This reference file was created as part of the Massage Medical Applications Project (MMAP). It contains selected articles from the medical literature on professionalism, competence, outcome-based education, and legal liability to physicians from use of CAM and CAM professionals. These form a meta-context for massage medical applications. Last modified 21 January 2006. Brian Mavis author Peter Vasilenko author Rae Schnuth author Joseph Marshall author Madeline Colavito Jeffs author 2005-Dec text continuing periodical academic journal 1040-2446 2005-Dec 80 12 1159 1165 Purpose In obstetrics and gynecology (ob-gyn), a physician's gender can affect patients' access to care as well as medical education curricula and career counseling. The authors focused on the importance that female patients place on various physician characteristics, and how this importance varied by patients' characteristics and compared for family practitioners, obstetrician-gynecologists, and surgeons. Method In 1999-2000, an anonymous questionnaire was distributed for one week to all women scheduled for an ob-gyn visit at six community campuses of Michigan State University College of Human Medicine. The first section of the questionnaire listed 16 physician characteristics and asked patients to rate the importance of each using a six-point scale (1 = not at all important, to 6 = very important). The items were presented three times, in reference to the patients' choice of a family physician, ob-gyn, and surgeon. The questionnaire also asked for patients' demographic information. Descriptive statistics were used to summarize patient demographics and ratings. Multivariate relationships were tested using analyses of variance (repeated-measures analysis of variance [ANOVA]) and multiple regression. Results In the 1,059 completed questionnaires, items related to physician gender were among the lowest rated, regardless of specialty. A factor analysis resulted in a three factor solution: Interpersonal Communications, Clinical Competence, and Gender. Interpersonal Communications ratings varied least by physician specialty and patient characteristics; Gender ratings varied most. Physician behaviors rather than physician attributes play an important role in women's choices. Conclusions For most women, physician gender was one of the least important characteristics, regardless of specialty. Excellent skills might give all physicians an edge in patients' choice decisions, a finding contrary to widely held beliefs about more limited future opportunities for men in some specialties. Mavis2005 http://www.academicmedicine.org/cgi/content/abstract/80/12/1159 Transcending Suffering Thomas R Egnew author 2005-05-01 text continuing periodical academic journal PURPOSE Medicine is traditionally considered a healing profession, but it has neither an operational definition of healing nor an explanation of its mechanisms beyond the physiological processes related to curing. The objective of this study was to determine a definition of healing that operationalizes its mechanisms and thereby identifies those repeatable actions that reliably assist physicians to promote holistic healing. METHODS This study was a qualitative inquiry consisting of in-depth, open-ended, semistructured interviews with Drs. Eric J. Cassell, Carl A. Hammerschlag, Thomas S. Inui, Elisabeth Kubler-Ross, Cicely Saunders, Bernard S. Siegel, and G. Gayle Stephens. Their perceptions regarding the definition and mechanisms of healing were subjected to grounded theory content analysis. RESULTS Healing was associated with themes of wholeness, narrative, and spirituality. Healing is an intensely personal, subjective experience involving a reconciliation of the meaning an individual ascribes to distressing events with his or her perception of wholeness as a person. CONCLUSIONS Healing may be operationally defined as the personal experience of the transcendence of suffering. Physicians can enhance their abilities as healers by recognizing, diagnosing, minimizing, and relieving suffering, as well as helping patients transcend suffering. Egnew2005 http://annalsfm.highwire.org/cgi/content/abstract/3/3/255 2005-5-1 3 3 255 262 David T Stern author Miriam Friedman Ben-David author Andre De Champlain author Brian Hodges author Andrzej Wojtczak author M Roy Schwarz author 2005-May text continuing periodical academic journal 0142-159X 2005-May 27 3 207 213 Increasing physician and patient mobility has led to a move toward internationalization of standards for physician competence. The Institute for International Medical Education proposed a set of outcome-based standards for student performance, which were then measured using three assessment tools in eight leading schools in China: a 150-item multiple-choice examination, a 15-station OSCE and a 16-item faculty observation form. The purpose of this study was to empanel a group of experts to determine whether international student-level performance standards could be set. The IIME convened an international panel of experts in student education with specialty and geographic diversity. The group was split into two, with each sub-group establishing standards independently. After a discussion of the borderline student, the sub-groups established minimally acceptable cut-off scores for performance on the multiple-choice examination (Angoff