Questioning the Premedical Paradigm

This book raises fundamental questions about the propriety of continuing to use a premedical curriculum developed more than a century ago to select students for training as future physicians for the twenty-first century. In it, Dr. Donald A. Barr examines the historical origins, evolution, and current state of premedical education in the United States. One hundred years ago, Abraham Flexner's report on Medical Education in the United States and Canada helped establish the modern paradigm of premedical and medical education. Barr’s research finds the system of premedical education that evolved to be a poor predictor of subsequent clinical competency and professional excellence, while simultaneously discouraging many students from underrepresented minority groups or economically disadvantaged backgrounds from pursuing a career as a physician. Analyzing more than fifty years of research, Barr shows that many of the best prospects are not being admitted to medical schools, with long-term adverse consequences for the U.S. medical profession. The root of the problem, Barr argues, is the premedical curriculum—which overemphasizes biology, chemistry, and physics by teaching them as separate, discrete subjects. In proposing a fundamental restructuring of premedical education, Barr makes the case for parallel tracks of undergraduate science education: one that would largely retain the current system; and a second that would integrate the life sciences in a problem-based, collaborative learning pedagogy. Barr argues that the new, integrated curriculum will encourage greater educational and social diversity among premedical candidates without weakening the quality of the education. He includes an evaluative research framework to judge the outcome of such a restructured system.This historical and cultural analysis of premedical education in the United States is the crucial first step in questioning the appropriateness of continuing a hundred-year-old, empirically dubious pedagogical model for the twenty-first century

A Single Dose of Nicotine Enhances Reward Responsiveness in Nonsmokers: Implications for Development of Dependence

Background: Tobacco smoking, driven by the addictive properties of nicotine, is the most prevalent preventable cause of death in the Western world. Accumulated evidence suggests that nicotine may increase appetitive responding for nondrug incentives in the environment. Methods: To test this hypothesis, we conducted a randomized, double-blind, placebo-controlled, crossover study of the effect of a single dose of transdermal nicotine on reward responsiveness in 30 psychiatrically healthy nonsmokers. A novel signal detection task in which correct responses were differentially rewarded in a 3:1 ratio was used to assess the extent to which participants modulated their behavior as a function of reward. Results: Despite expected adverse effects such as nausea, nicotine significantly increased response bias toward the more frequently rewarded condition, at the expense of accuracy, independent of effects on attention or overall vigilance. Additionally, response bias on placebo was greater in participants who received nicotine in the first session, indicating that an effect of nicotine on reward responsiveness or reward-based learning persisted for at least 1 week. Conclusions: These findings suggest that a single dose of nicotine enhances response to non-drug-related rewards in the environment, with lasting effects. This effect may contribute to reinforcement of early smoking behavior and development of nicotine dependence.Psycholog

Clinical characteristics of children with epilepsy managed at an urban hospital in Africa: a retrospective study

Background: Most children with epilepsy reside in resource-limited regions such as sub-Saharan Africa, where the majority of studies have been conducted in rural areas with limited investigations. Medical records from children with epilepsy seen at an urban hospital in Kenya were examined to provide a comprehensive description of epilepsy in children from this hospital. Methods: A retrospective observational study was conducted which involved reviewing medical records of 426 epilepsy patients (260 males and 166 females) aged 0 - 18 years, seen in Nairobi, Kenya between February 2011 and December 2014. Results: The most frequent age at presentation; documented in 29% was in infancy. Generalized seizures due to structural brain abnormalities were the most common form of epilepsy (28%). Lennox-Gastaut Syndrome was the most common electroclinical syndrome (7%). Focal seizures and focal seizures with loss of awareness were identified in 12% of the population. There were no cases of childhood absence epilepsy in this group. Brain atrophy was the most common MRI finding, occurring in a fifth of the population (20%), while cystic encephalomalacia occurred in 13%. Half (50%) of all EEG recordings performed for this cohort were abnormal. Generalized seizures due to structural brain abnormalities and Lennox-Gastaut Syndrome (LGS) were significant predictors of a treatment history of three or more AEDs. At the conclusion of the review period, 16% of the patients had not visited the clinic for more than 12 months and were considered to be lost to follow-up. Conclusion: The highest frequency of epilepsy cases was documented in children less than one year of age. Generalized seizures due to structural abnormalities and Lennox-Gastaut syndrome were the most common seizure type and syndrome. Improvement of public awareness of different types of seizures in children may increase identification of children with childhood absence epilepsy

Chemistry courses as the turning point for premedical students

Previous research has documented that negative experiences in chemistry courses are a major factor that discourages many students from continuing in premedical studies. This adverse impact affects women and students from under-represented minority (URM) groups disproportionately. To determine if chemistry courses have a similar effect at a large public university, we surveyed 1,036 students from three entering cohorts at the University of California, Berkeley. We surveyed students at the beginning of their first year at the university and again at the end of their second year. All subjects had indicated an interest in premedical studies at the time they entered the university. We conducted follow-up interviews with a stratified sub-set of 63 survey respondents to explore the factors that affected their level of interest in premedical studies. Using a 10-point scale, we found that the strength of interest in premedical studies declined for all racial/ethnic groups. In the follow-up interviews, students identified chemistry courses as the principal factor contributing to their reported loss of interest. URM students especially often stated that chemistry courses caused them to abandon their hopes of becoming a physician. Consistent with reports over more than 50 years, it appears that undergraduate courses in chemistry have the effect of discouraging otherwise qualified students, as reflected in their admission to one of the most highly selective public universities in the US, from continuing in premedical studies, especially in the case of URM students. Reassessment of this role for chemistry courses may be overdue

