By M. Kippler. Barton College. 2018.

A protocol should then be prepared so that individual responsibilities are clearly outlined purchase 50mg zoloft mastercard depression after test e. Unfortunately order 50 mg zoloft otc depression vs dementia, ideal methods for evaluating teaching in medical schools are scarce. There is a need for robust “off the shelf” instruments that can be used To reduce possible bias in evaluation, to evaluate curriculums reliably. The process of evaluation itself collect views from more than one group may produce a positive educational impact if it emphasises of people—for example, students, those elements that are considered valuable and important by teachers, other clinicians, and patients medical schools. Participation by students Several issues should be considered before designing an Areas of competence of students to evaluate teaching and evaluation that collects information from students. They are uniquely aware of what they can consume, learning objectives; whether it fits well with other parts of the and they observe teaching daily. Daily contact, however, does not mean that students are x Delivery: attributes of teacher and methods used x Administrative arrangements skilled in evaluation. Evaluation by students should be limited to areas in which they are competent to judge. Ownership—Students who are not committed to an evaluation may provide poor information. They need to feel ownership for an evaluation by participating in its development. The importance of obtaining the information and the type of Participation by teachers in evaluation information needed must be explicit. Usually the results of an evaluation will affect only subsequent cohorts of students, so current students must be convinced of the value of providing Self evaluation Peer evaluation • Academic staff increasingly • Direct observation of teachers by data. If they become bored by tedious repetition, objective is to provide motivation • Mutual classroom exchange visits the reliability of the data will deteriorate. One solution is to use to change beahviour between trusted colleagues can be • To help define what they are doing, valuable to both the teacher and different sampling strategies for evaluating different elements of teachers may find it useful to use the observer a curriculum. If reliable information can be obtained from 100 videotapes made during teaching, students, why collect data from 300? However, those who support asking students to sign evaluation forms say that Issues relating to students’ participation in evaluation may also apply to teachers, but self evaluation and peer evaluation are also relevant this helps to create a climate of responsible peer review. If students are identifiable from the information they provide, this must not affect their progress. Data should be collected centrally and students’ names removed so that they cannot be identified by teachers whom they have criticised. Feedback—Students need to know that their opinions are valued, so they should be told of the results of the evaluation and given details of the resulting action. Methods of evaluation Evaluation may involve subjective and objective measures and qualitative and quantitative approaches. The resources devoted to evaluation should reflect its importance, but excessive data collection should be avoided. A good system should be easy to administer and use information that is readily available. Interviews—Individual interviews with students are useful if the information is sensitive—for example, when a teacher has received poor ratings from students, and the reasons are not clear. Electronic methods for administering questionnaires may improve response rates. The quality of the data, however, is only as good as the questions asked, and the data may not provide the reasons for a poorly rated session. Information from student assessment—Data from assessment are Subjective Objective useful for finding out if students have achieved the learning outcomes of a curriculum. A downward trend in examination Analysis of tasks results over several cohorts of students may indicate a Qualitative Focus groups successfully Interviews completed in an deficiency in the curriculum. Caution is needed when OSCE station interpreting this source of information, as students’ examination performance depends as much on their application, ability, and motivation as on the teaching. Trends in Quantitative Surveys examination scores Completing the evaluation cycle The main purpose of evaluation is to inform curriculum development. If the results of an evaluation show that no further development is OSCE = objective structured clinical examination needed, doubt is cast on the methods of evaluation or the Examples of methods of evaluation interpretation of the results. This does not mean that curriculums should be in a constant state of change, but that the results of evaluation to Key points correct deficiencies are acted on, that methods continue to improve, and that content is updated. Then the process starts all Evaluation should: x Enable strategic development of a curriculum over again.