and Hofstee methods), the OSCE station and global rating performance (modified Angoff method and holistic criterion reference), and faculty observation domains (holistic criterion reference). Panelists within each group set very similar standards for performance. In addition, the two independent parallel panels generated nearly identical performance standards. Cut-off scores changed little before and after being shown pilot data but standard deviations diminished. International experts agreed on a minimum set of competences for medical student performance. In addition, they were able to set consistent performance standards with multiple examination types. This provides an initial basis against which to compare physician performance internationally. Stern2005 10.1080/01421590500129571 Susan Eggly author Simone Brennan author Wilhelmine Wiese-Rometsch author 2005-Apr text continuing periodical academic journal 1040-2446 2005-Apr 80 4 371 375 PURPOSE: To identify the degree to which interns' reported experiences with professional and unprofessional behavior converge and/or diverge with ideal professional behavior proposed by the physician community. METHOD: Interns at Wayne State University's residency programs in internal medicine, family medicine, and transitional medicine responded to essay questions about their experience with professional and unprofessional behavior as part of a curriculum on professionalism. Responses were coded for whether they reflected each of the principles and responsibilities outlined in a major publication on physician professionalism. Content analysis included the frequencies with which the interns' essays reflected each principle or responsibility. Additionally, a thematic analysis revealed themes of professional behavior that emerged from the essays. RESULTS: Interns' experiences with professional and unprofessional behavior most frequently converged with ideal behavior proposed by the physician community in categories involving interpersonal interactions with patients. Interns infrequently reported experiences involving behavior related to systems or sociopolitical issues. CONCLUSIONS: Interns' essays reflect their concern with interpersonal interactions with patients, but they are either less exposed to or less interested in describing behavior regarding systems or sociopolitical issues. This may be due to their stage of training or to the emphasis placed on interpersonal rather than systems or sociopolitical issues during training. The authors recommend future proposals of ideal professional behavior be revised periodically to reflect current experiences of practicing physicians, trainees, other health care providers and patients. Greater educational emphasis should be placed on the systems and sociopolitical environment in which trainees practice. Eggly2005 http://www.academicmedicine.org/cgi/content/abstract/80/4/371 Michael H Cohen author Andrea Hrbek author Roger B Davis author Steven C Schachter author Kathi J Kemper author Edward W Boyer author David M Eisenberg author 2005-Feb-14 text continuing periodical academic journal 0003-9926 2005-Feb-14 165 3 289 295 BACKGROUND: Little is known about policies governing the integration of complementary and alternative medical (CAM) therapies and providers. METHODS: To document emerging approaches in 19 US hospitals regarding credentialing, malpractice liability, and pharmacy policies governing integration of CAM therapies and providers into conventional medical settings, we surveyed 21 academic medical centers and 13 non-academically affiliated hospitals that are nationally visible and are integrating CAM therapies into conventional medical settings. Of the 19 respondents, 11 were tertiary care hospitals, 6 were community hospitals, 1 was a freestanding center associated with a community-based hospital, and 1 was a university-based rehabilitation hospital. RESULTS: Institutions had no consistent approach to provider mix and authority within the integrative care team, and minimum requirements for professional liability insurance, informed consent disclosure, and hiring status. Less than a third had a formal (stated) policy concerning dietary supplements; those selling supplements in their pharmacy lacked consistent, evidence-based rationales regarding which products and brands to include or exclude. Although many hospitals confiscated patient supplements on admission, institutions had inconsistent criteria regarding allowance of home supply. CONCLUSIONS: Hospitals are using heterogeneous approaches to address licensure, credentialing, scope of practice, malpractice liability, and dietary supplement use in developing models of integrative care. The environment creates significant impediments to the delivery of consistent clinical care and multisite evaluations of the safety, efficacy, and cost-effectiveness (or lack thereof) of CAM therapies (or integrative models) as applied to management of common medical conditions. Consensus policies need to be developed. Cohen2005 10.1001/archinte.165.3.289 J M Shumway author R M Harden author 2003-Nov text continuing periodical academic journal 0142-159X 2003-Nov 25 6 569 584 Two important features of contemporary medical education are recognized. The first is an emphasis on assessment as a tool to ensure quality in training programmes, to motivate students and