Réflexions des directeurs de programme sur les réformes des politiques nationales en matière d’éducation médicale : regards portés sur la prise de décision, l’agrément et le cadre CanMEDS

Background: Outcomes of national policy change impact all levels of the organizational hierarchy. The medical education literature is sparse on how reflections from program directors (PDs) on past large-scale policy changes can inform future policy initiatives. To fill this gap, we conducted a national survey on PDs’ perceptions of, and reflections on, decision-making in medical education, accreditation procedures, and the CanMEDS framework implementation. Methods: The survey was distributed to former Canadian specialty medicine PDs (N = 684). Descriptive analysis was performed on quantitative data, thematic analysis was performed on qualitative comments, and comparisons between the quantitative and qualitative findings were performed to identify areas of convergence and/or divergence. Results: A total of 265 (38.7%) former PDs participated. Quantitative analysis revealed that 52.8% of respondents did not feel involved in decision-making regarding policy changes, 45.1% of respondents did not feel prepared to assess the CanMEDS Roles, and PDs were divided on the reasonableness of accreditation documentation. Qualitative analysis produced four themes: communication, resources, expectations of outcomes, and buy-in. Nine sub-themes were also identified. A high level of convergence was identified across the content, with only four areas of divergence identified. Conclusions: Our findings have the potential to inform future policy and/or accreditation changes. Without the lens of those charged with overseeing the implementation, policy evaluation and quality improvement will remain uninformed. PDs, therefore, bring unique insights into our understanding of national policy changes, and without the voices of these frontline implementers, the true success of policy change implementation will be hindered.Contexte: Les effets des changements apportés aux politiques nationales se font sentir à tous les niveaux de la hiérarchie organisationnelle. La littérature traite peu du fait que l’opinion des directeurs de programme (DP) concernant les réformes d’envergure intervenues dans les politiques sur l'éducation médicale par le passé peut servir à éclairer les révisions de politiques futures. Afin de combler cette lacune, nous avons mené une enquête nationale pour sonder les DP sur leurs perceptions et réflexions quant à la prise de décision dans l'éducation médicale, aux procédures d'agrément et à la mise en œuvre du cadre CanMEDS. Méthodes: Le sondage a été distribué aux anciens DP en médecine spécialisée du Canada (N = 684). Les données quantitatives ont fait l'objet d'une analyse descriptive, les commentaires qualitatifs d'une analyse thématique, et une comparaison entre les résultats quantitatifs et qualitatifs a été effectuée pour repérer les domaines de convergence et de divergence. Résultats: Un total de 265 (38.7%) anciens DP ont participé au sondage. L'analyse quantitative a révélé que 52.8% des répondants ne se sentaient pas inclus dans la prise de décision en matière de changements de politiques, que 45.1% des répondants ne se sentaient pas en mesure d’évaluer les rôles CanMEDS, et qu’ils étaient partagés sur la question du caractère raisonnable des documents d'agrément. L'analyse qualitative a permis de dégager quatre thèmes: la communication, les ressources, les attentes en matière de résultats et l'adhésion. Neuf sous-thèmes ont également été définis. Nous avons constaté un niveau élevé de convergence sur l'ensemble du contenu, des divergences n'apparaissant que dans quatre domaines. Conclusions: Nos conclusions peuvent servir à orienter les changements futurs en matière de politiques et d'agrément. Sans le regard de ceux qui sont chargés de superviser leur mise en œuvre, l'évaluation des politiques et l'amélioration de la qualité demeureront mal fondées. La perspective unique des DP est essentielle à notre compréhension des révisions des politiques, et sans la contribution de ces responsables de première ligne de leur application, les réformes ne pourront être mises en œuvre de façon optimale

Immorality and Irrationality

Does immorality necessarily involve irrationality? The question is often taken to be among the deepest in moral philosophy. But apparently deep questions sometimes admit of deflationary answers. In this case we can make way for a deflationary answer by appealing to dualism about rationality, according to which there are two fundamentally distinct notions of rationality: structural rationality and substantive rationality. I have defended dualism elsewhere. Here, I’ll argue that it allows us to embrace a sensible – I will not say boring – moderate view about the relationship between immorality and irrationality: roughly, that immorality involves substantive irrationality, but not structural irrationality. I defend this moderate view, and argue that many of the arguments for less moderate views turn either on missing the distinction between substantive and structural rationality, or on misconstruing it

Protein kinase B controls transcriptional programs that direct cytotoxic T cell fate but is dispensable for T cell metabolism

SummaryIn cytotoxic T cells (CTL), Akt, also known as protein kinase B, is activated by the T cell antigen receptor (TCR) and the cytokine interleukin 2 (IL-2). Akt can control cell metabolism in many cell types but whether this role is important for CTL function has not been determined. Here we have shown that Akt does not mediate IL-2- or TCR-induced cell metabolic responses; rather, this role is assumed by other Akt-related kinases. There is, however, a nonredundant role for sustained and strong activation of Akt in CTL to coordinate the TCR- and IL-2-induced transcriptional programs that control expression of key cytolytic effector molecules, adhesion molecules, and cytokine and chemokine receptors that distinguish effector versus memory and naive T cells. Akt is thus dispensable for metabolism, but the strength and duration of Akt activity dictates the CTL transcriptional program and determines CTL fate

