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Perry R, Sciolla A, Rea M, Sandholdt C, Jandrey K, Rice E, Yu A, Griffin E, Wilkes M. Modeling the social determinants of resilience in health professions students: impact on psychological adjustment. Adv Health Sci Educ Theory Pract 2023; 28:1661-1677. [PMID: 37193860 PMCID: PMC10187518 DOI: 10.1007/s10459-023-10222-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/05/2023] [Indexed: 05/18/2023]
Abstract
Stressors inherent to training and stemming from the learning environment are associated with high rates of burnout, depression, and mental health problems in health professions students (HPS). There is evidence that disadvantaged or stigmatized groups are particularly affected. These problems not only impact students after graduation but may also have detrimental effects on patient outcomes. Resilience, conceptualized as the process of adapting well in the face of adversity, has inspired an increasing number of interventions aimed at addressing those problems in HPS. These interventions have mostly targeted individual students and their psychological traits while ignoring social and structural factors that may enhance or undermine individual resilience. To address this gap in the literature, the authors reviewed the evidence for psychosocial determinants of resilience and proposed a model inspired by the social determinants of health literature and the "upstream-downstream" metaphor. In this theoretical paper, the authors propose that upstream determinants such adverse childhood experiences and socioeconomic and sociodemographic markers of disadvantage have a direct effect on psychological adjustment and an indirect effect mediated by resilience. Additionally, the authors propose that the institutional downstream drivers of learning environment, social support, and sense of belonging moderate the direct and indirect effects of the upstream determinants on psychological adjustment. Future research should test these hypotheses and gather evidence that may guide the development of interventions. The authors present their model as part of a comprehensive response to recent calls to action to address diversity, equity and inclusion in health professions education.
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Affiliation(s)
- Ross Perry
- School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Andres Sciolla
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, USA
| | - Margaret Rea
- School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Cara Sandholdt
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, USA
| | - Karl Jandrey
- School of Veterinary Medicine, University of California, Davis , Davis, CA, USA
| | - Elizabeth Rice
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, USA
| | - Allison Yu
- School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Erin Griffin
- Washington State University, Elson S. Floyd College of Medicine, Spokane, WA, USA
| | - Michael Wilkes
- School of Medicine, University of California, Davis, Sacramento, CA, USA.
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Nurlaili N, Eriani K, Salma I, Maulida S, Rahayu SR, Handayani LS, Kocabas FK, Siti-Azizah MN, Wilkes M, Muchlisin ZA. Motility, viability and fertility of goldfish Carassius auratus (Pisces: Cyprinidae) post short-term cryopreservation. Cryo Letters 2023; 44:169-177. [PMID: 37883170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGRUND Goldfish Carassius auratus is a popular ornamental fish extensively cultured worldwide. Sperm cryopreservation is a common fish breeding method that ensures sperm availability around the year. Studies on cryopreservation of goldfish sperm, especially on the suitability of cryoprotectant types and pre-freezing time, are scarcely available. OBJECTIVE To determine the most suitable type of cryoprotectant and pre-freezing for the successful cryopreservation of goldfish sperm. MATERIALS AND METHODS A completely randomized design with two factors was utilized in this study. The first factor is the type of cryoprotectants, which included methanol, ethanol, ethylene glycol, glycerol, and DMSO. The second is pre-freezing times of 10, 20, 30, and 40 min at each of the pre-freezing temperatures of 4 degree C, -10 degree C, and -79 degree C, meaning that the total times for the ramping down of temperature were 30, 60, 90 and 120 min, respectively. The Ringer solution and 10% egg yolk were used as extender and extracellular cryoprotectant. The sperm was stored at -179 degree C for 7 days. RESULTS The ANOVA test showed that cryoprotectants and pre-freezing significantly affected the motility, viability, and fertility of goldfish sperm after freezing in liquid nitrogen for 7 days (P<0.05). Furthermore, 10% DMSO combined with 15% egg yolk with an pre-freezing time of 20 min can maintain sperm motility, viability, and fertility higher than other treatments, by 79%, 80%, and 33%, respectively. The agarose gel electrophoresis showed no DNA fragmentation in all samples, including fresh sperm. CONCLUSION We conclude that 10% DMSO combined with 15% egg yolk and 20 min pre-freezing is the best treatment for goldfish sperm cryopreservation. DOI: 10.54680/fr23310110412.
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Affiliation(s)
- N Nurlaili
- Master Program in Biology, Faculty of Matemathics and Natural Sciences, Syiah Kuala University, Banda Aceh, 23111, Indonesia
| | - K Eriani
- Master Program in Biology, Faculty of Matemathics and Natural Sciences, Syiah Kuala University, Banda Aceh, 23111, Indonesia
| | - I Salma
- Master Program in Biology, Faculty of Matemathics and Natural Sciences, Syiah Kuala University, Banda Aceh, 23111, Indonesia
| | - S Maulida
- Department of Aquaculture, Faculty of Marine and Fisheries, Syiah Kuala University, Banda Aceh, 23111 Indonesia
| | - S R Rahayu
- Department of Aquaculture, Faculty of Marine and Fisheries, Syiah Kuala University, Banda Aceh, 23111 Indonesia
| | - L S Handayani
- Department of Aquaculture, Faculty of Marine and Fisheries, Syiah Kuala University, Banda Aceh, 23111 Indonesia
| | - F K Kocabas
- Faculty of Fisheries, Munzur University, Turkey
| | | | - M Wilkes
- University of Essex, Essex, England
| | - Z A Muchlisin
- Department of Aquaculture, Faculty of Marine and Fisheries, Syiah Kuala University, Banda Aceh, 23111 Indonesia.
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Kim TY, Baldrias L, Papageorgiou S, Aguilar E, Tee M, Kelly T, Hill J, Wilkes M. A community-based survey to assess risk for one health challenges in rural Philippines using a mobile application. One Health Outlook 2022; 4:7. [PMID: 35379343 PMCID: PMC8979641 DOI: 10.1186/s42522-022-00063-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/24/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Recent emerging and re-emerging diseases in animals and humans show the vulnerability of humans, animals, and crops to disease outbreaks and the large potential impact on health, food security, and economies worldwide. A technology-enabled One Health (OH) surveillance program offers an opportunity for early detection and response as well as prevention of disease outbreaks in resource-limited settings. As an initial step toward developing the surveillance program, we aimed to identify at-risk groups of households for potential shared health challenges at the human-animal-environmental interface in a rural community of the Philippines. METHODS A cross-sectional household survey was conducted in the municipality of Los Baños in proximity (63 kilometers south) to Metro Manila by enumerators living in the same community. Twenty-four enumerators conducted household interviews asking a) household characteristics including ownership of animals and crops; b) awareness, beliefs and knowledge about OH; c) family-level health practices related to sanitation, hygiene, and food safety; and d) risk factors for potential OH issues. All data collection and transferring process were streamlined using a mobile application. RESULTS Of 6,055 participating households, 68% reported having one or more of gardens, farms, and animals for various reasons. While only 2% of the households have heard about OH, 97% believed they can get disease from animals, plants or the environment. A latent class analysis with nine risk factors for potential OH issues suggested that 46% of the households were at moderate to high risk for exposure to zoonotic pathogens and environmental contaminants. CONCLUSION Our findings indicate that there are unaddressed threats to human, animal, and plant health. Given the importance of the interconnections between the health of humans, animals, and plants, further evaluations of the at-risk households would be necessary to mitigate potential shared health threats in the community. Further, our study demonstrates that mHealth technology can provide an opportunity to systematically assess potential one health problems in the rural communities with limited internet connection.
