The Mount Sinai journal of medicine, New York
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Comparative Study
Correlation between housestaff performance on the United States Medical Licensing Examination and standardized patient encounters.
There is interest in the use of "standardized patients" to assist in evaluating medical trainees' clinical skills, which may be difficult to evaluate with written exams alone. Previous studies of the validity of observed structured clinical exams have found low correlation with various written exams as well as with faculty evaluations. Since the United States Medical Licensing Examination (USMLE) results are often used by training programs in the selection of applicants, we assessed the correlation between performance on an observed structured clinical exam and the USMLE, steps 1 and 2, for internal medicine housestaff. ⋯ The low correlation between the USMLE and performance on a structured clinical exam suggests that either the written exam is a poor predictor of actual clinical performance, the small window of clinical skills measured by the structured clinical exam is inadequate, or the two methods evaluate different skill sets entirely. Our findings are consistent with previous work finding low correlations between structured clinical exams and accepted common means of evaluation, such as faculty evaluations, other written exams and program director assessments. The medical education community needs to develop an objective, valid method of measuring important, yet subjective, skill-sets such as interpersonal communication, empathy and efficient data collection.
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It is important to teach community members about the causes, magnitude and effects of health disparities that affect them, and to partner with them to develop, test and disseminate programs that they can sustain to improve health. East and Central Harlem are two underserved, predominantly minority, inner-city communities whose residents have disproportionately high morbidity and mortality from chronic conditions. We developed an approach to educate and work together with Harlem residents to study health disparities, and to use peer-led classes to improve chronic disease management and outcomes. ⋯ Researchers, clinicians and community leaders worked together to disseminate knowledge about health disparities and a peer-organized education program to address these disparities. This approach provides a foundation to attain a cadre of community-based experts to inform the community about ways to reduce health disparities. By pooling local and academic expertise and resources, we hope to develop programs that are workable, effective and sustainable without outside control or funding.
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The endoplasmic reticulum (ER) is a command center of the cell that is second only to the nucleus in terms of the breadth of its influence on other organelles and activities. It is a major site of protein synthesis, contains the cellular calcium stores that are an essential component of many signaling pathways, and is the proximal site of a signal transduction cascade that responds to cellular stress conditions and serves to maintain homeostasis of the cell. ⋯ Our studies during the past several years have revealed that the ER molecular chaperone BiP is a master regulator of ER function. It is responsible for maintaining the permeability barrier of the ER during protein translocation, directing protein folding and assembly, targeting misfolded proteins for retrograde translocation so they can be degraded by the proteasome, contributing to ER calcium stores, and sensing conditions of stress in this organelle, to activate the mammalian unfolded protein response.
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The United States has achieved dramatic improvements in overall health and life expectancy, largely due to initiatives in public health, health promotion and disease prevention. Academic health centers have played a major role in this effort, given their mission of engaging in research, educating health professionals, providing primary and specialty medical services, and caring for the poor and uninsured. However, national data indicate that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer and HIV/AIDS. Two factors contribute heavily to these racial and ethnic disparities in health: minorities are subjected to adverse social determinants, and they are disproportionately represented among the uninsured. In the last twenty years, however, the literature has highlighted the fact that racial and ethnic disparities occur not only in health, but also in health care. The Institute of Medicine Report, "Unequal Treatment." The Institute of Medicine (IOM) was asked to determine the extent of racial and ethnic disparities in health care. Their report, entitled "Unequal Treatment," found that racial and ethnic disparities in health care do exist, and that many sources, including health care systems, health care providers, patients and utilization managers, are contributors. Recommendations from "Unequal Treatment": Implications for Academic Health Centers. The IOM Report, "Unequal Treatment," provides a series of recommendations to address racial and ethnic disparities in health care, targeted to a broad audience (the executive summary and full IOM Report can be found at www.nap.edu under the search heading "Unequal Treatment"). Several of the recommendations speak directly to the mission and roles of academic health centers, and have clear and direct implications for patient care, education, and research. These recommendations include collecting and reporting health care access and utilization data by patient=s race/ethnicity, encouraging the use of evidence-based guidelines and quality improvement, supporting the use of language interpretation services in the clinical setting, increasing awareness of racial/ethnic disparities in health care, increasing the proportion of underrepresented minorities in the health care workforce, integrating cross-cultural education into the training of all health care professionals, and conducting further research to identify sources of disparities and promising interventions. ⋯ "Unequal Treatment" provides the first detailed, systematic examination of racial/ethnic disparities in health care, and provides a blueprint for how to address them. The report=s recommendations are broad in scope, yet have direct implications for academic health centers.
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Physicians play the central role in decisions to initiate, withhold and withdraw life-sustaining medical care. Prior studies show that physicians= religiosity is related to end-of-life care attitudes and practices, which if not in concert with the patient or family may be a source of conflict. We surveyed physicians of one religion to describe the relationship between religiosity and end-of-life care. ⋯ Physicians' religiosity can have a major effect on the way their patients die, including whether patients receive adequate analgesia near death. Patients may need to query physicians' religious perspectives to ensure that they are consistent with patients' end-of-life care preferences. Evaluation of religiosity-related clinical behavior in other cultures is needed.