The wheelchair makes you seem like your legs’re broke or you just can’t walk buy cheap zoloft 100mg depression disease. Eva said she would never use it: “As much pain as I’d be in generic 100mg zoloft with amex anxiety books, I’d be embar- rassed because it’s me. That way I don’t have to depend on my daughter to leave work and come over and do it for me. I just felt very elderly all of a sudden, but then we started having fun with it. The three-year-old stands on the front; the five-year- old gets in the back. Other than problems with transportation and the curb cuts—things that have to do with the system and the city—I love my Wheeled Mobility / 215 chair. But the urban environment still presents barriers, both physical and interpersonal. Sometimes people find their equipment doesn’t work for them, and they abandon it—the wheelchair just gathers dust. Views on the Street Much of society remains uneasy with persons who roll rather than walk. The anthropologist Robert Murphy, who had a spinal tumor, found that something changed when he started using a wheelchair: Not long after I took up life in the wheelchair, I began to notice other curious shifts and nuances in my social world. After a dentist patted me on the head in 1980, I never returned to his office.... I am now a white man who is worse off than they are, and my subtle loss of public standing brings me closer to their own status. We share a common position on the pe- riphery of society—we are fellow Outsiders. During my first couple of years in the wheelchair, I noticed that men and women responded to me differently. My peer group of middle-aged, middle-class males seemed most menaced by my dis- ability, probably because they identify most closely with me. On the other hand, I found that my relations with most women of all ages have become more relaxed and open. A department of medicine chairman once patted me on the head—affectionately, I think. When I roll around the hospital, the cleaning staff often greet me, while many physicians gaze fixedly above my head. These behaviors symbolize societal attitudes and have practical consequences too. Traveling by wheelchair on busy Manhattan streets is particularly unnerving. Stereotypical New Yorkers look straight ahead, rushing for- ward at full throttle, intent on their destination. They pirouette away in near misses that are heart-stopping (my heart, that is), surging onward, not glancing down. Yet other New Yorkers are at my eye level: I face the beseeching pleas of homeless people huddled on the pavement. Hair flying, arms cradling her briefcase, she sprinted, eyes fixed on the television monitor overhead. I didn’t veer out of her way 216 W heeled Mobility quickly enough, and she went sprawling. I felt terrible and now stop dead in my tracks whenever I see anyone running toward me. Because wheelchair users are the height of children, Mairs suggests, so- ciety will “demand little of her beyond obedience and enough self-restraint so that she doesn’t filch candy bars at the checkout counter” (1996, 62). Sally Ann Jones was ticketed for speeding in her car: The town’s courtroom is upstairs from the police department, and there’s no elevator. They don’t know what to do with me exactly, and they’re very deferential: Do I want a cup of coffee?

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In some respects purchase zoloft 25 mg without prescription anxiety nursing care plan, EMQs share similarities with the context- dependent MCQ we described earlier 50mg zoloft fast delivery depression ribbon. It is not enough simply to select 100 questions from the item bank or from among those recently prepared by your colleagues. The selection must be done with great care and must be based on the objectives of the course. A blueprint, or table of test specifications, should be prepared which identifies the key topics of the course which must be tested. The number of questions to be allocated to each topic should then be determined according to its relative importance. Sort out the items into the topics and select those which cover as many areas within the topic as possible. It is advisable to have a small working group at this stage to check the quality of the questions and to avoid your personal bias in the selection process. You may find that there are some topics for which there is an inadequate number or variety of questions. You should then commission the writing of additional items from 146 appropriate colleagues or, if time is short, your committee may have to undertake this task. This process of blue- printing will establish the content validity of the test. It is less confusing to students if the items for each topic are kept together. Check to see that the correct answers are randomly distributed throughout the paper and if not, reorder accordingly. Organise for the paper to be word- processed, with suitable instructions about the format required and the need for security. At the same time make sure that the ‘Instructions to Students’ section at the beginning of the paper is clear and accurate. Check and recheck the copy as errors are almost invariably discovered during the examination, a cause of much consternation. Finally, have the paper printed and arrange for secure storage until the time of the examination. Scoring and analysing an objective test The main advantage of the objective type tests is the rapidity with which scoring can be done. This requires some attention to the manner in which the students are to answer the questions. It is usually inappropriate to have the students mark their answers on the paper itself. When large numbers are involved a separate structured sheet should be used. Where facilities are available it is convenient to use answer sheets that can be directly scored by computer or for responses to be entered directly into a computer by students. An overlay is produced by cutting out the positions of the correct responses. This can then be placed over the student’s answer sheet and the correct responses are easily and rapidly counted. Before doing so ensure that the student has not marked more than one answer correct! In most major medical examinations a computer will be used to score and analyse objective-type examinations. You must therefore be familiar with the process and be able to interpret the subsequent results. The computer programme will generally provide statistical data about the examination including a reliability coefficient for internal consistency, a mean and standard deviation for the class and analyses of individual items. Should you be 147 the person responsible for the examination you will need to know how to interpret this information in order to process the examination results and to help improve subsequent examinations. If you are not familiar with these aspects we strongly suggest you seek expert advice or consult one of the books on educational measurement listed at the end of the chapter. DIRECT OBSERVATION Direct observation of the student performing a technical or an interpersonal skill in the real, simulated or examination setting would appear to be the most valid way of assessing such skills. Unfortunately, the reliability of these observa- tions is likely to be seriously low. This is particularly so in the complex interpersonal area where no alternative form of assessment is available.