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Affiliation(s)
- Tae Youn Kim
- Betty Irene Moore School of Nursing, University of California Davis, 2450 48th Street, Suite 2600, Sacramento, CA, 95817, USA.
| | - Loinda Baldrias
- College of Veterinary Medicine, University of the Philippines, Los Baños, Laguna, Philippines
| | - Sophia Papageorgiou
- One Health Institute, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Edna Aguilar
- College of Agriculture and Food Science, University of the Philippines, Los Baños, Laguna, Philippines
| | - Michael Tee
- College of Medicine, University of the Philippines, Manila, Philippines
| | - Terra Kelly
- One Health Institute, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Jim Hill
- College of Agriculture and Environmental Sciences, University of California Davis, Davis, CA, USA
| | - Michael Wilkes
- School of Medicine, University of California Davis, Sacramento, CA, USA
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Yu A, Wilkes M, Iosif AM, Rea M, Fisher A, Fine J, Perry R, Rice E, Jandrey K, Griffin E, Sciolla A. Exploring the Relationships Between Resilience and News Monitoring with COVID Distress in Health Profession Students. Acad Psychiatry 2021; 45:566-574. [PMID: 33928535 PMCID: PMC8083098 DOI: 10.1007/s40596-021-01444-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/22/2021] [Indexed: 05/21/2023]
Abstract
OBJECTIVE Alarming rates of anxiety and burnout in pre-clinical health profession trainees are now challenged by additional COVID-19 stressors. This study explored COVID-related stressors among first-year medical, physician assistant, nurse practitioner, and veterinary medical students. The authors examined associations between resilience, news monitoring, and COVID stress. METHODS Students completed an online questionnaire that included the Brief Resilience Scale at their matriculation in August 2019. Survey results were linked to demographic information collected by all schools. A follow-up survey in May 2020 included original questions on COVID-19 stressors and news monitoring. Statistical analyses included descriptive statistics and multivariable linear regression models. RESULTS Across schools, 74% (266/360) provided consent for the 2019 survey, and 76% (201/264) responded to COVID-19 questions in the follow-up 2020 survey. Students were "extremely" or "very" concerned about family members getting infected (n = 71, 76% School of Medicine (SOM); n = 31, 76% School of Nursing (SON); n = 50, 75% School of Veterinary Medicine (SVM)) and curriculum schedule changes (n = 72, 78%, SOM; n = 28, 68% SON; n = 52, 79% SVM). Greater frequency of COVID news monitoring was associated with greater COVID-related stress (p = 0.02). Higher resilience at matriculation was associated with lower COVID-related stress ten months later (p < 0.001). CONCLUSIONS Amid COVID-19 uncertainty, health science schools should address the immense student stress regarding curriculum disruptions. The results of this study underscore the powerful role of resilience in protecting against stress not only during the known academic rigor of health professions training but also during unprecedented crises.
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Affiliation(s)
- Allison Yu
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Michael Wilkes
- University of California, Davis School of Medicine, Sacramento, CA, USA.
| | - Ana-Maria Iosif
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Margaret Rea
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Alice Fisher
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Jeffrey Fine
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Ross Perry
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Elizabeth Rice
- University of California, Davis School of Nursing, Sacramento, CA, USA
| | - Karl Jandrey
- University of California, Davis School of Veterinary Medicine, Davis, CA, USA
| | - Erin Griffin
- University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Andres Sciolla
- University of California, Davis School of Medicine, Sacramento, CA, USA
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Williams HJ, Shipley JR, Rutz C, Wikelski M, Wilkes M, Hawkes LA. Future trends in measuring physiology in free-living animals. Philos Trans R Soc Lond B Biol Sci 2021; 376:20200230. [PMID: 34176330 PMCID: PMC8237165 DOI: 10.1098/rstb.2020.0230] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 02/07/2023] Open
Abstract
Thus far, ecophysiology research has predominantly been conducted within controlled laboratory-based environments, owing to a mismatch between the recording technologies available for physiological monitoring in wild animals and the suite of behaviours and environments they need to withstand, without unduly affecting subjects. While it is possible to record some physiological variables for free-living animals using animal-attached logging devices, including inertial-measurement, heart-rate and temperature loggers, the field is still in its infancy. In this opinion piece, we review the most important future research directions for advancing the field of 'physiologging' in wild animals, including the technological development that we anticipate will be required, and the fiscal and ethical challenges that must be overcome. Non-invasive, multi-sensor miniature devices are ubiquitous in the world of human health and fitness monitoring, creating invaluable opportunities for animal and human physiologging to drive synergistic advances. We argue that by capitalizing on the research efforts and advancements made in the development of human wearables, it will be possible to design the non-invasive loggers needed by ecophysiologists to collect accurate physiological data from free-ranging animals ethically and with an absolute minimum of impact. In turn, findings have the capacity to foster transformative advances in human health monitoring. Thus, we invite biomedical engineers and researchers to collaborate with the animal-tagging community to drive forward the advancements necessary to realize the full potential of both fields. This article is part of the theme issue 'Measuring physiology in free-living animals (Part II)'.
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Affiliation(s)
- H. J. Williams
- Department of Migration, Max Planck Institute of Animal Behavior, 78315 Radolfzell, Germany
- Department of Biology, University of Konstanz, Universitätsstraße 10, 78464, Konstanz, Germany
| | - J. Ryan Shipley
- Department of Migration, Max Planck Institute of Animal Behavior, 78315 Radolfzell, Germany
- Department of Biology, University of Konstanz, Universitätsstraße 10, 78464, Konstanz, Germany
| | - C. Rutz
- Centre for Biological Diversity, School of Biology, University of St Andrews, St Andrews KY16 9TH, UK
| | - M. Wikelski
- Department of Migration, Max Planck Institute of Animal Behavior, 78315 Radolfzell, Germany
- Department of Biology, University of Konstanz, Universitätsstraße 10, 78464, Konstanz, Germany
- Centre for the Advanced Study of Collective Behaviour, University of Konstanz, 78457 Konstanz, Germany
| | - M. Wilkes
- Extreme Environments Research Group, University of Portsmouth, Spinnaker Building, Cambridge Road, Portsmouth PO1 2EF, UK
| | - L. A. Hawkes
- Hatherly Laboratories, University of Exeter, College of Life and Environmental Sciences, Exeter EX4 4PS, UK
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Berrian AM, Wilkes M, Gilardi K, Smith W, Conrad PA, Crook PZ, Cullor J, Nyatanyi T, Smith MH, Kazwala R, Mazet JAK. Developing a Global One Health Workforce: The "Rx One Health Summer Institute" Approach. Ecohealth 2020; 17:222-232. [PMID: 32685999 PMCID: PMC7471195 DOI: 10.1007/s10393-020-01481-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 01/21/2020] [Accepted: 05/15/2020] [Indexed: 06/08/2023]
Abstract
The One Health approach has gained support across a range of disciplines; however, training opportunities for professionals seeking to operationalize the interdisciplinary approach are limited. Academic institutions, through the development of high-quality, experiential training programs that focus on the application of professional competencies, can increase accessibility to One Health education. The Rx One Health Summer Institute, jointly led by US and East African partners, provides a model for such a program. In 2017, 21 participants representing five countries completed the Rx One Health program in East Africa. Participants worked collaboratively with communities neighboring wildlife areas to better understand issues impacting human and animal health and welfare, livelihoods, and conservation. One Health topics were explored through community engagement and role-playing exercises, field-based health surveillance activities, laboratories, and discussions with local experts. Educational assessments reflected improvements in participants' ability to apply the One Health approach to health and disease problem solving, as well as anticipate cross-sectoral challenges to its implementation. The experiential learning method, specifically the opportunity to engage with local communities, proved to be impactful on participants' cultural awareness. The Rx One Health Summer Institute training model may provide an effective and implementable strategy by which to contribute to the development of a global One Health workforce.
