How will medical students assess a standardized whiplash patient? Will they order a cervical radiographie study based on the history provided? Will they change their minds about ordering radiographs after reading an abstract from a peer-reviewed medical journal recommending against them on the basis of some criteria? How will their opinions change based on a) the relative sensitivity and specificity of the findings of that study; and b) the class of evidence (i.e., prospective cohort design vs. retrospective chart reviews)? Finding the answers to these questions was the object of a recent study.1

The Medical Students

Fourth-year medical students from the University of Chicago were presented with a standardized whiplash patient to test their clinical perspicacity. he was a 21-year-old male who gave a history of being a passenger in a car that was struck from the rear at a speed of 25 mph. Shortly after the crash, he began to experience neck pain and was transported by ambulance to the ER. Students were asked whether they would order radiographs of his neck, and for their level of confidence in their decision. They were then presented with a variable of the abstract from a recent paper by Stiell, et al.,2 in which the authors developed a radiography algorithm. (I will discuss that paper next.)

After reviewing the abstract, the students were allowed to reaffirm their decision to order plain films, or to change it, and were asked to once again rank their level of confidence. Most of the 165 students did endorse the idea of ordering radiographs initially. Many apparently changed their minds after being exposed to the abstract informing them that radiographs were unnecessary under the circumstances. Of those initially reject- ing the idea of radiographs, their confidence in that decision was strengthened by the abstract.

These medical students correctly assigned the proper weight in accordance with the relative reported sensitivity vs. specificity (i.e., high sensitivity and low specificity would be preferable to low sensitivity and high specificity). However, the results showed that the students did not consider the prospective cohort design more persuasive than the weaker case review design. Of course, other factors could have influenced their decisions.

The standardized patient completed a questionnaire for each medical student, reporting the depth of the exam. Sixty-seven percent correctly inquired as to whether the patient had numbness and tingling in the upper extremities. However, only 21% palpated the posterior neck, and only 17% asked the patient to turn his head from side to side. A scant 11% did all three. This is disturbing, but perhaps not surprising, in light of another recent study, which reported a surprisingly low level of knowledge of musculoskeletal disorders among a group of medical residents.

One wonders what might be the basis for the seemingly absurd recommendation to forego radiographs in a 25 mph rear-impact motor vehicle crash. Carle Ward has reported that spinal fractures, dislocations, and spinal cord injuries are not uncommon in rearimpact crashes in which delta Vs are often only in the 15-20 mph range,3 as represented below.

While at least one study has shown that police officers are able to gauge collision velocity from damage severity with some accuracy, my experience is that real-world subjects nearly always overestimate crash speed. I suspect there are a number of explanations for this observation, including the volume of the resulting crash noise and the subjective violence of the collision. Patients may also be concerned that physicians will not take them seriously if the physicians perceive the crash to be trivial. Meanwhile, it is not clear from reading the present paper how the Canadian authors arrived at the 25 mph threshold for safety, or whether other occupant risk factors were considered, such as the nature of presenting symptoms, the patient’s age, spinal condition, etc. However, it seems unwise to base a criteria for radiography on a crash metric that has been shown to be a) not strongly correlated with injury risk; b) unlikely to be accurately estimated by vehicle occupants; and c) only somewhat better gauged by police.

In general, the authors of this paper endorsed the Canadian guidelines and anticipated that the medical students would either forego the radiographs initially or decide against them after reviewing the abstract of the Canadian paper. Interestingly, students who were more “in tune” with the epidemiological and clinical literature, vis-a-vis c-spine trauma and MVC, unequivocally chose to examine the c-spine radiographically, including the use of flexion and extension views, as recommended by some radiologists.4

The Canadian C-Spine Rule Study

So, what is this Canadian c-spine “rule” and how was this research conducted? Perhaps a better question might be, “Why should we be concerned?” The results of the study were reproduced in JAMA, one of the most influential of the American medical journals. It is likely that it will not escape the attention of those interested in medical cost containment. It could become transmogri-fied into public policy in Canada, in a way similar to that of the British Columbia Whiplash Initiative, which used the Quebec Task Force on Whiplash Associated Disorders’ (QTF-WAD) dubious guidelines to influence medical decision-making by practitioners there. That project, of course, was put together by the Insurance Corporation of British Columbia, the chief insurer for the province. (The QTF-WAD was also financed by the insurance industry.) This c-spine rule study was funded, at least in part, by the Ontario Ministry of Health Emergency Health Services Committee. One of the authors of the present paper, incidentally, has also been active in the development of a decision rule for whiplash.5

Somatropin, commonly referred to as human growth hormone (HGH), is currently one of the most popular drugs on the market. Because of this, many companies would like to make a profit from its popularity. Unfortunately, companies that sell HGH drugs are not always legitimate, and there are many forms of human growth hormone that are simply ineffective or, even worse, dangerous.