to direct what they learn. The second is a move to outcome-based education where the learning outcomes are defined and decisions about the curriculum are based on these. These two trends are closely related. If teachers are to do a better job of assessing their students, they need an understanding of the assessment process, an appreciation of the learning outcomes to be assessed and a recognition of the most appropriate tools to assess each outcome. Assessment tools selected should be valid, reliable, practical and have an appropriate impact on student learning. The preferred assessment tool will vary with the outcome to be assessed. It is likely to be some form of written test, a performance test such as an OSCE in which the student's competence can be tested in a simulated situation, and a test of the student's behaviour over time in clinical practice, based on tutors' reports and students' portfolios. An assessment profile can be produced for each student which highlights the learning outcomes the student has achieved at the required standard and other outcomes where this is not the case. For educational as well as economic reasons, there should be collaboration across the continuum of education in test development as it relates to the assessment of learning outcomes and in the implementation of a competence-based approach to assessment. Shumway2003 10.1080/0142159032000151907 David T Stern author Andrzej Wojtczak author M Roy Schwarz author 2003-Nov text continuing periodical academic journal 0142-159X 2003-Nov 25 6 589 595 Using an international network of experts in medical education, the Institute for International Medical Education (IIME) developed the Global Minimum Essential Requirements (GMER) as a set of competence-based outcomes for graduating students. To establish a set of tools to evaluate these competences, the IIME then convened a Task Force of international experts on assessment that reviewed the GMER. After screening 75 potential assessment tools, they identified three that could be used most effectively. Of the 60 competences envisaged in the GMER, 36 can be assessed using a 150-item multiple-choice question (MCQ) examination, 15 by using a 15-station objective structured clinical examination (OSCE), and 17 by using a 15-item faculty observation form. In cooperation with eight leading medical schools in China, the MCQ, OSCE and Faculty Observation Form were developed to be used in an assessment program that is scheduled to be given to all seven-year students in October 2003. Stern2003 10.1080/0142159032000151295 Eileen J Klein author J Craig Jackson author Lyn Kratz author Edgar K Marcuse author Heather A McPhillips author Richard P Shugerman author Sandra Watkins author F Bruder Stapleton author 2003-01-01 text continuing periodical academic journal The need to teach professionalism during residency has been affirmed by the Accreditation Council for Graduate Medical Education, which will require documentation of education and evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has proposed the following components of professionalism be taught and measured: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The authors describe a curriculum for introducing the above principles of professionalism into a pediatrics residency that could serve as a model for other programs. The curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions devoted to addressing key professionalism issues. The authors also explain how the retreat is evaluated and how the retreat's topics are revisited during the residency, and discuss general issues of teaching and evaluating professionalism. Klein2003 http://www.academicmedicine.org/cgi/content/abstract/78/1/26 2003-1-1 78 1 26 34 GMER Core Committee 2002-Mar text continuing periodical academic journal 0142-159X 2002-Mar 24 2 130 135 The process of globalization is increasingly evident in medical education and makes the task of defining global essential competences required by 'global physicians' an urgent matter. This issue was addressed by the newly established Institute for International Medical Education (IIME). The IIME Core Committee developed the concept of 'global minimum essential requirements' ('GMER') and defined a set of global minimum learning outcomes that medical school students must demonstrate at graduation. The 'Essentials' are grouped under seven broad educational domains with a set of 60 learning objectives. Besides these 'global competences', medical schools should add national and local requirements. The focus on student competences as outcomes of medical education should have deep implications for curricular content as well as the educational processes of medical schools. GMER_CORE2002 10.1080/01421590220120731 http://www.iime.org/documents/gmer.htm David M Eisenberg author Michael H Cohen author Andrea Hrbek author Jonathan Grayzel author Maria I Van Rompay author Richard A Cooper author 2002-Dec-17 text continuing periodical academic journal 1539-3704 2002-Dec-17 137 12 965 973 Since the late 19th century, state legislatures and professional medical organizations have developed mechanisms to license physicians and other conventional nonphysician providers, establish standards of practice, and protect health care consumers by establishing standardized credentials as markers of competence. The popularity of