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Affiliation(s)
- Amanda M Berrian
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA
- Department of Veterinary Preventive Medicine, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Michael Wilkes
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA
- School of Medicine, University of California, Davis, CA, USA
| | - Kirsten Gilardi
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA
| | - Woutrina Smith
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA
| | - Patricia A Conrad
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA
- Global Programs, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - Paulina Zielinska Crook
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA
- Global Programs, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - James Cullor
- Department of Population Health and Reproduction, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - Thierry Nyatanyi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Martin H Smith
- Department of Population Health and Reproduction, School of Veterinary Medicine, University of California, Davis, CA, USA
| | | | - Jonna A K Mazet
- One Health Institute, School of Veterinary Medicine, University of California, 1089 Veterinary Medicine Drive, Davis, CA, 95616, USA.
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Wilkes M, Papageorgiou S, Kim TY, Baldrias L, Aguilar E, Kelly T, Tee M. One Health workers: innovations in early detection of human, animal, and plant disease outbreaks. Journal of Global Health Reports 2019. [DOI: 10.29392/joghr.3.e2019093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Broukhim M, Yuen F, McDermott H, Miller K, Merrill L, Kennedy R, Wilkes M. Interprofessional conflict and conflict management in an educational setting. Med Teach 2019; 41:408-416. [PMID: 30309278 DOI: 10.1080/0142159x.2018.1480753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Background: Whenever health professionals work together as a team, conflict is inevitable - some would argue even necessary. However, conflict can have negative effects on patient care, job satisfaction, personal wellness, and professional productivity. Purpose: This study aims to describe interprofessional conflicts in a hospital setting from the perspective of three groups of health science students. Methods: An online questionnaire survey collected data from 225 health science students (medicine, nursing, and social work) in Northern California (USA). Quantitative and qualitative analyses were conducted resulting in seven central themes of conflict. Results: There are differences among health professional students in terms of how conflict is experienced and managed. Nursing students and medical students were more likely to take on the "victim" role when explaining their conflict, and their conflicts were more likely to be intra-professional. The most common cause of conflicts was related to hierarchy and power issues. The majority were dissatisfied with the way the conflict was resolved. Conclusions: Findings from this study can be used to design interprofessional curriculum to improve outcomes from conflicts and improve wellbeing, job satisfaction, and reduce patient turnover.
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Affiliation(s)
- Michael Broukhim
- a College of Osteopathic Medicine , Touro University of California , Vallejo , CA , USA
| | - Francis Yuen
- b Division of Social Work , California State University, Sacramento , Sacramento , CA , USA
| | - Haley McDermott
- c School of Medicine , University of California Davis , Davis , CA , USA
| | - Keri Miller
- b Division of Social Work , California State University, Sacramento , Sacramento , CA , USA
| | - Leslie Merrill
- b Division of Social Work , California State University, Sacramento , Sacramento , CA , USA
| | - Robin Kennedy
- b Division of Social Work , California State University, Sacramento , Sacramento , CA , USA
| | - Michael Wilkes
- c School of Medicine , University of California Davis , Davis , CA , USA
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Wilkes M. Medical school in 2029. Med Teach 2018; 40:1016-1019. [PMID: 30370807 DOI: 10.1080/0142159x.2018.1507253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Wilkes M, Cassel C, Klau M. If we keep doing what we're doing we'll keep getting what we're getting: A need to rethink "academic" medicine. Med Teach 2018; 40:364-371. [PMID: 29320901 DOI: 10.1080/0142159x.2017.1417580] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE For generations there have been warnings of the need to reform medical education at all levels. Today the voices pushing reform are louder, the need is greater, and there is an urgency not seen before. Approaches that have worked in the past to train physicians are no longer as relevant today as demographics, disease patterns, human resources, practice behaviors, technology, and attention to costs demand new collaborative approaches to clinical practice. To prepare for this practice tomorrow's doctors will need a different type of educational model, a different type of learning, in different environments, often taught by different faculty. This paper provides one innovative approach to redefine "academic medicine". METHODS After reviewing current trends in medical education, this paper describes one approach being taken by a large nonprofit American health care system to move medical education and discovery (research) out of traditional academic universities and placing it within a health care delivery system. CONCLUSIONS The creation of a learning laboratory in a high functioning health care delivery system allows for leveraging the successes in quality health care delivery to transform medical education with a focus on prevention, improving health care quality, reducing disparities in health, and promoting practical evidence-based clinical and outcomes focused research.
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Affiliation(s)
- Michael Wilkes
- a Davis School of Medicine , University of California , Davis , CA , USA
| | | | - Marc Klau
- b Kaiser Permanente Medical School , Pasadena , USA
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Cassel C, Wilkes M. Location, Location, Location: Where We Teach Primary Care Makes All the Difference. J Gen Intern Med 2017; 32:411-415. [PMID: 28243875 PMCID: PMC5377892 DOI: 10.1007/s11606-016-3966-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/02/2016] [Accepted: 12/13/2016] [Indexed: 11/29/2022]
Abstract
Creating a new model to train a high-quality primary care workforce is of great interest to American health care stakeholders. There is consensus that effective educational approaches need to be combined with a rewarding work environment, emphasize a good work/life balance, and a focus on achieving meaningful outcomes that center on patients and the public. Still, significant barriers limit the numbers of clinicians interested in pursuing careers in primary care, including low earning potential, heavy medical school debt, lack of respect from physician colleagues, and enormous burdens of record keeping. To enlarge and energize the pool of primary care trainees, we look especially at changes that focus on institutions and the practice environment. Students and residents need training environments where primary care clinicians and interdisciplinary teams play a crucially important role in patient care. For a variety of reasons, many academic medical centers cannot easily meet these standards. The authors propose that a major part of primary care education and training be re-located to settings in high-performing health systems built on comprehensive integrated care models where primary care clinicians play a principle role in leadership and care delivery.