HGH’s popularity stems from its wide-ranging effects on the human body. HGH is a hormone that is naturally produced in the human body, and the drug form of HGH is an exact replica of natural human growth hormone. In the medical industry, HGH is used to treat short stature in children caused by both growth hormone deficiency and certain diseases, including Turner’s, Prader-Willi, and short bowel syndromes, renal disease, and a genetic condition known as X-Linked Hypophosphatemia (XLH). Additionally, it’s used to treat muscle wasting in AIDS and cachexia patients, and short stature in children with an undetermined cause.

However, much of human growth hormone’s popularity stems from its cosmetic effects; it is most widely used as a bodybuilding and physical enhancement drug. As an intravenous drug, HGH can promote lean muscle growth and weight loss, increase energy, shorten recovery time between workouts, heal damaged tissue, and strengthen joints and ligaments. HGH is also commonly used as an anti-aging drug to prevent and repair the damage responsible for wrinkled skin, osteoporosis, and memory loss.

In an attempt to prevent HGH scams, several HGH manufacturers (GeneScience Pharmaceuticals, Neogenica BioScience, AnkeBio, etc.) have developed a web site–www.somatropin.net–devoted entirely to somatropin. Covering the basic facts on the drug, the web site defines growth hormone terminology, presents a basic history on the development of the recombinant HGH drug, and explains in detail how HGH works as both a medical and cosmetic drug.

The web site is innovative in its attempt to prevent HGH scams. Information on the site explains some of the ineffective methods of HGH administration widely available on the market, and also explains certain methods of HGH manufacturing that are impure and can cause damage.

The web site lists the companies that sell HGH, the type of HGH they manufacture, and their contact information. When questioned about their intentions for this web site, a representative from Neogenica BioScience explained, “We basically want to stop HGH scams, prevent abuse, and educate people on what HGH can and cannot do for them.” For more information, please visit www.somatropin.net.

When FAIM and coalition supporters passed the New York health freedom law in 1994 [L.1994,C.558], permitting “non-conventional” methods, we knew that eventually the Office of Professional Medical Conduct, OPMC, would test and try to overturn our law. That time is before us now — in spades.

The vehicle for challenge to our law by OPMC is the treacherously flawed system of professional discipline, which is sorely lacking the due process that the constitution affords those who are accused of crimes. Having had the opportunity to research and compare New York’s administrative process to that of 16 other states, I assure Townsend readers that while many states fail in some aspect of due process or another, New York is uniquely awful — which is strange since it is one of the few states which still embraces “peer review.” In most other states, the facts are tried before administrative law judges who make the determinations of guilt or innocence, which are then confirmed by the medical board. In New York, the administrative law judge is present but only to rule on process; the testimony is heard and the facts are determined by a panel of three, including two doctors. It is becoming apparent that peer review can enforce bias, that is, depending upon whose peers are sitting in review and depending as w ell, on what evidence is allowed into their view.

Further, it is our observation that the staff of the OPMC have gained much too much leeway in the prosecution of cases. They have driven the agenda away from the control of the BPMC, the Board for Professional Medical Conduct, which is supposed to be the governing body of physicians and laypersons who hear and try the cases.

Lastly, it is clear that the failures of due process and the hubris of OPMC staff are being used by insurers to wage a war on patients; to deprive them of the physicians who advocate for their care against the denial of benefits, and to stifle the science that would promote treatments insurers simply don’t want to pay for. While advocating for Lyme patients in New York, FAIM has become witness not only to the insurance lobby’s declarations of their support for OPMC actions against innovative Lyme doctors, but as well, OPMC staff have acceded to lawmakers that they rely on insurers’ ability to audit patient’s charts and generate complaints.

Legislation is being drafted at this time by a team of bill drafters from the three legislative committees who have jurisdiction over the law. FAIM’s concern begins, of course, with protecting patient access to CAM physicians. But all patients and all physicians who think progressively and who innovate in order to individualize care, are at risk.

These concepts are being developed into balanced legislation that will reform the physician discipline process to protect patient privacy and choice as well as patient safety from harm. A public legislative hearing on OPMC reform is scheduled by the Assembly Health Committee for January 31, 2002 in Manhattan.

