Clinical teaching: Maintaining an educational role for doctors in the new health care environment

Context and objectives: Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching. Methods: Seven roles are used as a framework for analysing good clinical teaching. The roles are medical expert, communicator, collaborator, manager, advocate, scholar and professional. Results: The analysis of clinical teaching and clinical practice demonstrates that they are closely linked. As experts, clinical teachers are involved in research, information retrieval and sharing of knowledge or teaching. Good communication with trainees, patients and colleagues defines teaching excellence. Clinicians can 'teach' collaboration by acting as role models and by encouraging learners to understand the responsibilities of other health professionals. As managers, clinicians can apply their skills to the effective management of learning resources. Similarly skills as advocates at the individual, community and population level can be passed on in educational encounters. The clinicians' responsibilities as scholars are most readily applied to teaching activities. Clinicians have clear roles in taking scholarly approaches to their practice and demonstrating them to others. Conclusion: Good clinical teaching is concerned with providing role models for good practice, making good practice visible and explaining it to trainees. This is the very basis of clinicians as professionals, the seventh role, and should be the foundation for the further development of clinicians as excellent clinical teachers.

Indication of pollution in a teaching and research farm reservoir

The production and productivity of a water body is largely dependent on its quality. One major source of water pollution is from the agrochemicals from nearby farmlands. The quality of water in the Obafemi Awolowo University Teaching and Research Farm Reservoir (Ile-Ife, Nigeria) was monitored between October, 1993 and March, 1994. Structured questionnaires were administered to obtain information on the types of agrochemicals in use on the farm. Water samples were collected fortnightly for analyses of the physico-chemical parameters and ionic content of the water. Investigation revealed that 21 agrochemicals had been in use on the farm. The physico-chemical parameters of the water showed that the water was very poor in nutrient. The high concentration of ammonium ion contents of the water shows an indication that the residues of certain agrochemicals got into the water to pollute it. Agrochemicals should be used with great caution on farmlands especially in areas close to water bodies from which man obtains fish and other proteinous foods. This paper also suggests a regular monitoring of water quality of reservoirs in order to pick the earliest signs of pollution

Fish quality and processing in Malawi: responding to challenges through institutional capacity building

Fish processing and quality control in Malawi are still poorly developed. Traditional fish processing methods are widely employed resulting in considerable post-harvest losses. One of the major challenges to steady and sustainable development in fish processing and quality management is the lack of adequately trained personel. This is directly reflected in poor institutional capacity. This project analyses the situation in fish processing and quality management in Malawi to identify gaps that require improvement. Specifically, the project assesses the role of training institutions in Malawi in capacity building for fish processing and quality management. The institution under discussion in this project is the Aquaculture and Fisheries Science Department at Bunda College of Agriculture, Malawi which is responsible for training students in aquaculture and fisheries science at the undergraduate level.Improvement in the teaching of fish processing and quality management in the Department of Aquaculture and Fisheries Science was identified as the major gap requiring action. The current teaching syllabus was thus analysed to identify weak areas. In conclusion, the project developed (as the major output) a teaching handbook for the Department of Aquaculture and Fisheries Science.

Reflections on the development of a dynamic learning, teaching and assessment strategy.

Developing learning, teaching and assessment strategies that foster ongoing engagement and provide inspiration to academic staff is a particular challenge. This paper demonstrates how an institutional learning, teaching and assessment strategy was developed and a ‘dynamic’ strategy created in order to achieve the ongoing enhancement of the quality of the student learning experience. The authors use the discussion of the evolution, development and launch of the Strategy and underpinning Resource Bank to reflect on the hopes and intentions behind the approach; firstly the paper will discuss the collaborative and iterative approach taken to the development of an institutional learning, teaching and assessment strategy; and secondly, the development of open access educational resources to underpin the strategy. The paper then outlines staff engagement with the resource bank and positive outcomes which have been identified to date, identifies the next steps in achieving the ambition behind the strategy and outlines the action research and fuller evaluation which will be used to monitor progress and ensure responsive learning at institutional level.

