Richard J. Pels

Becoming a Doctor -- Critical-Incident Reports from Third-Year Medical Students

“Critical-incident reports” are short narratives of events judged to be particularly meaningful by participants in the events1–3. Our medical students wrote such reports at the beginning, in the mi...

A New educational approach for supporting the professional development of third-year medical students

This paper describes a new course designed to support the professional development of third-year medical students. The course runs through the clinical clerkships, and has several additional features: it includes a multidisciplinary faculty; it is centrally based in the medical school; it addresses students’ values and attitudes in addition to their knowledge and skills; and it makes use of small-group learning methods, and faculty, student, and group continuity during the year. The curriculum, which addresses ethical, social, and communicative issues in medicine, plus the evaluation of students and of the course, are described.

Medical students' empathic understanding of their patients.

No abstract available.

A First-Year Problem-based Curriculum in Health Promotion and Disease Prevention.

This paper describes Harvard Medical Schools integration of a curriculum on health promotion and disease prevention into the first year of its New Pathway to General Medical Education. The goals of the curriculum were to develop in each student (1) the knowledge and skills necessary to evaluate critically the major issues in prevention and (2) an attitude that acknowledges the pertinence of prevention in virtually every clinical encounter. The case method was used for all teaching in the curriculum, as it is throughout the New Pathway. Students worked together in small groups, addressing the issues raised by each case under the direction of faculty preceptors. The component was taught by clinicians as part of a two-year course in which students learned clinical skills and addressed topics from the social sciences and medical humanities. In addition, issues in health promotion and disease prevention were integrated into the cases used to teach the other components of the New Pathway curriculum.

Community Health Training for Internal Medicine Residents Working with Community Partners

Graduate and undergraduate medical training are incorporating public health curricula into their programs to enable future physicians to participate in public health activities and improve the health of the communities. This paper highlights two approaches to a community health curriculum implemented at the Cambridge Health Alliance Internal Medicine Training Program from 2008-2010. Between 2008 and 2009, the residency program incorporated a longitudinal curriculum for first-year residents. The goal of the curriculum was to expose residents to basic community health research models while giving them time to participate in a 1-year practicum with the Cambridge Public Health Department. Strengths included increasing resident knowledge about the local public health department and providing residents with an opportunity to work with staff and patients in that setting. Limitations of such a design included staff time constraints for coordinating with community partners as well as resident dissatisfaction with being involved in only select portions of an evolving project. This curriculum was therefore revised into a 1-month ambulatory block consisting of didactics and a practicum with the local YWCA in September 2010. Residents felt that this design yielded more time in didactics than in the practicum. Both designs offer important learning points in terms of practically incorporating public health activities in a tightly scheduled residency-training program. The current paper highlights the importance of partnering with a community organization such as a public health department or the YWCA. Emphasis is placed on the contributions that residents can make to these organizations while they learn how to integrate clinical and community health activities.

Hematuria and Proteinuria

Dipstick urinalysis (UA) is simple and quick to perform, has no morbidity (other than sometimes labeling a healthy person as sick), and is among the most commonly performed screening tests. It typically costs patients

Free Fall: Finding Solid Ground in the Treatment of a Patient with Catastrophic Injury

3 per test, but even this modest charge adds over

Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. II. Bacteriuria

150 million each year to health expenditures. This considerable expense, the potential morbidity of working up false positive results, and the fact that clinicians respond to less than two thirds of abnormal UAs1 justify a critical appraisal of this humble and non-invasive test. In this chapter, we review screening for asymptomatic urinary tract disease with the dipstick tests for hemoglobin and protein. In Chapter 38 we assess screening with the leukocyte esterase and nitrite dipsticks. We will not consider other components of the dipstick or the problem of multiple testing inherent in the multi-pad design of most dipsticks.

Dipstick urinalysis screening of asymptomatic adults for urinary tract disorders. I. Hematuria and proteinuria.

KT is a 30-year-old single, wheelchair-bound, paraplegic woman. Despite a recent increase in self-injurious behavior and numerous recommendations that she accept more psychiatric help, she has had limited psychiatric treatment since a severe physical injury ten years ago. Her case has presented continual diagnostic and therapeutic challenges because of her medical, psychiatric, and substance abuse comorbidities and her unwillingness to engage in ongoing psychiatric treatment. The third of five children, KT was born and raised in a working class New England city. Her oldest sister (36 years old) works cleaning houses; a sister (34 years old) currently works in a supermarket; a brother (28 years old) works in construction; and a sister (25 years old) is unemployed and lives with her boyfriend. Her father was a fireman and a heavy drinker. He is reported to have been verbally abusive to her mother and occasionally to KT. Nevertheless, KT notes that she was his “favorite” and that he was usually very good to her. Her special status with her father created “tension” between KT and her mother and siblings. The mother is described as “the strongest woman I ever knew,” although their relationship was always strained. KT’s parents separated when she was 7 years old. She spent the next nine years moving back and forth between her mother’s and father’s homes. KT notes that she was not much of a student, never liked school, and began to miss school regularly as an

Dipstick Urinalysis Screening of Asymptomatic Adults for Urinary Tract Disorders: II. Bacteriuria

Using criteria adopted by the US Preventive Services Task Force, we evaluated use of the dipstick urinalysis to screen for bacteriuria. When the leukocyte esterase and nitrite dipstick tests are combined, the positive predictive value for detecting bacteriuria exceeded 12% in groups with a 5% or higher prevalence of bacteriuria: women who are pregnant, diabetic, or over 60 years of age and all institutionalized elderly. Conventional antimicrobial regimens for asymptomatic bacteriuria have proved efficacious only for pregnant women. We conclude that pregnant women should be screened for bacteriuria, but with the more sensitive urine culture, because treatment prevents serious fetal and maternal sequelae. Dipstick screening may be justified in women who are over 60 years of age or diabetic. The prevalence of bacteriuria in other groups is too low to justify screening.