The following are reforms of OPMC due process being promoted by FAIM:

1) Before an investigative interview, the OPMC should provide fort the licensee to review the Department expert’s investigative report.

Currently, the licensee does not know in advance of his or her interview just what the concerns are, and therefore cannot prepare to offer a resolution. Currently, the interview does give opportunity for further discovery by OPMC, but not serve at a11 as an opportunity for mediation.

2) Before the investigative interview, the licensee should be advised that their statements may be used against them in a subsequent disciplinary hearing.

3) When the subject of investigation involves in any way, the use of a non-conventional or individualized therapy, an expert who practices similarly should be consulted who can attest to the appropriateness or not of the care in question.

Despite assurances by the Department at the passage of L.1994,C.558, that specific assignment would be logical and was not necessary to place into law, OPMC has failed to avail itself of the expertise of any non-conventional physicians in current investigations of non-conventional practice. Consequently, OPMC faultily prosecutes scientific disputes.

4) The name, address, and qualifications (including past/present employers and affiliations and consultant-ships), of any expert relied upon or to be used at trial, as well as of BPMC committee members, shall be provided to the licensee under investigation, and any amendments to the expert or committee lists should be provided “promptly” to the licensee.

Currently, the only experts who will testify at trial are disclosed shortly before trial, with no accompanying disclosure for examination for conflict of interest.

5) Orders for a “comprehensive review” of patient records in a medical office should be made only upon a majority vote by an investigative committee of the BPMC after having heard a rebuttal by the licensee to the investigator’s report.

When conventional and Complementary and Alternative Medicine (CAM) educators gathered at Georgetown University in June 2005 for The National Education Dialogue to Advance Integrated Health Care (NED), they were looking for ways to create common ground in the education of health care professionals. Since creating major change is never easy, they took time to reflect on the basic principles underlying change.

Dale W. Lick, PhD, the facilitator of the NED meeting, was selected in part due to his experience working with leaders of diverse institutions to create common ground for change. Lick, a professor in the Learning Systems Institute at Florida State University, told NED participants, “even the word ‘change’ scares people and makes them feel uncomfortable. When you’re seeking change, learning must precede change. If you’re thinking about a really major change, you need a lot of learning first.” Traditionally, Lick said, you work to change people’s behavior, so that eventually you’ll change their beliefs and assumptions. But when you’re seeking major organizational changes, you often need to start by looking at, and changing, basic assumptions. Then it becomes possible to change beliefs and behaviors, and that leads to sustainable change. Transformational leaders must create a shared, inspiring vision that provides direction, motivation, and commitment to your desired long-range future, Lick said. “In change efforts, vision is the essential direction-setter, people-aligner, and emotion-grabber!”

Lick invited NED participants to think about key roles they can play as part of any change process:

* A change sponsor has the power to sanction or legitimize change–it might be the organization’s board, or a president, division director, or department head.

* A change agent is an individual or group responsible for implementing the desired change.

* A change target is an individual or group that must change as a result of the change process.

* A change advocate is someone who desires change but doesn’t have the authority or power to sanction it; they can recommend actions to those who do have the authority to legitimize change.

“The key thing is, if you don’t have strong sponsorship, your project, is almost certain to fail,” Lick said. “If your sponsorship isn’t strong enough, first work to strengthen it.” Change advocates should find ways to help people change appropriate assumptions and increase learning among potential sponsors and others, he advised.

Innovative Curriculum at Georgetown University School of Medicine

Faculty at the Georgetown University School of Medicine have been working to develop an improved curriculum in ways that exemplify the principles put forth by Dr. Lick. Their primary goal is to train better physicians. One step in that process, they find, is to train physicians who are familiar with CAM.

“Mind-body approaches are particularly important … by their very nature they put high value on and teach the power of self-awareness and self-care,” says the Georgetown website. “In so doing, they help shape the new integrative model of healthcare–one in which treatment is balanced with teaching; in which prevention and self-care are given as much respect as procedures and pharmacological interventions.”

If you go to that website today, you’ll see that information on CAM is integrated throughout Georgetown’s curriculum. For example, the anatomy course looks at the anatomy of acupuncture; physiology includes biofeedback and neuromuscular manipulation; while human endocrinology discusses stress hormone modulation through the relaxation response, meditation, imagery, and breathing. Georgetown also offers a master’s level course in CAM (within the physiology department) and a five-year program combining that course of study with an MD degree.