Teaching Crossroads: 11th IPB Erasmus Week

In the wake of the latest news regarding IPB’s award for best Polytechnic Institute in Portugal, we would like to congratulate the IPB community who has always striven for the quality of the institution within the national and international academic milieu. We are, undoubtedly, bowled over by the 1st place in the national context (out of the 27 national institutions under evaluation) and the 7th position in the international scope. In fact, it is worth mentioning that the IPB has won this award, three years in a row, being in a leading position in the ranking promoted and sponsored by the European Union. This year’s edition has selected and evaluated over 1300 world higher education institutions. Teaching Crossroads intends thus to give a watershed contribution to the IPB’s successful and most valued pathway. Numbers indicate that Teaching Crossroads has had over 2550 downloads since it first came out. But let’s cut to the chase. Once again, we are delighted to present the 5th number of Teaching Crossroads. This wholly calculated and well-sustained editorial adventure started in 2012 when the first number of Teaching Crossroads first saw the light. This year’s publication includes the areas of Human Geography/anthropology, Information Technology and Forensics and Language and culture, focusing on minority languages. Alongside this, as in the two last previous numbers, we’ve included the specific area for International mobility, Intensive Programmes and Erasmus+ Mobility of Individuals, being the latter financed by the European Union within the Erasmus+ Programme, whereas the former is sponsored uniquely by the foreign partner institution, in this case, Lillebaelt Academy in Denmark. These types of programmes convey very positive and overarching ideas, resonant in cross-cultural and educational benefits, valuable for all the involved partners. We would very kindheartedly like to thank the authors for having contributed with much enlightening and serious articles on a wide array of areas. Pablo M. Orduna Pórtus’s article focuses on border culture and heritage management. The author’s study is placed on two borderlands of the Iberian Peninsula: Roncal Valley (Navarre) and Riverbanks of Douro. Going beyond the linear or physical conception of the border, the author centres his study on the metaphysical and symbolic ideas of the frontier that sustain his anthropological analysis. Michal Popdora manages to find evidence for his proposal of a new conception of teaching Image Processing, based on the student-centered approach. A hands-on experience on a Project-based Learning methodology sustains the teaching project. Grounded on “a forensic-flavored style”, using the author’s own words, he shows how students can become engaged in a highly effective learning process. Cláudia Martins is already a confirmed habitué of this publication, as in every Erasmus Week she delivers a lecture on Portuguese language and culture to visiting teaching and non-teaching staff. This time, the author decided to delve into a Portugal’s official language, Mirandese, spoken in a small designated area in the northeastern part of Portugal, Miranda do Douro and its surrounding area. The author gives account of some thought-provoking facts about the language, from the origin and the survival of the language, however still a minority language, up to the moment when it was acknowledged Portugal’s second official language, together with the challenges that nowadays faces. Luís Frölen Ribeiro, João Eduardo Ribeiro, Carlos Casimiro Costa, António Duarte, Carlos Andrade from the Polytechnic Institute and Arne Svinth, John Madsen, Morten Thomsen, Kent Smidstrup, Carsten John Jacobsen from the Lillebaelt Academy, in Denmark, participate in a joint project which they describe, outlining the main goals and gains of the project. To overcome teaching difficulties regarding the engineering degrees, a 12-ECTS joint course from Lillebaelt Academy and Polytechnic Institute of Bragança was created based on the Danish model. The course Product Development and Industrial Processing was hence created. Rui Pedro Lopes presents an insightful and acute account of the Internationalization programmes in Higher Education in Europe. At one go, the author describes his own experience as a visiting lecturer, within the Erasmus+ programme, to Università Politecnica delle Marche in Ancona, Italy, in a Master’s degree in computer science, bringing to light a personal reflection on the goals and benefits of the mobility for both students and teachers. Finally, the author puts forth some suggestions that would improve the whole mobility process. We sincerely hope to have stimulated you to keep on reading, upholding the belief that these texts can represent valuable sources for both teachers and students in their research work.