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Affiliation(s)
- Christine Cassel
- Kaiser Permanente School of Medicine, 1 Kaiser Plaza, 18th Floor, Oakland, CA, 94612, USA.
| | - Michael Wilkes
- University of California, Davis School of Medicine, Sacramento, CA, USA
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Nyatanyi T, Wilkes M, McDermott H, Nzietchueng S, Gafarasi I, Mudakikwa A, Kinani JF, Rukelibuga J, Omolo J, Mupfasoni D, Kabeja A, Nyamusore J, Nziza J, Hakizimana JL, Kamugisha J, Nkunda R, Kibuuka R, Rugigana E, Farmer P, Cotton P, Binagwaho A. Implementing One Health as an integrated approach to health in Rwanda. BMJ Glob Health 2017; 2:e000121. [PMID: 28588996 PMCID: PMC5335763 DOI: 10.1136/bmjgh-2016-000121] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 11/30/2022] Open
Abstract
It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. ‘One Health’ refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwanda's people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwanda's lead and consider incorporating One Health principles into their national strategic health plans.
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Affiliation(s)
- Thierry Nyatanyi
- Ministry of Health, Kigali, Rwanda
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Wilkes
- University of California Davis, Davis, California, USA
- University of Rwanda, Butare, Rwanda
- Harvard Medical School, Boston, Massachusetts, USA
| | - Haley McDermott
- University of California Davis, Davis, California, USA
- Partners in Health, Rwanda
| | - Serge Nzietchueng
- University of Minnesota, Minneapolis, Minnesota, USA
- USAID Preparedness and Response Project
| | | | | | | | | | - Jared Omolo
- Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | - Denise Mupfasoni
- Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | | | | | | | | | | | | | | | | | - Paul Farmer
- Harvard Medical School, Boston, Massachusetts, USA
- Partners in Health, Rwanda
- University of Global Health Equity
| | | | - Agnes Binagwaho
- Harvard Medical School, Boston, Massachusetts, USA
- University of Global Health Equity
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Affiliation(s)
- Michael Wilkes
- School of Medicine, University of California, Davis, CA 95616, USA.
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Ndenga E, Uwizeye G, Thomson DR, Uwitonze E, Mubiligi J, Hedt-Gauthier BL, Wilkes M, Binagwaho A. Assessing the twinning model in the Rwandan Human Resources for Health Program: goal setting, satisfaction and perceived skill transfer. Global Health 2016; 12:4. [PMID: 26822614 PMCID: PMC4730618 DOI: 10.1186/s12992-016-0141-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 01/12/2016] [Indexed: 11/17/2022] Open
Abstract
Background Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model. Methods All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression. Results Most RF and USF reported setting goals with their twin (89 % and 71 %, respectively). Half of RF (52 %) reported effective skill transfer compared to 10 % of USF. Only 38 % of RF and 28 % of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect. Conclusions Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce. Electronic supplementary material The online version of this article (doi:10.1186/s12992-016-0141-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Esperance Ndenga
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Glorieuse Uwizeye
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Dana R Thomson
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | - Eric Uwitonze
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Joel Mubiligi
- Human Resources for Health, Ministry of Health, P.O. Box 84, Kigali, Rwanda.
| | - Bethany L Hedt-Gauthier
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | - Michael Wilkes
- College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda. .,Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.
| | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA. .,Ministry of Health, P.O. Box. 84, Kigali, Rwanda. .,Geisel School of Medicine, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
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Wright CY, Wilkes M, du Plessis JL, Reeder AI, Albers PN. In multiple situational light settings, visual observation for skin colour assessment is comparable with colorimeter measurement. Skin Res Technol 2015; 22:305-10. [PMID: 26346825 DOI: 10.1111/srt.12261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Finding inexpensive and reliable techniques for assessing skin colour is important, given that it is related to several adverse human health outcomes. Visual observation is considered a subjective approach assessment and, even when made by trained assessor, concern has been raised about the need for controlled lighting in the study venue. The aim of this study is to determine whether visual skin colour assessments correlate with objective skin colour measurements in study venues with different lighting types and configurations. METHODS Two trained investigators, with confirmed visual acuity, visually classified the inner, upper arm skin colour of 556 adults using Munsell(®) colour classifications converted to Individual Typology Angle (°ITA) values based on published data. Skin colour at the same anatomic site was also measured using a colorimeter. Each participant was assessed in one of 10 different buildings, each with a different study day. Munsell(®) -derived °ITA values were compared to colorimeter °ITA values for the full sample and by building/day. RESULTS We found a strong positive, monotonic correlation between Munsell(®) derived °ITA values and colorimeter °ITA values for all participants (Spearman ρ = 0.8585, P < 0.001). Similar relationships were found when Munsell(®) and colorimeter °ITA values were compared for participants assessed in the same building for all 10 buildings (Spearman ρ values ranged from 0.797 to 0.934, all correlations were statistically significant at P < 0.001). CONCLUSION It is possible to visually assess individual skin colour in multiple situational lighting settings and retrieve results that are comparable with objective measurements of skin colour. This was true for individuals of varying population groups and skin pigmentation.
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Affiliation(s)
- C Y Wright
- Environment & Health Research Unit, South African Medical Research Council, Department of Geography, Meteorology and Geoinformatics, University of Pretoria, Pretoria, South Africa
| | - M Wilkes
- Department of Chemistry and Chemical Biology, Cornell University, Ithaca, NY, USA
| | - J L du Plessis
- Occupational Hygiene and Health Research Initiative, North-West University, Potchefstroom, South Africa
| | - A I Reeder
- Cancer Society of New Zealand Social and Behavioural Research Unit, Department of Preventive and Social Medicine, University of Otago Medical School, Dunedin, New Zealand
| | - P N Albers
- Environment & Health Research Unit, South African Medical Research Council, Pretoria, South Africa
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Winer JN, Nakagawa K, Conrad PA, Brown L, Wilkes M. Evaluation of medical and veterinary students' attitudes toward a one health interprofessional curricular exercise. J Interprof Care 2014; 29:49-54. [PMID: 25051087 DOI: 10.3109/13561820.2014.940039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study evaluates whether medical and veterinary students' attitudes toward "One Health" and interprofessional education changed after participating in a joint small group learning exercise focused on risk factors associated with zoonotic disease. A survey was distributed to third-year medical students (n = 98) and second-year veterinary students (n = 140), each with a 95% response rate. Overall, 92% of veterinary students and 73% of medical students agreed or strongly agreed that "One Health" was relevant to their desired specialty. Students from both schools largely agreed that interprofessional education should be a goal of the curriculum for their school, and that interprofessional approaches strengthen their overall education. Students reported increased confidence in their communication skills and improved ability to contribute to One Health collaborative teams. This educational intervention, built around a patient case, focused on a variety of learning objectives including skills (such as communication), knowledge (of zoonotic toxoplasmosis) and attitudes (toward collaborative learning and practice). By sparking an interest in One Health during their early professional education, we sought to encourage a new generation of physicians and veterinarians to adopt a more collaborative spirit to their clinical practice, which will ultimately benefit human, animal and environmental health.