Living standards and plague in London, 1560–1665

This article uses individual records of 930,000 burials and 630,000 baptisms to reconstruct the spatial and temporal patterns of birth and death in London from 1560 to 1665, a period dominated by recurrent plague. The plagues of 1563, 1603, 1625, and 1665 appear of roughly equal magnitude, with deaths running at five to six times their usual rate, but the impact on wealthier central parishes falls markedly through time. Tracking the weekly spread of plague, we find no evidence that plague emerged first in the docks, and in many cases elevated mortality emerges first in the poor northern suburbs. Looking at the seasonal pattern of mortality, we find that the characteristic autumn spike associated with plague continued into the early 1700s. Natural increase improved as smaller crises disappeared after 1590, but fewer than half of those born survived childhood

Probing the isovector transition strength of the low-lying nuclear excitations induced by inverse kinematics proton scattering

A compact approach based on the folding model is suggested for the determination of the isoscalar and isovector transition strengths of the low-lying ($\Delta S=\Delta T=0$) excitations induced by inelastic proton scattering measured with exotic beams. Our analysis of the recently measured inelastic $^{18,20}$O+p scattering data at $E_{\rm lab}=30$ and 43 MeV/nucleon has given for the first time an accurate estimate of the isoscalar $\beta_0$ and isovector $\beta_1$ deformation parameters (which cannot be determined from the (p,p') data alone by standard methods) for 2$^+_1$ and $3^-_1$ excited states in $^{18,20}$O. Quite strong isovector mixing was found in the 2$^+_1$ inelastic $^{20}$O+p scattering channel, where the strength of the isovector form factor $F_1$ (prototype of the Lane potential) corresponds to a $\beta_1$ value almost 3 times larger than $\beta_0$ and a ratio of nuclear transition matrix elements $M_n/M_p\simeq 4.2$.Comment: 5 pages, 3 figure

Nuclear Transparency to Intermediate-Energy Protons

Nuclear transparency in the (e,e'p) reaction for 135 < Tp < 800 MeV is investigated using the distorted wave approximation. Calculations using density-dependent effective interactions are compared with phenomenological optical potentials. Nuclear transparency is well correlated with proton absorption and neutron total cross sections. For Tp < 300 MeV there is considerable sensitivity to the choice of optical model, with the empirical effective interaction providing the best agreement with transparency data. For Tp > 300 MeV there is much less difference between optical models, but the calculations substantially underpredict transparency data and the discrepancy increases with A. The differences between Glauber and optical model calculations are related to their respective definitions of the semi-inclusive cross section. By using a more inclusive summation over final states the Glauber model emphasizes nucleon-nucleon inelasticity, whereas with a more restrictive summation the optical model emphasizes nucleon-nucleus inelasticity; experimental definitions of the semi-inclusive cross section lie between these extremes.Comment: uuencoded gz-compressed tar file containing revtex and bbl files and 5 postscript figures, totalling 31 pages. Uses psfi

Diatoms as indicators of fine sediment stress

Excessive delivery of fine sediments to water bodies has a detrimental impact on the biotic elements used for water body status classification. Although diatoms are typically used to assess stress from eutrophication, as fine sediment has the potential to impact diatoms in many ways, it is not surprising that an index based on benthic diatom assemblages has been proposed: the relative abundance of motile species. This measure is based on the fact that many raphid diatom species are capable of migrating through deposited sediment to avoid negative impacts. However, the use of such an index has yet to be fully tested. Various data analysis techniques were used to explore how indices based on diatom assemblages (related to eutrophication and siltation), diatom species, the traits motility, and nutrient affinity responded to a gradient of percentage cover of fine sediment. Although diatom species showed marked variation in their affinity for percentage cover of fine sediment, the relationship between motility (both percent motile and the trait motility) and deposited fine sediment is not sufficiently strong to be used as a reliable indicator of fine sediment stress. We present an approach, which could potentially be used to develop a new index (diatom indicator of sediment conditions) on the basis of the response of diatoms to fine sediment, but caution that this index requires further development before use. Despite the hydromorphology having considerable potential to affect benthic diatoms, existing indices designed to assess eutrophication were robust to hydromorphological modification, reducing the possibility of false diagnosis of impacts

Lived experience of vulnerability from a Gypsy Roma Traveller perspective.

AIMS AND OBJECTIVES: To describe the lived experience of vulnerability of individuals within a Gypsy Roma Travelling community. BACKGROUND: People experience vulnerability whenever their health or usual functioning is compromised. This may increase when they enter unfamiliar surroundings, situations or relationships. One's experience of vulnerability can also be heightened through interactions between the individual and the society within which they live. Gypsy Roma Travellers are often identified as vulnerable owing to increased morbidity and mortality as well as their marginalised status within society. Yet little is known of the experiences of vulnerability by the individuals themselves. Without their stories and experiences, health professionals cannot effectively develop services that meet their needs. DESIGN: This descriptive phenomenological study sought to explore the lived experience of vulnerability in a Gypsy Roma Travelling community. METHODS: Seventeen Gypsy Roma Travellers were interviewed in 2013-2014 about their experiences of feeling vulnerable. This paper reports on the findings from the depth phase in which 13 individuals were interviewed. The interviews were conducted and analysed using Giorgi's descriptive phenomenological approach. FINDINGS: Six constituents of the phenomenon of vulnerability were identified as feeling: defined and homogenised as a group; pressurised to conform to live in a particular way; split in one's identity; a loss of one's heritage; discriminated, persecuted and threatened; and powerlessness. RELEVANCE TO CLINICAL PRACTICE: There is a wealth of evidence that Gypsy Roma Travellers experience high levels of morbidity and mortality, which has led to them being identified by health professionals and policy makers as a vulnerable community. Exploring their lived experience of vulnerability presents a different perspective regarding this concept and can help explain why they may experience poorer levels of physical and mental health