Team-teaching for inclusive learning: Purposes, practices and perceptions of a team-teaching initiative in Irish post-primary schools

Background. Schools unequivocally privilege solo-teaching. This research seeks to enhance our understanding of team-teaching by examining how two teachers, working in the same classroom at the same time, might or might not contribute to the promotion of inclusive learning. There are well-established policy statements that encourage change and moves towards the use of team-teaching to promote greater inclusion of students with special educational needs in mainstream schools and mainstream classrooms. What is not so well established is the practice of team-teaching in post-primary settings, with little research conducted to date on how it can be initiated and sustained, and a dearth of knowledge on how it impacts upon the students and teachers involved. Research questions and aims. In light of the paucity and inconclusive nature of the research on team-teaching to date (Hattie, 2009), the orientating question in this study asks ‘To what extent, can the introduction of a formal team-teaching initiative enhance the quality of inclusive student learning and teachers’ learning at post-primary level?’ The framing of this question emerges from ongoing political, legal and educational efforts to promote inclusive education. The study has three main aims. The first aim of this study is to gather and represent the voices and experiences of those most closely involved in the introduction of team-teaching; students, teachers, principals and administrators. The second aim is to generate a theory-informed understanding of such collaborative practices and how they may best be implemented in the future. The third aim is to advance our understandings regarding the day-to-day, and moment-to-moment interactions, between teachers and students which enable or inhibit inclusive learning. Sample. In total, 20 team-teaching dyads were formed across seven project schools. The study participants were from two of the seven project schools, Ash and Oak. It involved eight teachers and 53 students, whose age ranged from 12-16 years old, with 4 teachers forming two dyads per school. In Oak there was a class of first years (n=11) with one dyad and a class of transition year students (n=24) with the other dyad. In Ash one class group (n=18) had two dyads. The subjects in which the dyads engaged were English and Mathematics. Method. This research adopted an interpretive paradigm. The duration of the fieldwork was from April 2007 to June 2008. Research methodologies included semi-structured interviews (n=44), classroom observation (n=20), attendance at monthly teacher meetings (n=6), questionnaires and other data gathering practices which included school documentation, assessment findings and joint examination of student work samples (n=4). Results. Team-teaching involves changing normative practices, and involves placing both demands and opportunities before those who occupy classrooms (teachers and students) and before those who determine who should occupy these classrooms (principals and district administrators). This research shows how team-teaching has the potential to promote inclusive learning, and when implemented appropriately, can impact positively upon the learning experiences of both teachers and students. The results are outlined in two chapters. In chapter four, Social Capital Theory is used in framing the data, the change process of bonding, bridging and linking, and in capturing what the collaborative action of team-teaching means, asks and offers teachers; within classes, between classes, between schools and within the wider educational community. In chapter five, Positioning Theory deductively assists in revealing the moment-to-moment, dynamic and inclusive learning opportunities, that are made available to students through team-teaching. In this chapter a number of vignettes are chosen to illustrate such learning opportunities. These two theories help to reveal the counter-narrative that team-teaching offers, regarding how both teachers and students teach and learn. This counter-narrative can extend beyond the field of special education and include alternatives to the manner in which professional development is understood, implemented, and sustained in schools and classrooms. Team-teaching repositions teachers and students to engage with one another in an atmosphere that capitalises upon and builds relational trust and shared cognition. However, as this research study has found, it is wise that the purposes, processes and perceptions of team-teaching are clear to all so that team-teaching can be undertaken by those who are increasingly consciously competent and not merely accidentally adequate. Conclusions. The findings are discussed in the context of the promotion of effective inclusive practices in mainstream settings. I believe that such promotion requires more nuanced understandings of what is being asked of, and offered to, teachers and students. Team-teaching has, and I argue will increasingly have, its place in the repertoire of responses that support effective inclusive learning. To capture and extend such practice requires theoretical frameworks that facilitate iterative journeys between research, policy and practice. Research to date on team-teaching has been too focused on outcomes over short timeframes and not focused enough on the process that is team-teaching. As a consequence team-teaching has been under-used, under-valued, under-theorised and generally not very well understood. Moving from classroom to staff room and district board room, theoretical frameworks used in this research help to travel with, and understand, the initiation, engagement and early consequences of team-teaching within and across the educational landscape. Therefore, conclusions from this study have implications for the triad of research, practice and policy development where efforts to change normative practices can be matched by understandings associated with what it means to try something new/anew, and what it means to say it made a positive difference.

Teaching yoga to seniors: essential considerations to enhance safety and reduce risk in a uniquely vulnerable age group.

