism.

Medical students' note-taking in a medical biochemistry course: an initial exploration

Beginning medical students spend numerous hours every week attending basic science lectures and taking notes. Medical faculty often wonder whether they should give students pre-printed instructors' notes before lectures. Proponents of this strategy argue that provided notes enhance learning by facilitating the accurate transmission of information, while opponents counter that provided notes inhibit students' cognitive processing or even discourage students from attending lectures. Little if any research has directly addressed medical students' note-taking or the value of providing instructors' notes. The educational literature does suggest that taking lecture notes enhances university students' learning. University students perform best on post-lecture testing if they review a combination of provided notes and their own personal notes, particularly if the provided notes follow a 'skeletal' format that encourages active note-taking.

The primary care specialties working together: a model of success in an academic environment

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

Periconception care

If we are to provide periconception care to all American men and women of reproductive age, we must consider it all "routine visits." For prevention of birth defects, all reproductive-age women should be counseled about folic acid supplementation and rubella immunity. Many clinicians consider risk reduction and anticipatory activities important in periconception care. This includes counseling families about avoiding tobacco and substance abuse, using passenger restraints, avoiding teratogens, seeking appropriate genetic counseling and early prenatal care, and a variety of other periconceptional health issues. Reproductive-age women with underlying medical problems should be identified and counseled about pregnancy risks.

Yesterday a learner, today a teacher too: residents as teachers in 2000

Resident physicians spend numerous hours every week teaching medical students and fellow residents, and only rarely are they taught how to teach. They can, however, be taught to teach more effectively. Teaching skills improvement initiatives for residents are taking a more prominent place in the educational literature. Limited evidence now suggests that better resident teachers mean better academic performance by learners. A small but important body of research supports selected interventions designed to improve residents' teaching skills, but not all studies have demonstrated significant educational benefits for learners. An increasing number of valid and reliable instruments are available to assess residents' clinical teaching, including objective structured teaching examinations and rating scales. In all specialties, rigorous research in evidence-based teacher training for residents will help prepare academic medical centers to meet the diverse and changing learning needs of today's physicians-in-training.

Common peripartum emergencies

Peripartum emergencies occur in patients with no known risk factors. When the well-being of the fetus is in question, the fetal heart rate pattern may offer etiologic clues. Repetitive late decelerations may signify uteroplacental insufficiency, and a sinusoidal pattern may indicate severe fetal distress. Repetitive variable decelerations suggesting umbilical cord compression may be relieved by amnioinfusion. Regardless of the etiology of the nonreassuring fetal heart pattern, measures to improve fetal oxygenation should be attempted while options for delivery are considered. Massive obstetric hemorrhage requires prompt action. Clinical signs, such as painless bleeding, uterine tenderness and nonreassuring fetal heart patterns, may help to differentiate causes of vaginal bleeding that may or may not require emergency cesarean delivery. The causes of postpartum hemorrhage include uterine atony, vaginal or cervical laceration, and retained placenta. The challenge of managing shoulder dystocia is to effect a rapid delivery while avoiding neonatal and maternal morbidity. The McRoberts maneuver has been shown to be the safest and most successful technique for relieving shoulder dystocia. Eclampsia responds best to magnesium sulfate, supportive care and supplemental hydralazine or labetalol as needed for severe hypertension.

Controversies in women's health maintenance

Because the health care system has become more cost-conscious, and because professional organizations vary in their recommendations for women's health maintenance, it is more important than ever to use an evidence-based approach for selecting health maintenance interventions wisely. The Papanicolaou smear is a gold standard for cancer screening if women undergo regular testing; however, data conflict on how often women should be screened and how risk factors for cervical cancer should be interpreted. Postmenopausal estrogen replacement therapy slows osteoporotic bone loss and may decrease a woman's relative risk of coronary artery disease. The relationship of hormone replacement therapy (estrogen plus progestin) to the risk of breast cancer still remains unclear. Although new data suggest that screening mammography may reduce breast cancer mortality by 20 percent or more in women over 40 years of age, its use in women who are 40 to 49 years of age is still controversial. Family physicians, as advocates for women's health, are ideally positioned for leadership roles in the policy making that may ultimately find solutions to these controversial issues.