complementary and alternative medical (CAM) therapies presents new challenges. This article describes the current status of, and central issues in, efforts to create models for health care credentialing of chiropractors, acupuncturists, naturopaths, massage therapists, and other CAM practitioners. It also suggests a strategy of CAM provider credentialing for use by physicians, health care administrators, insurance companies, and national professional organizations. The credentialing debate reflects fundamental questions about who determines which providers and therapies will be accepted as safe, effective, appropriate, and reimbursable. More nationally uniform credentialing mechanisms are necessary to ensure high standards of care and more generalizable clinical research. However, the result of more uniform licensure and credentialing may be excessive standardization and a decrease in individualization of services. Thus, increased standardization of credentialing for CAM practitioners may alter CAM practice substantially. Furthermore, even credentialed providers can deliver ineffective therapy. The suggested framework balances the desire to protect the public from dangerous practices against the wish to grant patients access to reasonably safe and effective therapies. Eisenberg2002 http://www.annals.org/cgi/content/abstract/137/12/965 Michael H Cohen author David M Eisenberg author 2002-Apr-16 text continuing periodical academic journal 1539-3704 2002-Apr-16 136 8 596 596 Physicians are increasingly grappling with medical liability issues as complementary and integrative health care practices are made available in conventional medical settings. This article proposes a framework in which physicians can assess potential malpractice liability issues in counseling patients about complementary and integrative therapies. The framework classifies complementary and integrative therapies according to whether the evidence reported in the medical and scientific literature supports both safety and efficacy; supports safety, but evidence regarding efficacy is inconclusive; supports efficacy, but evidence regarding safety is inconclusive; or indicates either serious risk or inefficacy. Clinical examples in each category help guide the clinician on how to counsel patients regarding use of complementary and alternative medical therapies in a given clinical situation. Specific strategies to reduce the risk for potential malpractice liability include the following: 1) determine the clinical risk level; 2) document the literature supporting the therapeutic choice; 3) provide adequate informed consent; 4) continue to monitor the patient conventionally; and 5) for referrals, inquire about the competence of the complementary and alternative medicine provider. This framework provides a basis for clinical decisions involving complementary and integrative care. Cohen2002 http://www.annals.org/cgi/content/abstract/136/8/596 M Roy Schwarz author Andrzej Wojtczak author 2002-Mar text continuing periodical academic journal 0142-159X 2002-Mar 24 2 125 129 With the growing globalization of medicine and the emerging concept of a 'global profession of physicians', the issue of the essential competences that all physicians must possess becomes sharply focused. If defined, these competences would help indicate what teachers are supposed to teach, what students are expected to learn and what educational experiences all physicians must have. The 'minimum essential competences' that all graduates must have if they wish to be called physicians were identified by the Institute for International Medical Education (IIME), sponsored by the China Medical Board of New York, through working groups of educational and health policy experts and representatives of major international medical education organizations. In the first phase of the project, seven domains have been identified that define the knowledge, skills, professional behavior and ethics that all physicians must have, regardless of where they received their general medical training. Appropriate tools to assess each of the domains have been identified. In the second phase of the project the 'global minimum essential requirements' (GMER) will be implemented experimentally in a number of Chinese medical schools. The aim of the third phase will be to share the outcomes of this educational experiment, aimed at improving the quality of medical education, with the global education community. Schwarz2002 10.1080/01421590220120740 http://www.iime.org/documents/sv.htm R M Harden author 2002-Mar text continuing periodical academic journal 0142-159X 2002-Mar 24 2 151 155 Learning outcomes are broad statements of what is achieved and assessed at the end of a course of study. The concept of learning outcomes and outcome-based education is high on today's education agenda. The idea has features in common with the move to instructional objectives which became fashionable in the 1960s, but which never had the impact on education practice that it merited. Five important differences between learning outcomes and instructional objectives can be recognized: (1) Learning outcomes, if set out appropriately, are intuitive and user friendly. They can be used easily in curriculum planning, in teaching and learning and in assessment. (2) Learning outcomes are broad statements and are usually