BACKGROUND: Seniors age 65 and older represent the fastest-growing sector of the population and, like many Americans, are increasingly drawn to yoga. This presents both an extraordinary opportunity and a serious challenge for yoga instructors who must be both a resource and guardians of safety for this uniquely vulnerable group. A typical class of seniors is likely to represent the most diverse mix of abilities of any age group. While some may be exceedingly healthy, most fit the profile of the average older adult in America, 80% of whom have at least one chronic health condition and 50% of whom have at least two. OBJECTIVES: This article discusses the Therapeutic Yoga for Seniors program, offered since 2007 at Duke Integrative Medicine to fill a critical need to help yoga instructors work safely and effectively with the increasing number of older adults coming to yoga classes, and explores three areas that pose the greatest risk of compromise to older adult students: sedentary lifestyle, cardiovascular disease, and osteoporosis. To provide a skillful framework for teaching yoga to seniors, we have developed specific Principles of Practice that integrate the knowledge gained from Western medicine with yogic teachings.

What students can tell about lecturers when they are teaching: manifestations of confident and under-confident lecturers

Delivering a lecture requires confidence, a sound knowledge and well developed teaching skills (Cooper and Simonds, 2007, Quinn and Hughes, 2007). However, practitioners who are new to lecturing large groups in higher education may initially lack the confidence to do so which can manifest itself in their verbal and non-verbal cues and the fluency of their teaching skills. This results in the perception that students can identify the confident and non-confident teacher during a lecture (Street, 2007) and so potentially contributing to a lecturer’s level of anxiety prior to, and during, a lecture. Therefore, in the current educational climate of consumerisation, with the increased evaluation of teaching by students, having the ability to deliver high-quality, informed, and interesting lectures assumes greater significance for both lecturers and universities (Carr, 2007; Higher Education Founding Council 2008, Glass et al., 2006). This paper will present both the quantitative and qualitative data from a two-phase mixed method study with 75 nurse lecturers and 62 nursing students in one university in the United Kingdom. The study investigated the notion that lecturing has similarities to acting (Street, 2007). The findings presented here are concerned with how students perceived lecturers’ level of confidence and how lecturers believed they demonstrated confidence. In phase one a specifically designed questionnaire was distributed to both lecturers and students and a response rate of 91% (n=125) was achieved, while in phase two 12 in-depth semi-structured interviews were conducted with lecturers. Results suggested that students in a lecture could identify if the lecturer was confident or not by the way they performed a lecture. Students identified 57 manifestations of non-confidence and lecturers identified 85, while 57 manifestations of confidence were identified by students and 88 by lecturers. Overall, these fell into 12 main converse categories, ranging from body language to the use of space within the room. Both students and lecturers ranked body language, vocal qualities, delivery skills, involving the students and the ability to share knowledge as the most evident manifestations of confidence. Elements like good eye contact, smiling, speaking clearly and being fluent in the use of media recourses where all seen as manifestations confidence, conversely if these were poorly executed then a presentation of under confidence was evident. Furthermore, if the lecturer appeared enthusiastic it was clearly underpinned by the manifestation of a highly confidence lecturer who was secure in their knowledge base and teaching abilities: Some lecturers do appear enthusiastic but others don’t. I think the ones that do know what they are talking about, you can see it in their voice and in their lively body language. I think they are also good at involving the students even. I think the good ones are able to turn boring subjects into lively and interesting ones. (Student 50) Significantly more lecturers than students felt the lecturer should appear confident when lecturing. The lecturers stated it was particularly important to do so when they did not feel confident, because they were concerned with appearing capable. It seems that these students and lecturers perceived that expressive and apparently confident lecturers can make a positive impact on student groups in terms of involvement in lectures; the data also suggested the reverse, for the under confident lecturer. Findings from phase two indicated that these lecturers assumed a persona when lecturing, particularly, but not exclusively, when they were nervous. These lecturers went through a process of assuming and maintaining this persona before and during a lecture as a way of promoting their internal perceptions of confidence but also their outward manifestation of confidence. Although assuming a convincing persona may have a degree of deception about it, providing the knowledge communicated is accurate, the deception may aid rather than hinder learning, because enhances the delivery of a lecture. Therefore, the deception of acting a little more confidently than one feels might be justified when the lecturer knows the knowledge they are communicating is correct, unlike the Dr Fox Effect where the person delivering a lecture is an actor and does not know the subject in any detail or depth and where the deception to be justified (Naftulin, et al., 1973). In conclusion, these students and lecturers perceive that confident and enthusiastic lecturers communicate their passion for the subject in an interesting and meaningful manner through the use of their voice, body, space and interactions in such a way that shows confidence in their knowledge as well as their teaching abilities. If lecturers, therefore, can take a step back to consider how they deliver lectures in apparently confident ways this may increase their ability to engage their students and not only help them being perceived as good lecturers, but also contribute to the genuine act of education.