Psychosocial stress and strategies for managing adversity: measuring population resilience in New South Wales, Australia

<p>Abstract</p> <p>Background</p> <p>Populations around the world are facing an increasing number of adversities such as the global financial crisis, terrorism, conflict, and climate change. The aim of this paper was to investigate self-reported strategies and sources of support used to get through "tough times" in an Australian context and to identify patterns of response in the general population and differences in potentially vulnerable subgroups.</p> <p>Methods</p> <p>Data were collected through a cross-sectional survey of the New South Wales population in Australia. The final sample consisted of 3,995 New South Wales residents aged 16 years and above who responded to the question: "What are the things that get you through tough times?"</p> <p>Results</p> <p>Respondents provided brief comments that were coded into 14 main subject-area categories. The most frequently reported responses were family and self (52%); friends and neighbors (21%); use of positive emotional and philosophical strategies (17%), such as sense of humor, determination, and the belief that things would get better; and religious beliefs (11%). The responses of four population subgroups were compared, based on gender, household income, level of psychological distress, and whether a language other than English was spoken at home. Women reported greater use of friends and neighbors and religious or spiritual beliefs for support, whereas men reported greater use of drinking/smoking and financial supports. Those with lower incomes reported greater reliance on positive emotional and philosophical strategies and on religious or spiritual beliefs. Those with high levels of psychological distress reported greater use of leisure interests and hobbies, drinking/smoking, and less use of positive lifestyle strategies, such as adequate sleep, relaxation, or work/life balance. Those who spoke a language other than English at home were less likely to report relying on self or others (family/friends) or positive emotional and philosophical strategies to get through tough times.</p> <p>Conclusions</p> <p>Understanding strategies and sources of support used by the population to get through adversity is the first step toward identifying the best approaches to build and support strengths and reduce vulnerabilities. It is also possible to reflect on how large-scale threats such as pandemics, disasters, conflict, bereavement, and loss could impact individual and population resilience.</p

Clinical Significance of Symptoms in Smokers with Preserved Pulmonary Function

Currently, the diagnosis of chronic obstructive pulmonary disease (COPD) requires a ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.70 as assessed by spirometry after bronchodilator use. However, many smokers who do not meet this definition have respiratory symptoms

Respiratory Symptoms Items from the COPD Assessment Test Identify Ever-Smokers with Preserved Lung Function at Higher Risk for Poor Respiratory Outcomes

Rationale: Ever-smokers without airflow obstruction scores greater than or equal to 10 on the COPD Assessment Test (CAT) still have frequent acute respiratory disease events (exacerbation-like), impaired exercise capacity, and imaging abnormalities. Identification of these subjects could provide new opportunities for targeted interventions. Objectives: We hypothesized that the four respiratory-related items of the CAT might be useful for identifying such individuals, with discriminative ability similar to CAT, which is an eight-item questionnaire used to assess chronic obstructive pulmonary disease impact, including nonrespiratory questions, with scores ranging from 0 to 40. Methods: We evaluated ever-smoker participants in the Subpopulations and Intermediate Outcomes in COPD Study without airflow obstruction (FEV1/FVC≥0.70; FVC above the lower limit of normal). Using the area under the receiver operating characteristic curve, we compared responses to both CAT and the respiratory symptom–related CAT items (cough, phlegm, chest tightness, and breathlessness) and their associations with longitudinal exacerbations. We tested agreement between the two strategies (k statistic), and we compared demographics, lung function, and symptoms among subjects identified as having high symptoms by each strategy. Results: Among 880 ever-smokers with normal lung function (mean age, 61 yr; 52% women) and using a CAT cutpoint greater than or equal to 10, we classified 51.8% of individuals as having high symptoms, 15.3% of whom experienced at least one exacerbation during 1-year follow-up. After testing sensitivity and specificity of different scores for the first four questions to predict any 1-year followup exacerbation, we selected cutpoints of 0–6 as representing a low burden of symptoms versus scores of 7 or higher as representing a high burden of symptoms for all subsequent comparisons. The four respiratory-related items with cutpoint greater than or equal to 7 selected 45.8% participants, 15.6% of whom experienced at least one exacerbation during follow-up. The two strategies largely identified the same individuals (agreement, 88.5%; k = 0.77; P \u3c 0.001), and the proportions of high-symptoms subjects who had severe dyspnea were similar between CAT and the first four CAT questions (25.9% and 26.8%, respectively), as were the proportions reporting impaired quality of life (66.9% and 70.5%, respectively) and short walking distance (22.4% and 23.1%, respectively). There was no difference in area under the receiver operating characteristic curve to predict 1-year follow-up exacerbations (CAT score ≥10, 0.66; vs. four respiratory items from CAT ≥ 7 score, 0.65; P = 0.69). Subjects identified by either method also hadmore depression/anxiety symptoms, poor sleep quality, and greater fatigue. Conclusions: Four CAT items on respiratory symptoms identified high-risk symptomatic ever-smokers with preserved spirometry as well as the CAT did. These data suggest that simpler strategies can be developed to identify these high-risk individuals in primary care