designed round a framework of 8-12 higher order outcomes. (3) The outcomes recognize the authentic interaction and integration in clinical practice of knowledge, skills and attitudes and the artificiality of separating these. (4) Learning outcomes represent what is achieved and assessed at the end of a course of study and not only the aspirations or what is intended to be achieved. (5) A design-down approach encourages ownership of the outcomes by teachers and students. Harden2002 10.1080/0142159022020687 Ronald M Epstein author Edward M Hundert author 2002-Jan-09 text continuing periodical academic journal 0098-7484 2002-Jan-9 287 2 226 235 CONTEXT: Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. OBJECTIVES: To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment. DATA SOURCES: We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents. STUDY SELECTION: We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations. DATA EXTRACTION: Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs. DATA SYNTHESIS: We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes. CONCLUSIONS: In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs. Epstein2002 http://jama.ama-assn.org/cgi/content/abstract/287/2/226 Michael H Cohen author 2002-Jan text continuing periodical academic journal 0025-7125 2002-Jan 86 1 185 196 Physicians integrating CAM therapies into clinical practice face many legal challenges, including the fact that legal rules governing CAM providers and practices are new and evolving in many cases. Laws vary by state, and their application depends on the specific clinical scenario in question. As more evidence accumulates regarding safety and efficacy or lack thereof of specific therapies for given conditions, physicians will find clinical knowledge more abundantly mapped and that the parameters of liability are increasingly clear. Meanwhile, good clinical practice and a working knowledge of major legal rules can help provide physicians with a good measure of legal protection in situations involving integration of CAM providers and therapies in conventional medical practice. Cohen2002 10.1016/S0025-7125(03)00080-4 http://www.medical.theclinics.com/article/PIIS0025712503000804/abstract Johanna Shapiro author 2002-04-01 text continuing periodical academic journal To explore how primary care clinician--teachers actually attempt to convey empathy to medical students and residents, the author carried out a qualitative study in 1999-2000 in which 12 primary care physicians reflected on their views of empathy, how they demonstrated empathy to patients, and how they went about teaching empathy to learners. Interview data were triangulated with observations of actual teaching sessions and informal questioning of students and residents who had been taught by the faculty participants. Grounded theory was used to interpret the data. The faculty had clear conceptualizations of what empathy meant in clinical practice, but differed as to whether it was primarily a measurable, behavioral skill or a global attitude. Respondents stressed the centrality of role modeling in teaching, and most used debriefing strategies, as well as both learner- and patient-centered approaches, in instructing learners about empathy. Findings suggest that limiting the teaching of empathy to a skill-based approach does not reflect the richness of what actually occurs in the clinical setting, and that it is important to teach empathy comprehensively, acknowledging both behavioral and attitudinal tools. Shapiro2002 http://www.academicmedicine.org/cgi/content/abstract/77/4/323 2002-4-1 77 4 323 328 Friedman Ben David author Davis author Harden author Howie author Ker author Pippard author 2001-Oct text continuing periodical academic journal 0142-159X 2001-Oct 23 6 535 535 This guide is intended to inform medical teachers about the use of portfolios for student assessment. It provides a background to the topic, reviews the range of assessment purposes for which portfolios have been used, identifies possible portfolio contents and outlines the advantages of portfolio assessment with particular focus on assessing professionalism. The experience of one medical school, the University of Dundee, is presented as a case study. The current state of understanding of the technical, psychometric issues relating to portfolio assessment is clarified. The final part of the paper provides a practical guide for those wishing to design and implement portfolio assessment in their own institutions. Five steps in the portfolio assessment process are identified: documentation, reflection, evaluation, defence and decision. It is concluded that portfolio assessment is an important addition to the assessor's toolkit. Reasons for using portfolios for assessment purposes include the impact that they have in driving student learning and their ability to measure outcomes such as professionalism that are difficult to assess using traditional methods. Friedman Ben David2001 10.1080/01421590120090952 Andrzej Wojtczak author M Roy Schwarz author 2000-November text continuing Taylor & Francis periodical academic journal Increasing globalization of medicine and worldwide migration of physicians call for urgent definition of a set of global standards and requirements to guide medical education curricula. This article reviews the definition of standards