Socialising young literacy learners into a discourse of failure: Dominant discourses in literacy teaching and assessment and their impact on the progression of young literacy learners into employment

This paper argues that contemporary literacy programmes are a mismatch for the expectations of both the government and employers as well as the goals of learners. It submits that the dominant discourses in literacy provision have led to the emergence of a learning culture which not only fails the learners but is also incapable of meeting the aspirations of both the government and employers. To support this argument, the paper reports a small scale research project that analyses the perceptions of learners, teachers and employers who were involved in a work placement scheme for young literacy learners in a college of further education. Data for the study were collected through focus group and face to face interviews and analysed using the framework of discourse analysis provided by Gill (2000) with findings codified and analysed thematically. The study found that teachers were aware that their learners were not adequately prepared for the world of work because of the demands of the dominant discourses of quality and performance measurement which were most obviously manifested in their assessment, teaching methods and the attitudes of learners. It found that employers perceive young learners as inadequate in terms of the workplace expectations. Learners in the study revealed that their workplace culture and expectations were totally different from the culture to which they had been socialised in their studies. The study concludes that unless the dominance of these discourses is ameliorated, young literacy learners will continue to be socialised into a discourse of failure.

Teaching and cognitive outcomes in A-levels and Advanced GNVQ's: Case studies from Science and Business Studies Classrooms

The purpose of the paper is to demonstrate how a research diary methodology, designed to analyse A-level and GNVQ classrooms, can be a powerful tool for examining pedagogy and quality of learning at the level of case study. Two subject areas, science and business studies, are presented as cases. Twelve teachers and thirty-four students were studied over a four-week period in May 1997 and contrasts were drawn between lessons from three A-level physics teachers/three Advanced GNVQ science teachers and two A-level business/economics teachers/four Advanced GNVQ business teachers. Lessons were analysed within a cognitive framework which distinguishes between conceptual and procedural learning and emphasizes the importance of metacognition and epistemological beliefs. Two dimensions of lessons were identified: pedagogical activities (e.g. teacher-led explanation, teacher-led guidance on a task, question/answer sessions, group discussions, working with IT) and cognitive outcomes (e.g. structuring and memorizing facts, understanding concepts and arguments, critical thinking, problem-solving, learning core skills, identifying values). Immediately after each lesson, teachers and students (three per class) completed structured research diaries with respect to the above dimensions. Data from the diaries reveal general and unique features of the lessons. Time-ofyear effects were evident (examinations pending in May), particularly in A-level classrooms. Students in business studies classes reported a wider range of learning activities and greater variety in cognitive outcomes than did students in science classes. Science students self-rating of their ability to manage and direct their own learning was generally low. The phenomenological aspects of the classrooms were consistently linked to teachers' lesson plans and what their teaching objectives were for those particular students at that particular time of the year.

The use of interactive video in teaching teachers: an evaluation of a link with a primary school

This paper presents an evaluation of the use of videoconferencing in learning and teaching in a United Kingdom higher education institution involved in initial teacher education. Students had the opportunity to observe naturalistic teaching practices without physically being present in the classroom. The study consisted of semi-structured interviews with the co-ordinator of the link, the head of ICT services in Stranmillis University College and the teacher of the classroom being observed. Students were invited to complete an online questionnaire. The views of the students, the co-ordinator of the link, the teacher of the classroom being observed and the head of ICT services in Stranmillis University College were then triangulated to gain an overall view of the effectiveness of the videoconferencing link. Interviews suggested students benefited in terms of pedagogy. In the early stages of the project, the teacher thought it acted as a form of classroom control. Technical problems were encountered initially and camera control was modified in the light of these. The online questionnaire suggested that students viewed this experience in a positive way and were impressed with the content, technical quality, and potential benefits of the use of this example of new technologies.