The development of articular cartilage: II. The spatial and temporal patterns of glycosaminoglycans and small leucine-rich proteoglycans

Articular cartilage is both morphologically and biochemically heterogeneous. Its susceptibility to degenerative diseases such as arthritis and its limited repair capacity has made cartilage the focus of intense study; surprisingly, little is known of its development. Using a panel of specific antibodies, we have documented the temporal and spatial patterns of the small leucine-rich proteoglycans fibomodulin, decorin and biglycan in the developing knee cartilage of the marsupial South American opposum (Monodelphis domestica) from parturition to adulthood. The major proteoglycan of cartilage, aggrecan, can be substituted with a variety of isomers of chondroitin sulphate (CS) and keratan sulphate (KS) glycosaminoglycans. Consequently, we have used monoclonal antibodies to determine the distribution of the chondroitinase generated epitopes of CS isomers (delta di-6S and delta di-4S oligosaccharide 'stubs'). Other monoclonal antibodies (3B3[-], 7D4) were used to investigate temporal changes in the expression of specific sulphation patterns within native chondroitin sulphate chains in addition to keratan sulphate chains (5D4). We found the distributions of the small proteoglycans (PGs) to be highly dynamic during development. Both fibromodulin and biglycan appeared to specifically label early articular cartilage as opposed to epiphyseal or growth plate cartilage. All 3 small PGs become preferentially distributed to the upper half of the adult articular cartilage depth. Similarly, delta di-6S, delta di-4S oligosaccharide 'stubs', KS and epitope 7D4 were variably distributed during development but all were again preferentially located to the upper depth of the mature tissue. The epitope recognised by antibody 3B3[-] was extensively distributed in the neonate, but became more restricted to hypertrophic chondrocytes by day 19. It was not detected in the adult tissue. These data suggest that in Monodelphis, proteoglycans are preferentially synthesised and elaborated in the upper half of the tissue depth and contrasts with the patterns observed in eutherian mammals. The data also pose questions as to the functional significance of these molecules within the tissues and to the idea that global patterns of matrix components exist in mammalian articular cartilages.

The development of articular cartilage: I. The spatial and temporal patterns of collagen types

Articular cartilage is both morphologically and biochemically heterogeneous. Its susceptibility to degenerative diseases such as arthritis and its limited repair capacity have made cartilage the focus of intense study; surprisingly, little is known of its development. Using a panel of specific antibodies, we have documented the temporal and spatial patterns of collagen types I, II, III, VI and X in the developing knee cartilage of the marsupial Monodelphis domestica from parturition to adulthood. Type I collagen was initially detected in the presumptive articular cartilage of the epiphyses in addition to the perichondrium. By 14 d postparturition, type I collagen was not detectable in the epiphyseal cartilage apart from insertion sites of ligaments and tendons of the joint. Similarly, type III collagen was detected at insertion sites of the major ligaments and tendons and within the perichondrium/periosteum but was never detected in the cartilage per se. Type II collagen was predictably distributed throughout the cartilage matrix and was also detected in the perichondrium. Type VI collagen was widely distributed throughout the cartilage matrix at parturition, but during development became restricted to a pericellular location particularly towards the presumptive articular cartilage, i.e. the epiphysis. Interestingly, generalised matrix immunopositivity was only retained in the hypertrophic cartilage of the secondary centre of ossification. After the formation of the secondary centre, type VI collagen became localised pericellularly in the deeper regions of the articular cartilage but was absent in the cartilage of the growth plate. Type X collagen showed a novel distribution pattern. In addition to being synthesised by hypertrophic chondrocytes, this collagen type was also expressed transiently by some cells at the presumptive articular surface. Furthermore, these surface chondrocytes also stained histochemically for alkaline phosphatase, suggesting that they were terminally differentiated. The fate of these terminally differentiated cells is unknown.

Novel articular cartilage structure in the South American opossum, Monodelphis domestica

Articular cartilage provides smooth surfaces for low-friction, unrestricted movement of opposing skeletal elements. The surface topography of articular cartilage has been the subject of numerous studies and, with few exceptions, is considered to be smooth (at least at the light microscopic level). Some studies have reported 'humps' on the articular surface which have been related to underlying chondrocytes residing very close to the surface. Here we report on a highly nodular form of articular cartilage in the distal limb joints of the South American opossum, Monodelphis domestica. Unlike previous reports, these articular 'humps' are visible under a dissecting microscope. Each 'hump' or 'nodule' represents the surrounding matrix of single or sometimes paired rounded chondrocytes. Flattened chondrocytes normally associated with mammalian articular cartilage were absent from these joints. Interestingly, the articular cartilage of the more proximal limb joints such as the knee showed more typical features of articular cartilage including flattened superficial chondrocytes.

Measuring proliferation in routine fine needle aspirates. Immunocytochemical detection of bromodeoxyuridine incorporation and Ki-67 expression in breast aspirates

Two simple quantitative means of measuring tumour proliferation which can be applied to cytological material are described. One method involves immunocytochemical staining of cytological smears prepared from breast aspirates with the monoclonal antibody Ki-67. The other method involves incubation of aspirated material with 5-Bromo-2-deoxyuridine (BrdU). Direct measurement of the S phase of the cell cycle is feasible in breast fine needle aspirates by Bromodeoxyuridine incorporation and subsequent immunocytochemical detection. The proliferation indices obtained correlate with those derived from Ki-67 staining. This technique is suitable for routine use in the assessment of tumour proliferation.