In part, this wealth of information and options is due to a five-year, $1.7 million grant from the National Institutes of Health (NIH) that supported the planning phase to incorporate CAM into the curriculum. Even more, this integration is due to a step-wise strategy that started on a small scale and gradually gained support from many levels of the organization. For example, a course for first-year medical students on “Mind-Body Medicine: An Experiential and Didactic Introduction” started as a pilot program. The course is held two hours a week for eleven weeks and includes approaches such as relaxation, meditation, guided imagery, biofeedback, writing exercises, movement, music. and art. It’s designed to help students become self-aware and foster self-care strategies that should help them in their own lives (this is particularly important for stressed-out medical students.) It also gives them a clear sense of how helpful these skills can be for their future patients.

“Initially we planned to get a pilot started, look at outcomes, gauge student reactions, and see how it went,” says Aviad Haramati, PhD, professor of physiology, biophysics, and medicine. “Based on that, we’d make modifications. As the program improved, we’d scale it up.” Haramati’s research interests for 20 years focused on regulation of renal and electrolyte physiology during growth, and cardiovascular-renal-endocrine regulation of volume homeostasis in heart failure–not exactly CAM-centered. However, he is keenly interested in improving the training of physicians and other health professionals and, over the years, has helped develop major curricular initiatives at Georgetown. His solid professional background (and numerous teaching awards) give him additional credibility when he talks about the ways mind-body training will benefit medical students.

The term epidemic (from the Greek epi [on] plus demos [people]), first used by Homer, took its medical meaning when Hippocrates used it as the title of one of his famous treatises. At that time, epidemic was the name given to a collection of clinical syndromes, such as coughs or diarrheas, occurring and propagating in a given period at a given location. Over centuries, the form and meaning of the term have changed. Successive epidemics of plague in the Middle Ages contributed to the definition of an epidemic as the propagation of a single, well-defined disease. The meaning of the term continued to evolve in the 19th-century era of microbiology. Its most recent semantic evolution dates from the last quarter of the 20th century, and this evolution is likely to continue in the future.

At the start of the 21st century, epidemics of infectious diseases continue to be a threat to humanity. Severe acute respiratory syndrome, avian influenza, and HIV/AIDS have, in recent years, supported the reality of this threat. Civil wars and natural catastrophes are sometimes followed by epidemics. Climate change, tourism, the concentration of populations in refugee camps, the emergence of new human pathogens, and ecologic changes, which often accompany economic development, contribute to the emergence of infectious diseases and epidemics (1). Epidemics, however, have occurred throughout human history and have influenced that history. The term epidemic is [approximately equal to] 2,500 years old, but where does it come from?

Before Hippocrates

When works that put forward new ideas are translated, determining the original terminology (in Ancient Greek in this case) is not easy. In 430 BC, when Hippocrates was collecting the clinical observations he would publish in Epidemics, his treatise that forms the foundation of modern medicine, at least 3 terms were used in Ancient Greece to describe situations that resembled those described by Hippocrates: nosos, phtoros, and loimos (2).

Nosos, meaning disease, was used by Plato in the 4th century BC and clearly had the same meaning 2 centuries earlier in the works of Homer and Aeschylus. Nosos encompasses disease of the mind, body, and soul: physical, including epilepsy, and moral (i.e., psychological and psychiatric). Phtoros or phthoros means ruin, destruction, deterioration, damage, unhappiness, and loss, after war for example. The word was frequently used by Aeschylus and Aristophanes, was known in the 8th century BC, and was later used by Plato and Thucydides. Its meaning has remained general. Bailly translates loimos as plague or contagious scourge. Used by Esiodus in the 7th century BC and later by Sophocles and Herodotus, this term is ancient. Its translation as plague should be interpreted in the sense of a scourge rather than as the disease plague. In the Septuagint, a translation of the Old Testament into Greek by 70 Greek Jews from Alexandria, this word is used in the book of Kings to describe the 10 plagues of Egypt.