Supporting group work in Scottish primary classrooms:Improving the quality of collaborative dialogue

A large body of research has demonstrated the value of fostering peer interaction in the context of collaborative group work as an effective strategy to facilitate learning. The present study attempted to enable teachers in a varied sample of 24 Scottish primary classrooms to improve the quality of collaborative group work interaction among their pupils. Observations were carried out at three time points during the year of the intervention, both during whole class teaching and planned group work activity. A global rating instrument was also used to evaluate the overall quality of classroom environment created by participating class teachers to support group work sessions. The results showed significant increases both in the observed frequencies of children's collaborative dialogue and in the rated quality of classroom learning environments over the course of the study. The implications of these results are discussed in the context of current curricular reform.

What Are the Effects of Teaching Evidence-Based Health Care (EBHC)? Overview of Systematic Reviews

Background

An evidence-based approach to health care is recognized internationally as a key competency for healthcare practitioners. This overview systematically evaluated and organized evidence from systematic reviews on teaching evidence-based health care (EBHC).

Methods/Findings

We searched for systematic reviews evaluating interventions for teaching EBHC to health professionals compared to no intervention or different strategies. Outcomes covered EBHC knowledge, skills, attitudes, practices and health outcomes. Comprehensive searches were conducted in April 2013. Two reviewers independently selected eligible reviews, extracted data and evaluated methodological quality. We included 16 systematic reviews, published between 1993 and 2013. There was considerable overlap across reviews. We found that 171 source studies included in the reviews related to 81 separate studies, of which 37 are in more than one review. Studies used various methodologies to evaluate educational interventions of varying content, format and duration in undergraduates, interns, residents and practicing health professionals. The evidence in the reviews showed that multifaceted, clinically integrated interventions, with assessment, led to improvements in knowledge, skills and attitudes. Interventions improved critical appraisal skills and integration of results into decisions, and improved knowledge, skills, attitudes and behaviour amongst practicing health professionals. Considering single interventions, EBHC knowledge and attitude were similar for lecture-based versus online teaching. Journal clubs appeared to increase clinical epidemiology and biostatistics knowledge and reading behavior, but not appraisal skills. EBHC courses improved appraisal skills and knowledge. Amongst practicing health professionals, interactive online courses with guided critical appraisal showed significant increase in knowledge and appraisal skills. A short workshop using problem-based approaches, compared to no intervention, increased knowledge but not appraisal skills.

Conclusions

EBHC teaching and learning strategies should focus on implementing multifaceted, clinically integrated approaches with assessment. Future rigorous research should evaluate minimum components for multifaceted interventions, assessment of medium to long-term outcomes, and implementation of these interventions.

Evaluation of Video Presentation to Deliver Surgical Anatomy Teaching

Title Evaluation of Video Presentation to Deliver Surgical Anatomy Teaching

Authors Walsh I.K., Boohan M., Dorman A.

Objectives To evaluate the efficacy of newly introduced video presentation to deliver Surgical Anatomy teaching to undergraduate medical students.

Design and Setting Qualitative and quantitative study using questionnaires and focus groups, employing students undertaking the perioperative medicine module of the phase 4 undergraduate medical curriculum at Queen’s University Belfast.

Outcome Measures To determine:
(1) if video presentation is effective in delivering surgical anatomy teaching,
(2) student’s learning preferences regarding this teaching method.
Results The questionnaire response rate was 89% (216 of 244 students; female: male ratio 1.25) and 42 students participated in 6 focus groups. Mean questionnaire responses indicated a favourable opinion on quality assurance items, with a mixed response to video presentation as a learning method. 71% of students preferred to receive a lecture in person, rather than via video presentation. There were no statistically significant differences between genders regarding learning preferences in general and regarding video versus live presentation in particular. Exploratory factor analysis demonstrated that favourable responses to video presentation were strongly associated with perceived audiovisual quality and learning preferences (Cronbach’s alpha coefficient 0.77), with 72% of students considering video presentation worthwhile. Positive perception of overall quality was strongly associated with learning preferences as well as more generic quality assurance issues (80% students; alpha coefficient 0.83).
The results were supported by triangulation of the above quantitative data with qualitative data generated by the focus groups. Students further articulated the view that video presentation may be more appropriate and effective in a mixed method setting.

Reference Basu Roy R, McMahon GT. Video-based cases disrupt deep critical thinking in problem-based learning. Med Educ 2012 Apr;46(4):426-435.