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Courtenay M, Wilkes M, Conrad PA, Ragione RL, Reeves S. One Health: the importance of education and the impact of interprofessional interventions. Vet J 2014; 201:241-2. [PMID: 24881510 DOI: 10.1016/j.tvjl.2014.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/03/2014] [Accepted: 05/05/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Molly Courtenay
- School of Health and Social Care, Faculty of Health and Medical Sciences University of Surrey GU2 7XH, UK.
| | - Michael Wilkes
- School of Medicine, University of California Davis and Global Health Institute Davis 95817, USA
| | - Patricia A Conrad
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine and One Health Center of Expertise: Water Animals, Food and Society, University of California Global Health Institute University of California Davis 95616, USA
| | - Roberto La Ragione
- School of Veterinary Medicine, Faculty of Health and Medical Sciences University of Surrey GU2 7XH, UK
| | - Scott Reeves
- Centre for Health and Social Care Research, Kingston Campus, Faculty of Health, Social Care and Education Kingston University and St Georges University London KT1 2EE, UK
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Courtenay M, Conrad P, Wilkes M, La Ragione R, Fitzpatrick N. Interprofessional initiatives between the human health professions and veterinary medical students: a scoping review. J Interprof Care 2014; 28:323-30. [PMID: 24621114 DOI: 10.3109/13561820.2014.895979] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This article presents the findings of a scoping review designed to identify the extent, nature and range of literature on interprofessional education (IPE) initiatives between the human health professions and veterinary medical students, which is particularly important to advance One Health education and research. Nine published articles were identified. The websites of six universities were searched in order to collect further information. Interventions vary widely with regards to their structure and delivery, their objectives, the participants involved, and outcome measures. Healthcare professional programmes focus upon interprofessional collaborative practice in the human healthcare setting. By contrast, postgraduate programmes focus upon topics under the One Health paradigm but make little mention of interprofessional collaboration. Evidence of the impact of interventions on team processes at the human, animal, and environmental interface is extremely limited. In order to enhance our understanding of what constitutes effective IPE between veterinary medical students and the human health professions, guide intervention development, and the development of outcome measures, there is a need to further explore, define, differentiate and validate some of the terms and concepts used to describe interprofessional interventions.
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Affiliation(s)
- Molly Courtenay
- School of Health and Social Care, Faculty of Health and Medical Sciences , University of Surrey, Guildford, Surrey , UK
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19
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Levi BH, Wilkes M, Der-Martirosian C, Latow P, Robinson M, Green MJ. An Interactive Exercise in Advance Care Planning for Medical Students. J Palliat Med 2013; 16:1523-7. [DOI: 10.1089/jpm.2013.0039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Benjamin H. Levi
- Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Michael Wilkes
- Office of the Dean, University of California, Davis, California
- School of Medicine, University of California, Davis, California
| | | | - Polly Latow
- Department of Internal Medicine, University of California, Davis, California
| | - Mark Robinson
- Department of Internal Medicine, University of California, Davis, California
| | - Michael J. Green
- Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
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Abstract
BACKGROUND AND AIMS Advance warning of patients who are difficult to intubate may prevent an airway catastrophe but relies on effective communication between specialties. Anaesthetists aim to inform general practitioners whenever a difficult airway is encountered and expect general practitioners to include this information in subsequent referrals. We investigated how anaesthetists communicated with general practitioners, their knowledge of the Read Code (used by general practitioner computer systems) for difficult tracheal intubation, and how likely general practitioners were to pass the information on. METHODS AND RESULTS We surveyed 631 consultant anaesthetists and 217 general practitioners. We found only 125 (20%) anaesthetists consistently wrote difficult airway letters to general practitioners. Only 20 (3%) knew the Read Code for difficult intubation (SP2y3), although 454 (72%) thought it to be useful. Most general practitioners (212, 98%) thought airway information to be important, but only half receiving a difficult airway communication forwarded it on. General practitioners recommended including the Read Code SP2y3 and labelling it 'high priority', ensuring that 'Difficult Tracheal Intubation' would be listed in the Emergency Care Summary generated for hospital referrals. CONCLUSION Communication between anaesthetists and general practitioners is currently poor, but could be improved by simplifying difficult airway letters and including the SP2y3 code and a statement of priority.
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Affiliation(s)
- M Wilkes
- South East Scotland School of Anaesthesia, UK
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21
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Wilkes M, Srinivasan M, Cole G, Tardif R, Richardson LC, Plescia M. Discussing uncertainty and risk in primary care: recommendations of a multi-disciplinary panel regarding communication around prostate cancer screening. J Gen Intern Med 2013; 28:1410-9. [PMID: 23649782 PMCID: PMC3797347 DOI: 10.1007/s11606-013-2419-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 08/22/2012] [Accepted: 12/05/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Shared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men. OBJECTIVE In July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians. DESIGN Two-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes. PARTICIPANTS Sixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations). MAIN MEASURES Panelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified. KEY RESULTS Highly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training. CONCLUSIONS Conference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers.
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Affiliation(s)
- Michael Wilkes
- University of California, Davis School of Medicine, 1 Shield Avenue, Sacramento, CA, USA,
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22
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Green MJ, Wilkes M, Robinson M, Dermart C, Levi BH. Medical students' experiences using an online decision aid to engage in advance care planning. BMJ Support Palliat Care 2012. [DOI: 10.1136/bmjspcare-2012-000250.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Conrad PA, Mazet JA, Clifford D, Scott C, Wilkes M. Evolution of a transdisciplinary "One Medicine-One Health" approach to global health education at the University of California, Davis. Prev Vet Med 2009; 92:268-74. [PMID: 19819575 PMCID: PMC7132481 DOI: 10.1016/j.prevetmed.2009.09.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In today's world health events in one nation or geographic area often have repercussions for the health and well-being of populations beyond that region; sometimes even globally. In recent years many factors, most notably concern about emerging infectious diseases, have contributed to an increasing appreciation of the interdependency of human, animal and ecosystem health worldwide. Integrated global approaches to improve the health of humans, animals and their shared environments are proving to be in the best interest of many countries. A special symposium and award were established in memoriam to the internationally renowned epidemiologist, Dr. Calvin W. Schwabe, who (while at the University of California, Davis) was a significant advocate of the “One Medicine” approach to public health, calling upon all health professionals, including veterinarians, to work collaboratively and comparatively to improve human health. This paper discusses the evolution of the “One Medicine” concept into a global “One Health” approach to research, training capacity and service infrastructure, focused not only on disease, but also on health at the individual, population, and ecosystem levels. Projects involving UCD faculty which attempt to integrate a One Health approach include the Health for Animals and Livelihood Improvement (HALI) Project in Tanzania, Envirovet Summer Institute, Avian Flu School and Newcastle Immunization Program in Africa, a web-based virtual global health training program, and the Calvin Schwabe One Health Project.
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Affiliation(s)
- Patricia A Conrad
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, One Shields Avenue, Davis, CA 95616, United States.