But the term epidemic already existed in 430 BC. The Greek word epidemios is constructed by combining the preposition epi (on) with the noun demos (people), but demos originally meant “the country” (inhabited by its people) before taking the connotation “the people” in classical Greek. Indeed, the word epidemios was used by Homer, 2 centuries before Hippocrates, in the Odyssey (canto I, verses 194 and 230), where it was used to mean “who is back home” and “who is in his country” in contrast to a voyager who is not: [TEXT NOT REPRODUCIBLE IN ASCII.], “because someone said that your father was back (home)” (canto I, verse 194). In this context, epidemios means indigenous or endemic. In the Iliad, Homer confirmed this meaning (canto XXIV, verse 262), by using also polemos epidemios to mean civil war:, “this one who [TEXT NOT REPRODUCIBLE IN ASCII.] liked passionately the frightening civil war” (canto IX, verse 64). Later, Plato and Xenophon (400 BC) used the word to describe a stay in a country or the arrival of a person: [TEXT NOT REPRODUCIBLE IN ASCII.], “a Parian who, I learned, was in town” (Plato, Apology, chapter I, paragraph 38). The verb epidemeo was used by Thucydides (460 BC-395 BC) to mean “to stay in one’s own country,” in contrast to apodemeo, “to be absent from one’s country, to travel.” For Plato, epidemeo meant “to return home after a voyage, to be in town.” Later, the orators Demosthenes (384 BC-322 BC) and Eschines (390 BC-314 BC) used this word to refer to a stranger who came to a town with the intention of living there, and the verb epidemeo was used to mean “to reside.” Typical of Greek semantics, epidemeo takes its meaning from the result of the action, rather than from the action itself. It relates to something that has already happened, with the implication that it had previously happened elsewhere. Authors before Hippocrates used epidemios for almost everything (persons, rain, rumors, war), except diseases. Hippocrates was the first to adapt this word as a medical term.

A NANDA representative attends the Nursing Terminology Summit held each summer at Vanderbilt University, Nashville, TN. This conference promotes the development and use of data standards. Given the advances being made in healthcare informatics and infrastructure development, such work is fundamental to nursing terminology implementation. I attended the July 2003 conference. Participants requested the Steering Committee to write a statement that summarizes the work of the Summit for the nursing profession and provides a brief overview of the role and function of the major standards organizations that impact nursing. The following represents their report.

Health Care Data Standards

As electronic communications and data storage become increasingly the norm in health care, as in other aspects of life, national and international efforts around the world are seeking to establish a robust infrastructure for Healthcare information. A key component of this infrastructure is healthcare data standards. These standards, with proper security to protect private information, will make it possible for healthcare providers to share information for the patient’s benefit, even when the information is in a different site or a different computer system. Use of such standards will increase patient safety, promote quality improvement, and facilitate clinical research based on patient care records. Standards for data and other aspects of information systems will also make it easier to track information for public health purposes - for early detection of disease outbreaks, for example, or for assessing effectiveness of a health promotion initiative.

The standards will affect all aspects of health care - medicine, nursing, dentistry, veterinary practice, ancillary services, administration, payment, and public health. Healthcare data standards are developed and recognized through independent, voluntary organizations. Some prominent ones include:

* The International Standards Organization (ISO), which uses democratic processes to establish worldwide standards for everything from photographic film to health care terminology. Technical Committee 215 of ISO is responsible for health care data standards.

* Technical Committee 251 of the European Standards Committee (Comitee Europeen de Normalisation [CEN]), which sets standards for health information in the European Union.

* Health Level 7 (HL7), which sets standards for electronic messages about all types of health information.

* The Systematic Nomenclature of Medicine Clinical Terms (SNOMED CT), a division of the College of American Pathologists, which represents health care concepts and the relationships among them.

* Logical Observation Identifier Names and Codes (LOINC), which sets standards for identifying laboratory tests and other clinical observations.

Reference Terminology: An Essential Standard

Among the many kinds of standards for healthcare data, an important one is “reference terminology.” Usually when nurses refer to standardized language, they mean the verbal expressions used in documents or computer systems to communicate among themselves and with other healthcare providers about nursing care. Reference terminology, by contrast, refers to the concepts and relationships necessary to define something (such as a nursing diagnosis or action), presented according to some formal set of rules about how to depict the concepts and relationships in models. In much the same way as a sentence diagram depicts the roles and relationships of the words in an English sentence, a reference terminology model shows how the defining components of a nursing diagnosis or action relate to one another. In both cases, the diagram or model removes ambiguity that may be present in the more usual vernacular expression.

Just as no one would want to read a paragraph composed of diagrammed sentences, no human would want to read a health record composed entirely of modeled reference terminology. Computers, however, can be programmed to be quite good at reading reference terminology. In fact, they can process reference terminology more accurately and “understand” its meaning better than they can everyday language. For this reason, many sets of terms that are used widely in health care-including, among others, ICD codes, CPT codes used in the United States to record medical procedures, and nursing languages recognized by the American Nurses Association - have been “modeled” within SNOMED Clinical Terms. In computer systems used to process health information for the National Health Service in the United Kingdom, and increasingly in the United States, humans will use familiar language on the screens to record and communicate, while SNOMED CT will operate behind the scenes to be sure that computer systems understand and process the information correctly.