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You may even find this more threatening than the students but it is important they learn that infallibility is not an attribute of clinical teachers and that it is quite normal for even the most experienced clinician to have to admit indecision and a need to obtain advice or further information order zoloft 25 mg line depression plate definition. ALTERNATIVES TO TRADITIONAL CLINICAL TEACHING We have already provided evidence that traditional clinical teaching is often inadequate in meeting the aims of both the medical school and the students order 100mg zoloft otc depression endogenous symptoms. This has led many schools to introduce structured courses to teach basic clinical skills in a less haphazard manner. The skills taught are often not restricted to interviewing and physical examination but include technical skills and clinical problem solving. Should you have the opportunity to introduce or participate in such an approach then the first step must be to define the objectives of the exercise. These must take into account the seniority of the students, the time allocated in the curriculum, the facilities, and the availability of teachers and other resources. There are obviously many ways in which this could be done but we will restrict ourselves to outlining such a programme 78 which has been run successfully for many years jointly by a Department of Medicine and a Department of Surgery. Opposite each are the teaching activities which are planned to help the student achieve the objectives. In the right-hand column are the assessment procedures which are also matched to the objectives. The key to the programme is the attachment of only three students to a preceptor for instruction on history taking and physical examination. You will note that the problem-orientated medical record approach has been adopted and we find this has been a valuable adjunct to our teaching. Whole-group problem- solving sessions include clinical decision making, emer- gency care, data interpretation (clinical chemistry, haema- tology and imaging) and management/therapeutics. The students are also expected to take responsibility for a lot of their own learning. Various self-learning materials are also available for the students to use in their own time. Though such a programme is far from perfect, it was introduced within a traditional curriculum and with the minimum of resources. The main change was a reallocation of staff time away from didactic activities and into more direct observation of student performance. A perusal of the medical educational literature will provide you with other examples of structured clinical teaching. Increasingly you will find descriptions of the use of clinical skills laboratories where medical schools have set up fully staffed and equipped areas devoted to putting groups of students through an intensive training in clinical skills, often using a wide range of simulations. You will also find many examples of training students in interpersonal and communication skills using simulated patients. All have the same general approach: to undertake the training of various clinical skills in a structured and supervised way to ensure that all students achieve a basic level of competence. TECHNIQUES FOR TEACHING PARTICULAR PRACTICAL AND CLINICAL SKILLS Many practical and clinical skills can be taught as separate elements. Because there is a wide range of these elements, and as clinical teaching is generally opportunistic, many medical schools have established programmes to teach basic skills in a piecemeal fashion. This is normally done early in the students’ career, often just prior to their first clinical attachments. This section will introduce you to a variety of ways of teaching basic skills some of which may not be of immediate relevance but some of which ought to be in operation in your medical school because of their proven efficacy. Video recording: any department which has the respon- sibility for teaching aspects of history taking or inter- personal skills should have access to video recording equipment, preferably of the portable kind that can be set up in ward side rooms, outpatients and other teaching situations. You should become familiar with the technical operation of the equipment. The simplest is to record examples of interviewing techniques (good and bad) for demonstration purposes. You may also wish to have an example of a basic general history so the novice student can get an idea of the questions that are routinely asked. Some medical schools have recorded segments of interviews with patients which show various emotional reactions (e. The most powerful way of using the video is to record the student’s interview with a patient remembering that informed consent is essential. This may be initially stressful but both student and patient usually forget they are being recorded after a few minutes.