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24
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Abstract
Michael Wilkes and Margaret Johns argue that the doctrine of informed consent should require doctors to disclose to patients when they are prescribing a drug off-label.
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Affiliation(s)
- Michael Wilkes
- School of Medicine, University of California, Davis, California, USA.
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Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007; 22:1429-33. [PMID: 17674111 PMCID: PMC2305862 DOI: 10.1007/s11606-007-0279-0] [Citation(s) in RCA: 185] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Revised: 05/22/2007] [Accepted: 06/21/2007] [Indexed: 11/29/2022]
Abstract
CONTEXT In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed. OBJECTIVE To test an intervention to reduce patients' unmet concerns. DESIGN Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys. SETTING Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania. PARTICIPANTS A volunteer sample of 20 family physicians (participation rate = 80%) and 224 patients approached consecutively within physicians (participation rate = 73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition. INTERVENTION After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: "Is there anything else you want to address in the visit today?" (ANY condition) and "Is there something else you want to address in the visit today?" (SOME condition). MAIN OUTCOME MEASURES Patients' unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys. RESULTS Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR) = .154, p = .001). The ANY intervention could not be significantly distinguished from the control condition (p = .122). Neither intervention affected visit length, or patients'; expression of unanticipated concerns not listed in previsit surveys. CONCLUSIONS Patients' unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.
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Affiliation(s)
- John Heritage
- Department of Sociology, University of California, Los Angeles, CA 90095-1551, USA.
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Srinivasan M, Hauer KE, Der-Martirosian C, Wilkes M, Gesundheit N. Does feedback matter? Practice-based learning for medical students after a multi-institutional clinical performance examination. Med Educ 2007; 41:857-65. [PMID: 17727526 DOI: 10.1111/j.1365-2923.2007.02818.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Malathi Srinivasan
- Department of Medicine, Davis School of Medicine, University of California, Sacramento, California 95833, USA.
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Abstract
OBJECTIVE Although the concept of altruism in medicine has a long tradition in Western thought, little empirical research has been carried out recently in this area. This study compares the altruistic attitudes of medical, legal and business students. METHODS We used a cross-sectional survey to compare the altruistic attitudes of 3 types of contemporary 'professional' students, those in medicine, law and business. RESULTS The results suggest that medical students report more altruistic attitudes than legal students, but not than business students. Overall, female students reported stronger attitudes consistent with altruism compared with males; African-American and Hispanic students reported more altruistic attitudes compared with White students. CONCLUSIONS Our results suggest that the recent trend in recruiting more women and under-represented minority group members into medicine may have a positive impact on altruism in the profession, if we can assume that attitudes correlate with behaviours.
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Affiliation(s)
- Ian D Coulter
- RAND Health, RAND Corporation, Santa Monica, California, USA.
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Srinivasan M, Wilkes M, Stevenson F, Nguyen T, Slavin S. Comparing problem-based learning with case-based learning: effects of a major curricular shift at two institutions. Acad Med 2007; 82:74-82. [PMID: 17198294 DOI: 10.1097/01.acm.0000249963.93776.aa] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE Problem-based learning (PBL) is now used at many medical schools to promote lifelong learning, open inquiry, teamwork, and critical thinking. PBL has not been compared with other forms of discussion-based small-group learning. Case-based learning (CBL) uses a guided inquiry method and provides more structure during small-group sessions. In this study, we compared faculty and medical students' perceptions of traditional PBL with CBL after a curricular shift at two institutions. METHOD Over periods of three years, the medical schools at the University of California, Los Angeles (UCLA) and the University of California, Davis (UCD) changed first-, second-, and third-year Doctoring courses from PBL to CBL formats. Ten months after the shift (2001 at UCLA and 2004 at UCD), students and faculty who had participated in both curricula completed a 24-item questionnaire about their PBL and CBL perceptions and the perceived advantages of each format RESULTS A total of 286 students (86%-97%) and 31 faculty (92%-100%) completed questionnaires. CBL was preferred by students (255; 89%) and faculty (26; 84%) across schools and learner levels. The few students preferring PBL (11%) felt it encouraged self-directed learning (26%) and valued its greater opportunities for participation (32%). From logistic regression, students preferred CBL because of fewer unfocused tangents (59%, odds ration [OR] 4.10, P = .01), less busy-work (80%, OR 3.97, P = .01), and more opportunities for clinical skills application (52%, OR 25.6, P = .002). CONCLUSIONS Learners and faculty at two major academic medical centers overwhelmingly preferred CBL (guided inquiry) over PBL (open inquiry). Given the dense medical curriculum and need for efficient use of student and faculty time, CBL offers an alternative model to traditional PBL small-group teaching. This study could not assess which method produces better practicing physicians.
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Affiliation(s)
- Malathi Srinivasan
- School of Medicine, University of California, Davis, Sacramento, CA 95817, USA.
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Mitchell M, Srinivasan M, West DC, Franks P, Keenan C, Henderson M, Wilkes M. Factors affecting resident performance: development of a theoretical model and a focused literature review. Acad Med 2005; 80:376-89. [PMID: 15793024 DOI: 10.1097/00001888-200504000-00016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PURPOSE The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance. METHOD Using expert consensus panel, in 2002-03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967-2002) for all original articles related to the factors of individual resident performance. RESULTS The authors found 52 original studies that examined factors of an individual resident's performance. They describe each study's measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies. CONCLUSIONS Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident's actual job performance. Additionally, they identify and discuss major gaps in the educational literature.
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Affiliation(s)
- Maya Mitchell
- Department of Medicine, University of California, Davis, School of Medicine, 4150 V. Street, Suite 2400, Sacramento, CA 95817, USA
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Murphy SJ, Doré JJE, Edens M, Coffey RJ, Barnard JA, Mitchell H, Wilkes M, Leof EB. Differential trafficking of transforming growth factor-beta receptors and ligand in polarized epithelial cells. Mol Biol Cell 2004; 15:2853-62. [PMID: 15075369 PMCID: PMC420108 DOI: 10.1091/mbc.e04-02-0097] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Epithelial cells in vivo form tight cell-cell associations that spatially separate distinct apical and basolateral domains. These domains provide discrete cellular processes essential for proper tissue and organ development. Using confocal imaging and selective plasma membrane domain activation, the type I and type II transforming growth factor-beta (TGFbeta) receptors were found to be localized specifically at the basolateral surfaces of polarized Madin-Darby canine kidney (MDCK) cells. Receptors concentrated predominantly at the lateral sites of cell-cell contact, adjacent to the gap junctional complex. Cytoplasmic domain truncations for each receptor resulted in the loss of specific lateral domain targeting and dispersion to both the apical and basal domains. Whereas receptors concentrate basolaterally in regions of direct cell-cell contact in nonpolarized MDCK cell monolayers, receptor staining was absent from areas of noncell contact. In contrast to the defined basolateral polarity observed for the TGFbeta receptor complex, TGFbeta ligand secretion was found to be from the apical surfaces. Confocal imaging of MDCK cells with an antibody to TGFbeta1 confirmed a predominant apical localization, with a stark absence at the basal membrane. These findings indicate that cell adhesion regulates the localization of TGFbeta receptors in polarized epithelial cultures and that the response to TGFbeta is dependent upon the spatial distribution and secretion of TGFbeta receptors and ligand, respectively.