Promoting Reference Terminology for Nursing: The Summit Conferences

To get the standards right, each professional discipline must set the standards for the information its practitioners collect and record in providing or managing patient care or public health services. A series of Nursing Terminology Summit Conferences held annually since 1999 at Vanderbilt University in. Nashville, TN, USA, has promoted and contributed to standards for nursing information not only in the United States but internationally.

Communication is the backbone of progress. To adapt, change, or develop requires incorporating the spirit and artful skills of communication into every step of a plan. As perioperative nurses, we realize the value of communication as we attempt to explain the importance of the nursing care role to administrators, legislators, students, peers, and others who query our roles and responsibilities. Nurses assess, interpret, make decisions, and evaluate daily as they implement care. They coordinate, collaborate, and optimize while working to establish a trusting and caring environment with team members. Translating those activities into words that describe patient care and that can be quantified and used to explain what a perioperative nurse does each day without offering an endless list of tasks is the ultimate challenge.

Describing perioperative patient care is difficult for many reasons, including that activities occur within restricted time frames and result from decisions and monitoring by many people at once. Even nurses who realize and believe that nursing is an important component of the care continuum during surgical and other invasive procedures have difficulty understanding and explaining how their roles, responsibilities, and nursing care activities are integrated in a highly technical environment. Overcoming various interpretations, role confusion, and inconsistent use of language, when also attempting to compare and measure nursing care, requires a common spoken and written language and consistent messages.

LEARNING THE LANGUAGE

When someone asks what care perioperative nurses provide, the first instinct is to describe tasks. Easy responses might include “assist the surgeon” or “ensure that supplies and equipment are ready and working.” These responses send a message to others about the value of the intraoperative nurse in patient care roles. They also confuse the issue when other health care providers claim that they are providing the same care and participating in the same activities.

The challenge is to identify the best way to describe the patient’s problems and associated care using nursing language, not a list of tasks. The language must be consistent with the knowledge necessary to determine patient needs associated with the task. For example, applying an electrosurgical dispersive pad is considered an intraoperative task. It is performed several times each day in many locations where surgical procedures take place, usually without adverse outcomes. Translating that task into nursing language requires understanding the equipment’s use and function, as well as patient needs associated with using electrosurgical units (ESU) and associated devices. Applying the electrosurgical pad seems to be a routine, harmless activity because of the warning signals built into the equipment and guidelines for its use (eg, presence of implants, appropriate pad size, presence of muscle tissue, absence of scarring, proximity to the incision). We even make it seem harmless by spending very little time discussing the ESU during orientation. After all, what does a person need to know about applying an electrosurgical dispersive pad when it is so easy?

Information and knowledge needed to use the ESU is more comprehensive than it seems and should not be taken for granted. Patient considerations, such as compromised skin and tissue integrity (eg, dryness, scaling, excess sweating, lesions), a procedure that might vary from the standard approach (eg, different incision, different skin prep site), or changing positions throughout the procedure, can be identified during the nursing assessment and result in. patient-specific interventions and evaluations to prevent adverse outcomes associated with the task. This requires nursing assessment, as well as knowledge of the equipment and its function. What other person in the room has this understanding?

There is an unlimited number of tasks that can be identified and associated with nursing knowledge. Applying compression devices, tourniquets, or dressings; using positioning devices; monitoring urinary output; having safety equipment available; preparing equipment for a difficult intubation; decreasing the length of surgical procedures; and classifying wounds are activities managed every day by care providers who do their jobs without thinking about how they are preventing adverse outcomes because of the knowledge they provide during patient care. Nursing knowledge plays a role in these and many other responsibilities in health care settings.

OVERCOMING COMMUNICATION BARRIERS

Nursing language is not new. Every educational program attempts to help students understand and use the nursing process; however, when students select an OR career, the language changes from one of assessment, diagnosis, intervention, evaluation, and outcomes to one that revolves around a medical diagnosis and surgical procedures. Those of us who learned perioperative patient care understand this because proving oneself in an OR means efficiently and effectively doing multiple tasks with minimal direction or assistance. In the eyes of team members, however, this may mean that completing tasks is seen as comparable to providing nursing, care.