in general, and proposes a definition of standards and global minimum essential requirements for use in medical education. They may serve as a tool for the improvement of quality and international comparisons of basic medical programs. Reviewing the use of medical standards worldwide, the China Medical Board established the Institute for International Medical Education (IIME). The IIME project is aimed at defining 'global minimum essential requirements' comprising sciences basic to medicine, clinical knowledge and skills, professional values, behavior and ethics of universal value. They represent only a portion of requirements since the curriculum of each country and medical school has to address its unique health and social needs. Finally, existing impediments and hesitation in use of international standards in medical education are presented. Wojtczak2000 10.1080/01421590050175514 http://www.iime.org/documents/vs.htm 2000-November 22 6 555 559 K M Markakis author H B Beckman author A L Suchman author R M Frankel author 2000-Feb text continuing periodical academic journal 1040-2446 2000-Feb 75 2 141 150 Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes, and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician. Markakis2000 http://www.academicmedicine.org/cgi/content/abstract/75/2/141 Harden author Grant author Buckley author Hart author 2000 text continuing periodical academic journal 1382-4996 2000 5 1 71 71 There is a need to move from opinion-based education to evidence-based education. Best Evidence Medical Education (BEME) is the implementation, by teachers in their practice, of methods and approaches to education based on the best evidence available. It involves a professional judgement by the teacher about their teaching taking into account a number of factors - the QUESTS dimensions. The Quality of the research evidence available - how reliable is the evidence?, the Utility of the evidence - can the methods be transferred and adopted without modification?, the Extent of the evidence, the Strength of the evidence, the Target or outcomes measured - how valid is the evidence? and the Setting or context - how relevant is the evidence?The evidence available can be graded on each of the six dimensions. In the ideal situation the evidence is high on all six dimensions, but this is rarely found. Usually the evidence may be good in some respects, but poor in others. The teacher has to balance the different dimensions and come to a decision on a course of action based on his or her professional judgement.The QUESTS dimensions highlight a number of tensions with regard to the evidence in medical education: quality v relevance; quality v validity; and utility v the setting or context. The different dimensions reflect the nature of research and innovation. Best Evidence Medical Education encourages a culture or ethos in which decision making takes place in this context. Harden2000 10.1023/A:1009896431203 D M Studdert author 1999 text continuing periodical academic journal 0098-8421 1999 54 4 173 176 As use of alternative therapies grows, there appears to be heightened concern among health care professionals about the liability implications of delivering these therapies. Little is known about malpractice law in this area. We begin by reviewing the type and frequency of claims brought against alternative medicine practitioners and by analyzing the standard of care to which these practitioners are held when sued. Next we turn to the standard of care question as it relates to physicians (MDs/DOs) who incorporate alternative therapies into their practices. Few cases have addressed this question to date. We argue, however, that when courts decide cases at the intersection between conventional and alternative medicine, they may judge conduct according to standards enunciated by: 1) alternative medicine practitioners who regularly deliver the treatment at issue, 2) physicians who have established similar practices, or 3) conventional practitioners. This latter possibility should be taken seriously; it raises troubling questions for physicians at the outset of the negligence inquiry. Available case law highlights the importance of ensuring that patients are fully informed about any alternative therapies they elect to receive, as well as any conventional treatments they may be foregoing, and that patients expressly consent to treatment in light of this information, preferably in writing. Studdert1999 http://www.jamwa.org/index.cfm?objectid=33B3FE31-D567-0B25-598B91A9AD44B83E R M Harden J R Crosby M H Davis M Friedman 1999-November text continuing Taylor & Francis periodical academic journal Harden1999b 1999-November 21 6 546 552 Increased attention is being paid to the specification of learning outcomes.This paper provides a framework based on the three-circle model: what the doctor should be able to do ('doing the right thing'), the approaches to doing it ('doing the thing right') and the development of the individual as a professional ('the right person doing it').Twelve learning outcomes are specified, and these are further subdivided.The different outcomes have been defined at an appropriate level of generality to allow adaptability to the phases of the curriculum, to the subject matter, to the instructional methodology and to the students' learning needs. Outcomes in each of