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Affiliation(s)
- S J Murphy
- Thoracic Diseases Research Unit, Department of Biochemistry and Molecular Biology and Mayo Clinic Cancer Center, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Affiliation(s)
- Michael Wilkes
- Office of the Dean, School of Medicine, University of California-Davis, One Shields Avenue, Davis, CA, USA.
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Abstract
OBJECTIVE We designed a curricular exercise intended to expose healthy medical students, near the end of their basic science training, to the experience of hospitalization. We attempted to assess how a standardized hospitalization, for medical students just about to start their clinical rotations, was experienced by student participants. DESIGN A qualitative observational design was used, both to explore the perceptions of the hospitalized students and to generate hypotheses for further exploration. SETTING University and affiliated hospitals. PARTICIPANTS Second-year medical students, towards the end of their basic science training. OUTCOME MEASURES Qualitative assessment of hospitalization experience. RESULTS Among key themes expressed by student participants were the following: they felt a profound loss of privacy; they found the nursing staff to be caring, attentive and professional, and repeatedly commented about how much time the nurses took to talk and listen to them and to take a complete history; in contrast they were particularly upset about the distance and coldness they felt from the medical staff; they expect this experience to affect their own future practice as physicians. When asked how this might change their attitudes in the future, students' comments generally reflected a primary concern with improving the human aspects of the patient experience. CONCLUSIONS Student participants in a standardized inpatient hospitalization generally experienced strong feelings about issues of privacy, and about interactions with medical and nursing staff, which they expect to have an important impact on their own professional development.
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Affiliation(s)
- Michael Wilkes
- Center for Educational Development and Research, UCLA School of Medicine, 95616, USA
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Wilkes M, Hoffman J. Students benefit from experience of hospitalization. Med Educ 2002; 36:586-587. [PMID: 12047676 DOI: 10.1046/j.0308-0110.2002.01245.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Abstract
Many aspects of the medical education system lead trainees to a host of maladaptive reactions and behaviors, but far too little attention has been focused on the impact that interactions between teacher and learner can have on the development of professionalism. The authors discuss the concept of "social influence," a change of attitude, belief, or behavior resulting from the actions of another person in the context of the medical education setting. Using the example of a medical student who has not adequately completed his inpatient medicine requirements, they identify ten strategies of social influence that a medical educator might invoke to change the student's behavior and evaluate the benefits and drawbacks of these strategies. This overview can be used by faculty to explore new strategies of teaching and to reflect on their current teaching styles.
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Affiliation(s)
- Michael Wilkes
- University of California School of Medicine, Davis 95616, USA.
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Bonser RS, Wong CH, Harrington D, Pagano D, Wilkes M, Clutton-Brock T, Faroqui M. Failure of retrograde cerebral perfusion to attenuate metabolic changes associated with hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2002; 123:943-50. [PMID: 12019380 DOI: 10.1067/mtc.2002.120333] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Although retrograde cerebral perfusion has become a popular adjunctive technique and may improve cerebral ischemic tolerance during hypothermic circulatory arrest, direct cerebral metabolic benefit has yet to be demonstrated in human subjects. We investigated the post-arrest metabolic phenomena with and without retrograde cerebral perfusion in patients. METHODS In a prospective randomized trial, 42 patients undergoing aortic surgery requiring hypothermic circulatory arrest were allocated to receive hypothermic circulatory arrest alone (n = 21) or hypothermic circulatory arrest with additional retrograde cerebral perfusion (n = 21). Circulatory arrest was commenced at 15 degrees C, and retrograde perfusion was instituted through the superior vena cava at a maximum jugular bulb pressure of 25 mm Hg. Transcranial, paired, repeated samples of the arterial and jugular bulb blood were analyzed for oxygen and glucose. Velocity in the right middle cerebral artery was also measured simultaneously. RESULTS There were 3 (7.1%) deaths and 3 (7.1%) episodes of neurologic deficit. Mean bypass and circulatory arrest duration (in minutes) were similar between groups (P =.4 and.14). The mean retrograde perfusion duration was 23 minutes. Post-arrest nasopharyngeal temperature was similar (15.3 degrees C vs. 15.3 degrees C). Retrograde perfusion did not affect post-arrest oxygen extraction, glucose extraction, or jugular bulb Po(2). There was no immediate lactate release immediately after hypothermic circulatory arrest. CONCLUSIONS Retrograde cerebral perfusion did not influence immediate post-arrest nasopharyngeal temperature or cerebral metabolic recovery. The low jugular bulb Po(2) suggests equivalent ischemia. These findings cast doubt on the effectiveness of retrograde cerebral perfusion as a metabolic adjunct to hypothermic circulatory arrest.
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Affiliation(s)
- R S Bonser
- Cardiothoracic Surgical Unit and Department of Anaesthesia and Intensive Care, University Hospital Birmingham Queen Elizabeth Medical Centre, Birmingham, United Kingdom.
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Sekmen A, Wilkes M, Kawamura K. An application of passive human-robot interaction: human tracking based on attention distraction. ACTA ACUST UNITED AC 2002. [DOI: 10.1109/tsmca.2002.1021112] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mukadam ME, Pritchard P, Riddington D, Wilkes M, Graham TR, Horrow JC, Spiess BD. Case 7--2001. Management during cardiopulmonary bypass of patients with presumed fish allergy. J Cardiothorac Vasc Anesth 2001; 15:512-9. [PMID: 11505358 DOI: 10.1053/jcan.2001.25006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M E Mukadam
- Department of Cardiothoracic Surgery and Anaesthesiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Davis RM, Smith R, Wilkes M. The US sisters of the BMJ. BMJ 2001; 322:380. [PMID: 11179144 PMCID: PMC1119621 DOI: 10.1136/bmj.322.7283.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Tse WY, Williams J, Pall A, Wilkes M, Savage CO, Adu D. Antineutrophil cytoplasm antibody-induced neutrophil nitric oxide production is nitric oxide synthase independent. Kidney Int 2001; 59:593-600. [PMID: 11168940 DOI: 10.1046/j.1523-1755.2001.059002593.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Antineutrophil cytoplasm antibodies (ANCAs) are implicated in the pathogenesis of systemic vasculitis. We asked whether ANCA could induce nitric oxide (NO) release from human neutrophils and, if so, whether this NO production was dependent on NO synthase (NOS) activity. METHODS Neutrophil NO production was measured using a chemiluminescence assay, and NOS activity was determined by the conversion of [(14)C] L-arginine to [(14)C] L-citrulline and NOS mRNA expression by reverse transcription-polymerase chain reaction (RT-PCR). RESULTS Human neutrophils isolated from healthy donors were incubated at 37 degrees C with human ANCA, normal human IgG, murine monoclonal myeloperoxidase ANCA, murine proteinase-3 ANCA, or their respective isotypic controls for 6 to 12 hours in RPMI. Both human and monoclonal ANCA led to a dose-dependent increase of NO compared with control IgG. Neutrophils, either freshly isolated or incubated for seven hours with murine monoclonal myeloperoxidase ANCA, proteinase-3 ANCA, or a mixture of interleukin-1 beta, tumor necrosis factor-alpha, interferon-gamma plus lipopolysaccharide showed no NOS activity with low conversion rates of [(14)C] L-arginine to [(14)C] L-citrulline, which could not be inhibited by N(G)-monomethyl-L-arginine (NOS inhibitor). To detect NOS mRNA expression, RT-PCR was performed using oligonucleotide primers derived from mRNA sequences of either human constitutive endothelial NOS (eNOS), constitutive neuroneal NOS (nNOS), or human hepatocyte inducible NOS (iNOS). There was no expression of either eNOS, nNOS, or iNOS in untreated, human and murine monoclonal ANCA-treated, or cytokine-treated neutrophils. CONCLUSION These data suggest that human neutrophils produce NO in response to ANCA but in a NOS-independent way. NO can be generated from a nonenzymatic interaction between hydrogen peroxide and arginine. We postulate that this is the predominant pathway of NO synthesis in neutrophils, since ANCAs are capable of inducing reactive oxygen species production from neutrophils.