WASHINGTON — Ever hear a patient say that he or she is “feeling evil” and let the remark go by without comment? If so, an opportunity might have been missed to diagnose depression, Dr. Annelle Primm said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

Minority cultures have different ways of expressing depression. Latinos may speak of “having nerves”; Asians, of being “out of balance”; and African Americans, of “being angry,” said Dr. Primm of Johns Hopkins University, Baltimore. “This often gets overlooked as a mental health issue,” she said.

Dr. Primm recently produced a video, “Black and Blue: Depression in the African American Community,” which includes interviews with depression experts as well as African Americans who have the disease. One expert, Edgar Wiggins, director of Baltimore Crisis Response, noted that being an African American with depression carries a double stigma: that associated with mental illness and with being African American.

Culture plays a strong part in whether minority patients decide to get help, said Dr. Primm, who also serves as director of the American Psychiatric Association’s department of minority/national affairs. For example, in the black community, religion plays a big role. “Many people believe their depression is caused by a lack of faith or by not praying hard enough,” she said in the video. Several patients responded that they did pray before and during their illness but that they also sought other sources of help.

African Americans are less likely to seek help for depression, but they are more likely than are whites to be exposed to stressors such as poverty, racism, and violence that put them at a higher risk of developing the condition, Dr. Primm said. They also have higher rates of illness and death from heart disease, stroke, diabetes, and AIDS–and that also puts them at a higher risk of depression, she added.

Because FIPSE is so well known for its support of innovation and reform in numerous other areas, few outside of the education field have appreciated the centrality of its role in sponsoring innovations in the medical and health sciences. These changes have been varied and far reaching, and they have addressed some of the basic concerns about the provision of health services and medical training in this country. Some were motivated by notions that health service providers can be poor communicators or lack empathy. Others focused on the problem of assessing clinical competencies, exacerbated by concerns of the patients upon whom students practiced their new skills. Still others arose from the perception that the specific health needs of some groups were not receiving enough attention.

The demand to better prepare health-care providers in these and other areas collided with a curriculum that has exploded with so much content that it is often unmanageable–even while many are urging the addition of new content and altered pedagogy to provide more relevant learning and to motivate students to become more active participants in the learning process. And all of these demands come at a time when diminished funding within the health sciences has made innovation difficult.

FIPSE’ s role in supporting change has therefore been vital. But why FIPSE? Because no one else offers significant funding for research and innovation in medical and health education. The National Institutes of Health (NIH) has had and continues to have an essential and respected role in funding fundamental and clinical research in medicine and health, but support of education has not been part of its mandate. From its founding onward, the National Science Foundation (NSF) has supported science education, including pre-medical education, but as a matter of policy excludes the applied clinical sciences from all of its funding programs. So there is no agency other than FIPSE whose primary mission includes support for change in medical and health education.

By the end of its first decade, FIPSE was already a major player in bringing about far-reaching changes in medical education. Foremost among several such efforts was a sequence of projects, first funded in 1980, that invented, implemented, and refined a revolutionary new methodology to assess the clinical skills of medical students, physicians, and practitioners in many health disciplines. That technique–the use of standardized and simulated patients (trained lay people or actors who present or simulate particular disorders or symptoms) as expert assessors–is by now familiar to medical students and other would-be health-care professionals throughout the world.

A decade later, in 1993, another watershed was reached when FIPSE funded a series of initiatives to integrate women’s health throughout the medical curriculum, first, and throughout the curricula of the other health sciences later. Before then, research data from male subjects was extrapolated to females–except of course for reproductive differences–and there was thought to be no need for special attention to non-reproductive women’s health in medical training. But FIPSE had the vision and multifaceted experience needed to take on the issue of women’s health in medical education, as it had earlier embraced the new idea that lay people could become skilled teachers and evaluators in medical and health science.

The remainder of this article will discuss in depth these two landmark medical projects supported by FIPSE and will conclude by mentioning a few other significant FIPSE efforts that have been–or still promise to be–influential in the fields of medical and health education.

STANDARDIZED PATIENTS AND THE ASSESSMENT OF CLINICAL SKILLS

The Problem: Traditionally, new doctors’ progress through medical school and entry into the profession have both been governed by paper-and-pencil examinations. Even when advanced computer technology is employed to administer the test itself, the prospective physician is primarily asked to display intellectual skills. How to conduct valid, reliable, and cost-effective assessments of clinical and communication skills has been a perennial dilemma for both medical schools and licensing authorities ever since medicine replaced its original apprenticeship system with formal instruction in organized schools.