the three areas have distinct underlying characteristics.They move from technical competences or intelligences to meta-competences including academic, emotional, analytical, creative and personal intelligences. The Dundee outcome model offers an intuitive, user-friendly and transparent approach to communicating learning outcomes. It encourages a holistic and integrated approach to medical education and helps to avoid tension between vocational and academic perspectives.The framework can be easily adapted to local needs. It emphasizes the relevance and validity of outcomes to medical practice.The model is relevant to all phases of education and can facilitate the continuum between the different phases. It has the potential of facilitating a comparison between different training programmes in medicine and between different professions engaged in health care delivery. Harden1999b 10.1080/01421599978951 Problem-based learning: a practical guide M H Davis author 1999-March text continuing Taylor & Francis periodical academic journal This practical guide for health professions teachers provides a perspective of one of the most important educational developments in the past 30 years.Problem-based learning (PBL) is a continuum of approaches rather than one immutable process. It is a teaching method that can be included in the teacher's tool-kit along with other teaching methods rather than used as the sole educational strategy.PBL reverses the traditional approach to teaching and learning. It starts with individual examples or problem scenarios which stimulate student learning. In so doing, students arrive at general principles and concepts which they then generalize to other situations. PBL has many advantages. It facilitates the acquisition of generic competences, encourages a deep approach to learning and prepares students for the adult learning approach they need for a lifetime of learning in the health care professions. It is also fun. PBL helps in curriculum planning by defining core, ensuring relevance of content, integrating student learning and providing prototype cases. There are also drawbacks associated with PBL. Students may fail to develop an organized framework for their knowledge. The PBL process may inhibit good teachers sharing their enthusiasm for their topic with students and student identification with good teachers.Teachers may not have the skills to facilitate PBL.The problem scenario is of crucial significance. It should engage the students' interest and be skilfully written. While the medium selected for presentation of the scenario is usually print, other media may be used.The clinical tasks carried out by the student may replace the problem scenario as the focus for learning.Students are supported during the PBL process by tutors and/or study guides.The amount of support required is inversely related to the students' prior learning and understanding of the PBL process. A range of additional learning resources and opportunities may be made available to the students, including textbooks, videotapes, computer-based material, lectures and clinical sessions. Tutors require group facilitation skills, an understanding of the PBL process and knowledge of the course and of the curriculum in general.They need special personal qualities and it is preferable if they have expertise in the content area.While special assessment processes have been developed to assess students learning by the PBL method, the general principles of assessment apply to PBL courses and a mixed menu of assessment methods needs to be employed. Curriculum design involves a skilful blend of educational strategies designed to help students achieve the curriculum outcomes. PBL may make a valuable contribution to this blend but attention needs to be paid to how it is implemented. Davis1999 10.1080/01421599979743 1999-March 21 2 130 140 Outcome-based education: Part 1-An introduction to outcome-based education R M Harden author 1999-January text continuing Taylor & Francis periodical academic journal Outcome-based education, a performance-based approach at the cutting edge of curriculum development, offers a powerful and appealing way of reforming and managing medical education.The emphasis is on the product-what sort of doctor will be produced-rather than on the educational process. In outcome-based education the educational outcomes are clearly and unambiguously specified. These determine the curriculum content and its organisation, the teaching methods and strategies, the courses offered, the assessment process, the educational environment and the curriculum timetable.They also provide a framework for curriculum evaluation. A doctor is a unique combination of different kinds of abilities. A three-circle model can be used to present the learning outcomes in medical education, with the tasks to be performed by the doctor in the inner core, the approaches to the performance of the tasks in the middle area, and the growth of the individual and his or her role in the practice of medicine in the outer area. Medical schools need to prepare young doctors to practise in an increasingly complex healthcare scene with changing patient and public expectations, and increasing demands from employing authorities. Outcome-based education offers many advantages as a way of achieving this. It emphasises relevance in the