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Affiliation(s)
- W Y Tse
- Department of Nephrology, Queen Elizabeth Hospital, Birmingham, England, United Kingdom.
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Wilkes M. Chronic disease and mental health: a call for papers. West J Med 2001. [DOI: 10.1136/ewjm.174.2.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Danovitch I, Danovitch I, Yamey G, Wilkes M. Genesis, the voice of students. Wjm's new student section will be vital reading for physicians. West J Med 2001; 174:86. [PMID: 11156900 PMCID: PMC1071254 DOI: 10.1136/ewjm.174.2.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wilkes M. Medical students with developmental disabilities. Med Educ 2000; 34:978-979. [PMID: 11123559 DOI: 10.1046/j.1365-2923.2000.00807.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- M Wilkes
- Department of Medicine, UCLA School of Medicine, CA 90095, USA
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Patiag D, Qu X, Gray S, Idris I, Wilkes M, Seale JP, Donnelly R. Possible interactions between angiotensin II and insulin: effects on glucose and lipid metabolism in vivo and in vitro. J Endocrinol 2000; 167:525-31. [PMID: 11115780 DOI: 10.1677/joe.0.1670525] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Angiotensin II (ANGII) increases insulin sensitivity in diabetic and non-diabetic subjects, even at subpressor doses, and because there is 'crosstalk' between ANGII and insulin-signaling pathways the underlying mechanism may not be due solely to changes in regional blood flow. A series of experimental studies was undertaken to evaluate the effects of ANGII on glucose and lipid metabolism in vivo and in vitro. Groups of fructose-fed, insulin-resistant Sprague-Dawley (SD) rats were pre-treated with 0.3 mg/kg per day of the AT(1)-receptor antagonist L-158 809 (n=16), or vehicle (n=16), by oral gavage. This was prior to an oral glucose tolerance test (day 5) and measurement of the effects of ANGII infusion (20 ng/kg per min i.v. for 3 h) on whole-body insulin sensitivity using the insulin suppression test (day 7). The effect of ANGII infusion on total triglyceride secretion rate (TGSR) was evaluated in normal SD rats pretreated for 7 days with L-158 809 (n=12) or vehicle (n=12). AT(1)- and AT(2)- receptor mRNA expression and [(3)H]2-deoxyglucose uptake were assessed in cultured L6 myoblasts. Short-term treatment with L-158 809 had no effect on glucose tolerance or fasting triglyceride levels in fructose-fed rats. ANGII infusion had no effect on insulin sensitivity in fructose-fed rats pretreated with vehicle (steady-state plasma glucose (SSPG) values 8.1+/-1.6 vs 8. 4+/-0.4 mmol/l), but pretreatment with L-158 809 resulted in ANGII having a modest insulin antagonist effect in this insulin-resistant model (SSPG values 9.6+/-0.3 vs 7.1+/-0.6, P<0.03). ANGII infusion had no significant effect on TGSR (e.g. 24.6+/-1.4 vs 28.4+/-0.9 mg/100 g per h in vehicle-treated animals). RT-PCR analysis showed that L6 cells express both AT(1)- and AT(2)-receptor mRNA. Incubation with ANGII (10(-9) and 10(-8) M) had no significant effect on the dose-response curve for insulin-stimulated [(3)H]2-deoxyglucose uptake. For example, C(I200) values (dose of insulin required to increase glucose uptake by 200%) were 4.5 x 10(-9) M (control) vs 3.9 x 10(-9) M and 6.2 x 10(-9) M, whereas the positive control (glucagon-like peptide-1) increased insulin sensitivity. Thus, ANGII infusion may have a modest insulin antagonist effect on glucose disposal in insulin-resistant fructose-fed rats pretreated with an AT(1)-blocker, but ANGII has no effect on TGSR or in vitro glucose uptake in L6 myoblasts. These findings are relevant to recent clinical discussions about the metabolic effects of ANGII and renin-angiotensin system blockade.
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Affiliation(s)
- D Patiag
- School of Medical and Surgical Sciences, University of Nottingham, UK
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Abstract
INTRODUCTION Health care providers' positive attitudes toward prevention and health promotion are important in achieving national health care goals. Limited studies of incoming medical students have been conducted that measure predictors of positive attitudes toward health promotion and prevention. METHODS Data were obtained from a 1993 curriculum evaluation survey of first-year students at five different medical schools in California. Attitudes toward health promotion and prevention were measured using a nine-question Prevention Attitude Scale (PAS). We developed 2 multivariate linear regression models using demographics, education choices, and personal social values and beliefs to predict PAS scores. We also performed bivariate analysis. RESULTS Five hundred ninety-nine completed surveys were analyzed, with a response rate of 95%. Mean PAS score was 36.47 +/- 3.7 on a 0 to 44 scale. Female gender, Democratic party preference, and a planned specialty choice in preventive medicine or primary care predicted the highest PAS scores on bivariate analysis (p < 0.002). Significant correlation ( p < 0. 001) was shown between PAS scores and 2 additional scales regarding beliefs in associations of social factors and illness and in the importance of caring for the poor. Linear regression model using personal social values and beliefs explained 34% of the variance, as opposed to the demographic model that explained only 9% of the variance. CONCLUSIONS In the schools studied, participating first-year medical students had moderately positive attitudes toward health promotion and prevention, as measured by PAS scores. In designing curriculum to improve medical students' attitudes toward health promotion and prevention, medical educators may need to consider other personal and social values held by medical students and to address the "political" aspects of health promotion and prevention. Future studies are needed to longitudinally follow medical student attitudes.
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Affiliation(s)
- P A Bellas
- Department of Veterans Affairs, Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Division of General Internal Medicine, Los Angeles, California, USA.
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Doostan D, Wilkes M. Treating the developmentally disabled. West J Med 1999; 171:92-6. [PMID: 10510655 PMCID: PMC1305767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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