Patient Instructors in Arizona: A clever solution using what were first called “patient instructors,” but are now known everywhere as “standardized patients,” was invented by Paula L. Stillman, then a pediatrician on the faculty of the University of Arizona. Her idea, piloted with the help of a small grant in 1977 from the private National Fund for Medical Education (NFME), was fully developed and implemented with support from a 1980 FIPSE grant entitled “Patient instructors: a new methodology to assess clinical competence and ensure quality health care.”

Precursors to this idea did exist. During the 1970s, Robert Kretzschmar, an obstetrician/gynecologist at the University of Iowa, had been using volunteer women as live models to train medical students to do breast and pelvic exams. But these women were passive participants, lending their bodies for this purpose but playing no other instructional role.

Editors and publishers take our responsibilities seriously. There are international congresses on peer review in biomedical publications, the most important contributions from which are published in classic, special issues of JAMA. (1-3) A wide range of topics is discussed, including the nature of peer review, whether reviews should be anonymous, whether reviewers should be blinded to the identity of the authors, techniques to minimize publication bias, ways of dealing with plagiarism, the impact of fraudulent research on scientific literature, the effects of institutional prestige and author nationality on reviewers’ recommendations, and many other topics.

While the importance of correcting medical literature after fraudulent publication has been addressed, surprisingly little attention has been paid to the important issue of correcting the medical literature after publication of bad papers. As noted in a previous editorial, (4) the peer-review process is intended to detect poorly designed or misleading articles before they are published. The process is flawed, however; substandard articles can appear in any journal.

Editors try to avoid this unfortunate occurrence in several ways. Usually, we assign submitted manuscripts to more than one reviewer, and we select reviewers who should be knowledgeable about the subject matter being reviewed. Moreover, we encourage our editorial boards to return manuscripts that are outside their areas of expertise and to suggest alternate or supplemental reviewers. For example, it is common for reviewers to request that a manuscript receive additional review by a statistician, to be certain that no sophisticated errors go unrecognized, especially if such errors might affect the validity of the conclusions.

Despite our best efforts, once in a while we publish something that should not have been published. Hence, it is surprising that so little attention has been paid to the obligation of a journal to acknowledge this situation and correct the literature when correction is warranted. This shortcoming is true not only in international symposia, but also in our field.

Otolaryngology journal editors meet twice a year (at COSM and at the AAO-HNS meeting) to discuss a variety of subjects ranging from standardization of terminology to the problem of duplicate publication, but this issue has not been on our agenda. I suspect that most of us have assumed that such corrections are handled adequately through letters to the editor, editorials, or retractions. However, addressing such issues occurs at the discretion of the editor in most cases. So, response to such events varies.

The existence of this problem was brought to my attention recently through my correspondence with the Journal of the American College of Surgeons (JACS), certainly a deservedly well-respected publication. In October, JACS published an article on voice changes after thyroidectomy. (5) While I was delighted to see an article on voice in the College’s journal, I was dismayed at its quality. The clinical examinations were not sufficiently sophisticated to meet the current standards of clinical care, let alone those of clinical research. No blinded, subjective analysis of the clinical data was included. Preoperative and postoperative laryngeal electromyographic data were not provided, so the status of laryngeal nerve function remains unknown. The voice-analysis system used is not particularly sophisticated, and details of recording protocols were not provided. Also, the parameters selected for reporting were inappropriate. The analysis program used generates data on a variety of other measures, but this paper excluded those data and provided no information as to why they were excluded.

More importantly, the errors in the data reported in this article are profound in their naivete. For example, shimmer was described as a measure of intensity. This is completely inaccurate. Shimmer is a perturbation measure that describes cycle-to-cycle amplitude variation and has no predictable correlation with vocal intensity. Intensity should be measured in decibels SPL under carefully controlled conditions.

This article was fatally flawed and would not have been accepted in any otolaryngology journal. Immediately after the article was published, I wrote a letter to Timothy J. Eberlein, MD, editor of JACS, and I received an admirably prompt, standard rejection letter indicating that the rejection “usually reflects issues of timeliness, a backlog, or beliefs that the material, when complete, did not fit our readership.” I would have accepted this outcome happily if my letter had been rejected because another letter had been accepted and was to be published to point out the shortcomings of Sinagra et al’s article. However, follow-up contacts with the journal have indicated that this is not the case. Hence, readers of JACS, most of whom are not sophisticated in their analysis of voice literature, are likely to believe the unsupportable conclusions stated in this article. For otolaryngologists who read other voice literature, this may not be a problem; but for thyroid surgeons who primarily