curriculum and accountability, and can provide a clear and unambiguous framework for curriculum planning which has an intuitive appeal. It encourages the teacher and the student to share responsibility for learning and it can guide student assessment and course evaluation. What sort of outcomes should be covered in a curriculum, how should they be assessed and how should outcome-based education be implemented are issues that need to be addressed. Harden1999a 10.1080/01421599979969 1999-January 21 1 7 14 Outcome-based education: Part 3-Assessment in outcome-based education Miriam Friedman Ben-David author 1999-January text continuing Taylor & Francis periodical academic journal The role of performance assessment in outcomebased education is discussed emphasizing the relationship and interplay between these two related paradigms. Issues of the relevancy of assessment to student learning are highlighted in the context of outcome-based education.The importance of defining assessment premises and the role of institutions in defining their educational philosophy as it pertains to student learning and assessment is also presented. A brief description of implementation guidelines of assessment programs in outcome-based education are presented indicating the key features of such programs. Ben-David1999 10.1080/01421599979987 1999-January 21 1 23 25 Outcome-based education: Part 4-Outcome-based learning and the electronic curriculum at Birmingham Medical School Nick Ross author 1999-January text continuing Taylor & Francis periodical academic journal Outcome-led curricula are increasingly relevant to medical education as Universities seek means to make explicit the criteria against which the success of both the course and the students should be judged. This paper outlines some of the main factors which led the University of Birmingham School of Medicine to develop an outcome-led curriculum for the new undergraduate medical course. Having set the general context, it then describes how the specific structure used by the school for organising integrative learning outcomes both influenced and was influenced by the parallel decision to develop an 'electronic curriculum'database.The advantages of the electronic curriculum database developed by the School are discussed and examples are given to demonstrate the flexibility with which information can be accessed by students, clinicians and other teachers. Ross1999 10.1080/01421599979996 1999-January 21 1 26 31 Outcome-based education: Part 2-Planning, implementing and evaluating a competency-based curriculum. Stephen R Smith author 1999-January text continuing Taylor & Francis periodical academic journal In September, 1996, Brown University School of Medicine inaugurated a new competency-based curriculum, known as MD2000, which defines a comprehensive set of competency requirements that all graduates are expected to attain. The medical students entering in 1996 and thereafter are required to demonstrate mastery in nine abilities as well as a comprehensive knowledge base as a requirement for graduation. Faculty use performance-based methods to determine if students have attained competence. We describe in this article the reasons why we developed the new curriculum, how we planned and structured it, and the significance we anticipate the curricular innovation will have on medical education. Smith1999 10.1080/01421599979978 1999-January 21 1 15 22 D M Studdert author D M Eisenberg author F H Miller author D A Curto author T J Kaptchuk author T A Brennan author 1998-Nov-11 text continuing periodical academic journal 0098-7484 1998-Nov-11 280 18 1610 1615 Although use of alternative therapies in the United States is widespread and growing, little is known about the malpractice experience of practitioners who deliver these therapies or about the legal principles that govern the relationship between conventional and alternative medicine. Using data from malpractice insurers, we analyzed the claims experience of chiropractors, massage therapists, and acupuncturists for 1990 through 1996. We found that claims against these practitioners occurred less frequently and typically involved injury that was less severe than claims against physicians during the same period. Physicians who may be concerned about their own exposure to liability for referral of patients for alternative treatments can draw some comfort from these findings. However, liability for referral is possible in certain situations and should be taken seriously. Therefore, we review relevant legal principles and case law to understand how malpractice law is likely to develop in this area. We conclude by suggesting some questions for physicians to ask themselves before referring their patients to alternative medicine practitioners. Studdert1998 http://jama.ama-assn.org/cgi/content/abstract/280/18/1610 K Capen author 1997-May-01 text continuing periodical academic journal 0820-3946 1997-May-1 156 9 1307 1308 The growing interest in alternative medicine has come to the attention of both Canadian licensing bodies and the courts. Two recent cases, a disciplinary hearing and a medical-malpractice action, illustrate that physicians need to understand the range and complexity of issues surrounding nonconventional therapies and their clinical use. Capen1997 http://www.cmaj.ca/cgi/content/abstract/156/9/1307