Though the medical temperance campaign was eagerly taken up by health promotionists and radical epidemiologists discount 25mg zoloft visa mood disorder psychology definition, in the course of the 1990s it encountered some epidemiological difficulties of its own buy zoloft 50 mg otc depression definition in psychiatry. In face of earlier research revealing the adverse effects of alcohol, not only on the liver, but in increasing risks of heart disease and cancer, new studies claimed to show that moderate drinking had a beneficial effect on health and longevity (Marmot, Brunner 1991). In particular a study conducted by a team headed by Richard Doll, famed for revealing the smoking-lung cancer link forty years earlier, concluded that ‘among British men in middle or older age, the consumption of an average of one or two units of alcohol a day is associated with significantly lower all-cause mortality than is consumption of no alcohol, or the consumption of substantial amounts of alcohol’ (Doll et al. It appeared that drinking a 48 THE REGULATION OF LIFESTYLE couple of glasses of wine a day had a ‘cardio-protective’ effect, reducing the risk of coronary heart disease. Doll’s paper provoked an angry denunciation from the director of the World Health Organisation’s ‘programme on substance abuse’, whose response is quoted at the head of this section. The WHO was concerned that the publicity given to this study might encourage people to start drinking: ‘we are seeking to demystify the idea that alcohol is good for your health and to debunk the idea that to have a drink a day will keep the doctor away’ (Craft 1994). The following year, the royal colleges reviewed their anti-alcohol guidelines in the light of the discovery that the graph of mortality against alcohol intake was not linear, but ‘J-shaped’. These eminent medical authorities acknowledged the new research but recommended that there should be no change from the current 21/14 recommendations, which were ‘prudent’ and ‘justified’ (indeed Doll et al. However, in December 1995, in an apparent surge of Christmas cheer, the government announced new guidelines, recommending limits of 3–4 units a day for men and 2–3 units a day for women (DoH 1995). Though health minister Stephen Dorrell denied any intention of raising the threshold of ‘sensible drinking’, simple arithmetic revealed new weekly limits of 28 for men and 21 for women. This statement was immediately branded a ‘boozers’ charter’ in the tabloid press and as fervently condemned by the anti- alcohol movement as it was welcomed by the drink trade. The BMA described the government’s initiative as ‘both irresponsible and badly timed’ and the Royal College of Physicians complained that ‘by raising the “sensible limits” people are being encouraged to drink more’ (Times, 13 December 1995). This is how two leading epidemiologists posed the problem confronting health promotionists in this area: Is it possible to persuade older non-drinkers to drink a little for the benefit of their health, and is it possible to do this without increasing the number of people, especially teenagers, who drink at levels that are dangerous? For the vast majority of people, whether they are teetotallers 49 THE REGULATION OF LIFESTYLE or drunks, or at some point on the wide spectrum in between, concerns about health are not a significant factor in their drinking behaviour. People may drink alcohol in varying quantities (or may not drink at all) for all sorts of cultural, social and psychological reasons. In my experience most habitual heavy drinkers are well aware that alcohol does not have a beneficial effect on their health, but reminding them of this does not inhibit their consumption. People who drink only occasionally or not at all have their own reasons, among which concerns about health are not likely to be prominent. Only an epidemiologist could believe that either a middle aged non-drinker sitting at home or a teenager going out on a weekend is going to be influenced by government propaganda advising them of the health benefits of ‘sensible drinking’. But then only an epidemiologist could believe that data based on ‘self- reported’ levels of alcohol consumption can provide a useful basis for quantitative studies. The power of the ideology of health promotion is such that even its critics sometimes fall back on attempts to justify a particular lifestyle choice in terms of health. Thus, campaigners against the tyranny of counting units of alcohol in different beverages have seized on associations between moderate levels of alcohol consumption and reduced mortality to bolster their case. As Dalrymple observes, ‘even those who warn against health fanatics forget their own principles when an association emerges that pleases them’ (Dalrymple 1998). Both arguments, based—like most of the epidemiology underlying health promotion—on the confusion of association with causation, are equally irrational. Opponents of the ‘health fanatics’ would be on stronger ground if they pointed out that drinking alcohol in its wonderful diversity of forms is a highly pleasurable activity which has, in general, nothing to do with health. The familiar fact that some people drink an excessive amount of alcohol, causing adverse physical, psychological and social consequences, is strictly irrelevant to the drive to regulate the drinking habits of the entire population in the name of health. Exercise Over the past couple of years I have been able to refer my patients to an ‘Exercise on Prescription’ scheme organised by Hackney Council ‘education and leisure’ services in collaboration with the local health authority (Hackney Education and Leisure 1997). Under this scheme 50 THE REGULATION OF LIFESTYLE I can refer patients to a local leisure centre for a twelve week exercise programme, beginning with ‘a thirty minute consultation with the health and fitness adviser’. They will then ‘be asked to attend at least two sessions a week’ of activities, including ‘low intensity keep fit sessions’, ‘aqua-aerobics and learn-to-swim sessions’, a ‘walking programme’, ‘personal fitness programmes’ and ‘cardiac rehabilitation programmes’. Though the scheme is subsidised, participants are asked to pay between £1 and £2 per session. By 1999 more than 200 such schemes were in operation around the country and were reportedly popular with patients, doctors (and with leisure centres which gained a steady supply of customers during times of low demand). It may seem perverse to criticise a campaign to encourage people to take more exercise, something that many would regard as self- evidently beneficial. Yet it is important to note the subtly coercive character of these exercise programmes.

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