Early practical experience and the social responsiveness of clinical education: Systematic review

Objectives To find how early experience in clinical and community settings (early experience) affects medical education, and identify strengths and limitations of the available evidence. Design A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001. Data sources Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration. Selection of studies All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication. Results Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries,junior students provided preventive health care directly to underserved populations. Conclusion Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Chloroplast and total genomic diversity in the endemic Costa Rican tree Lonchocarpus costaricensis (J.D. Smith) Pittier (Papilionaceae).

In Mesoamerica, tropical dry forest is a highly threatened habitat, and species endemic to this environment are under extreme pressure. The tree species, Lonchocarpus costaricensis is endemic to the dry northwest of Costa Rica and southwest Nicaragua. It is a locally important species but, as land has been cleared for agriculture, populations have experienced considerable reduction and fragmentation. To assess current levels and distribution of genetic diversity in the species, a combination of chloroplast-specific (cpDNA) and whole genome DNA markers (amplified fragment length polymorphism, AFLP) were used to fingerprint 121 individual trees in 6 populations. Two cpDNA haplotypes were identified, distributed among populations such that populations at the extremes of the distribution showed lowest diversity. A large number (487) of AFLP markers were obtained and indicated that diversity levels were highest in the two coastal populations (Cobano, Matapalo, H = 0.23, 0.28 respectively). Population differentiation was low overall, F-ST = 0.12, although Matapalo was strongly differentiated from all other populations (F-ST = 0.16-0.22), apart from Cobano (F., = 0.11). Spatial genetic structure was present in both datasets at different scales: cpDNA was structured at a range-wide distribution scale, whilst AFLP data revealed genetic neighbourhoods on a population scale. In general, the habitat degradation of recent times appears not to have yet impacted diversity levels in mature populations. However, although no data on seed or saplings were collected, it seems likely that reproductive mechanisms in the species will have been affected by land clearance. It is recommended that efforts should be made to conserve the extant genetic resource base and further research undertaken to investigate diversity levels in the progeny generation.

The debate on human automatism in mid-Victorian England

During the 1830s, Marshall Hall carried out innumerable experiments on a great variety of animals to establish the concept of a ‘reflex arc’. In France F.L.Goltz showed that decerebrate frogs were still capable of complex behaviours. Thomas Laycock in England and Ivan Sechenov in Russia sought to apply the reflex idea to the brain. This paper follows the debate in the periodical literature of mid-Victorian England and discusses the contributions of WB Carpenter, Herbert Spencer, TH Huxley, W Clifford and others. The previous outing of this issue in the post-Cartesian seventeenth century had been largely suppressed by ecclesiastical authority. In the nineteenth century ecclesiastical power had waned, at least in England, and the debate could take a more open form. As neurophysiology and behavioural science developed, with the widespread acceptance of Darwinian evolution, it became more and more difficult to deny that brain and mind were part of the natural world and subject to the usual laws of cause and effect. This, of course, had powerful implications for the human self-image and for jurisprudence. These implications are still with us and the work of neurophysiologists such as Benjamin Libet have only reinforced them. Should humans be regarded as ‘automata’ and, if so, what becomes of ‘free will’, ‘responsibility’, and the rule of law? The Victorian debate is still useful and relevant.

Uncertainty and the influence of group norms in the attitude-behaviour relationship

Two studies were conducted to examine the impact of subjective uncertainty on conformity to group norms in the attitude-behaviour context. In both studies, subjective uncertainty was manipulated using a deliberative mindset manipulation (McGregor, Zanna, Holmes, & Spencer, 2001). In Study 1 (N = 106), participants were exposed to either an attitude-congruent or an attitude-incongruent in-group norm. In Study 2(N = 83), participants were exposed to either a congruent, incongruent, or an ambiguous in-group norm. Ranges of attitude-behaviour outcomes, including attitude-intention consistency and change in attitude-certainty, were assessed. In both studies, levels of group-normative behaviour varied as a function of uncertainty condition. In Study 1, conformity to group norms, as evidenced by variations in the level of attitude-intention consistency, was observed only in the high uncertainty condition. In Study 2, exposure to an ambiguous norm had different effects for those in the low and die high uncertainty conditions. In the low uncertainty condition, greatest conformity was observed in the attitude-congruent norm condition compared with an attitude-congruent or ambiguous norm. In contrast, individuals in the high uncertainty condition displayed greatest conformity when exposed to either an attitude-congruent or an ambiguous in-group norm. The implications of these results for the role of subjective uncertainty in social influence processes are discussed. © 2007 The British Psychological Society.

On being thrown into phenomenological research: a book review of J.A. Smith, P. Flowers & M. Larkin (2009) Interpretative Phenomenological Analysis: Theory, method and research. London: Sage.

Book review

Comparison of techniques for measuring anterior chamber depth:Orbscan imaging, Smith's technique, and van Herick's method

Background Evaluation of anterior chamber depth (ACD) can potentially identify those patients at risk of angle-closure glaucoma. We aimed to: compare van Herick’s limbal chamber depth (LCDvh) grades with LCDorb grades calculated from the Orbscan anterior chamber angle values; determine Smith’s technique ACD and compare to Orbscan ACD; and calculate a constant for Smith’s technique using Orbscan ACD. Methods Eighty participants free from eye disease underwent LCDvh grading, Smith’s technique ACD, and Orbscan anterior chamber angle and ACD measurement. Results LCDvh overestimated grades by a mean of 0.25 (coefficient of repeatability [CR] 1.59) compared to LCDorb. Smith’s technique (constant 1.40 and 1.31) overestimated ACD by a mean of 0.33 mm (CR 0.82) and 0.12 mm (CR 0.79) respectively, compared to Orbscan. Using linear regression, we determined a constant of 1.22 for Smith’s slit-length method. Conclusions Smith’s technique (constant 1.31) provided an ACD that is closer to that found with Orbscan compared to a constant of 1.40 or LCDvh. Our findings also suggest that Smith’s technique would produce values closer to that obtained with Orbscan by using a constant of 1.22.

Reply to J Rood and SR Smith

Triglyceride concentrations and endotoxemia

Creating citizen-consumers:changing publics and changing public services - by John Clarke, Janet E. Newman, Nick Smith, Elizabeth Vidler and Louise Westmarland

Book review: John Clarke, Janet E. Newman, Nick Smith, Elizabeth Vidler and Louise Westmarland. Sage, 2007, 192 pp., £21.99 (pb), ISBN: 9781412921343

Follow the money:the Audit Commission, Public Money and the Management of Public Services, 1983-2008, Duncan Campbell-Smith

Book review: Duncan Campbell-Smith. Allen Lane, 2008, 744 pp., £ 25 (hb), ISBN: 9781846140686

Smith v Trafford Housing Trust

Case law report - online