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Foo20151013 2023 1i9rgu8?1444773940
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220

The elephant in the room: Is everything you see on an x-ray relevant?

Recent 'tongue in cheek' research which has been reported in a Washington Post blog recently has caused a lot of questions to be raised concerning inattention blindness, which could cause concern unless you understand the underlying psychology. Here's a CT scan: During psychology lectures at Med School, you may have encountered the basketball bouncing students in front of a bank of elevators where you were asked to count the number of passes the basketball made from the player wearing the white T shirt, while a gorilla ran between the students. (Even if you did watch it before, you can re-watch the video on the Washington Post blog). The recent study asked radiologists to identify and count how many nodules are present in the lungs on a regular CT thorax. If you look at the image you may see a gorilla waving his arms about. As a radiologist, I see the anatomy in the background, the chambers of the heart and mediastinum, but nothing there out of the ordinary. As radiologists, we are looking for pathology, but also report pathological findings that are unexpected. The clinical history of a patient is very important for us in interpretation of imaging examinations, as we need to answer the question you are asking, but have to be careful we do not miss anything else of serious import. As we do not see any other pathology, we would not expect to find a gorilla in the chest, so our brains can pass over distracting findings. The other psychological issue is the satisfaction of search, where we can see the expected pathology, but may miss the other cancer if we do not carefully and systematically look through the images. So the main thing to learn from this is that your training should always keep you alert, not just to expected happening, but to not discount the unexpected, then many lives will be saved as a result of your attention to detail.  
Chris Flowers
over 6 years ago
Foo20151013 2023 1lz2a7y?1444773942
3
836

Integrated system-based medical education vs discipline-based medical education

I am an Anatomy Professor who has taught anatomy to the medical school students in discipline based medical education system for first 10years of academic life. When I started teaching Anatomy in system-based medical education in the later half of my academic life I was surprised to find out that my students in system-based education can retain a lot of anatomy knowledge as they can visualize the application of the contents in the pathology, clinical science contents, PBL triggers and clinical skills sessions. Surprisingly, medical schools in India still follow the discipline-based medical education. Mostly the students are forced to retain the factual knowledge of Anatomy in this system. When they are in Year 1,they study only Anatomy,Physiology and Biochemistry. Hence it is very difficult for the student to imagine the application of the knowledge of Anatomy learnt in lecture or dissection room. For example, the students in discipline-based system learn the gross anatomy of the sternum and anterior thoracic wall. They need to memorize the importance of sternal angle without visualizing it as they are still not practising palpation of anterior thoracic wall for apex beat. I know that they learn it provided they are lucky to get a tutor who is a medical doctor, who obviously takes them to the task of palpating intercostal space through palpation of sternal angle in skeleton or over their own body surface marking. But the lack of Clinical skills practice in traditional discipline based medical education in year 1 does not allow the student to apply their anatomy knowledge automatically. Dr Nilesh Mitra  
Nilesh Kumar Mitra
over 6 years ago
Foo20151013 2023 184etvn?1444773944
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133

Aspergillus and Human Health

Many may be familiar with aspergillosis as the infecting agent in acute cases where the patient is severely immunocompromised - but there is more to this fungus' repertoire. There are rare cases where the patient's immune system is overwhelmed by a large inhalation of spores e.g. after gardening, but these are insignificant in terms of total numbers effected. The following are far more common:- Aspergillus and other fungi are increasingly identified as the active agent in sinusitis - if you have cases that don't respond to antibiotics this is worth thinking about. Chronic pulmonary aspergillosis (CPA & aspergilloma) is an infection of immunocompetent people, causing respiratory difficulty, coughing and haemoptysis. The UK NHS has a specialist centre for these patients In Manchester (National Aspergillosis Centre (NAC)). NAC has particular expertise and extensive facilities for the diagnosis of CPA, ABPA, SAFS and use of systemic antifungal drugs. Allergic infection (Allergic Bronchopulmonary Aspergillosis - ABPA and chronic sinusitis) is thought to be heavily underdiagnosed and undertreated. ABPA is particularly common in Asthma, Cystic Fibrosis patients and those with bronchiectasis. There is estimated to be 25 000 cases in the UK alone. Many (50%) of the most severe asthma cases are sensitive to fungi (SAFS) - in particular Aspergillus. These tend to be the most unstable cases that don't respond to antibiotics and several studies have been published that show giving an antifungal helps reduce the use of steroids for these patients. Last but not least - Tuberculosis is on the rise in the UK and the rest of the world. It is estimated that 2% of cases progress to CPA and should be treated using an antifungal - this is usually not done until considerable time has passed and much damage has been done. In total it is estimated that many millions of people across the world suffer from aspergillus - ABPA - 5 million, Tb - 400 000 per year and Asthma (SAFS - 1 - 4 million cases in EU & US). Sinusitis cases may number many tens of millions worldwide. So - the next time you assume aspergillus infections and aspergillosis are rare and confined to those who are profoundly immunocompromised - think again! If you have a patient who has increasingly severe respiratory symptoms, doesn't respond to multiple courses of antibiotics then give aspergillus a thought. Browse around these articles for further information Aspergillus Website Treatment Section. NB For a broader look at the prevalence of fungal diseases worldwide the new charity Leading International Fungal Education (LIFE) website is worth looking at.  
Graham Atherton
over 6 years ago
Foo20151013 2023 7owyf5?1444773963
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152

Benchmarking Outpatient Referral Rates

Introduction GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients. It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons It's Very Difficult to Normalise Surgeries Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another. There Are Several Reasons For The Referral I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition. We Need To Look At The Bigger Picture The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital. Education, Education, Education When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories: 2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker. 2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc. Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis. Consultant to Consultant Referral. As advised between consultants. Patient Choice. Sometimes the patient just wants to see the hospital doctor. The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below. Reasons For Referrals Firstly a few disclaimers and thoughts. These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures. There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right. The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption. This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further. In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason. So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services. 3 Step Plan As I’m not one to just give problems here are my 3 suggestions to help referrals. To have a more responsive Layered Outpatient Service. Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation. Education, education, education It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first. Diagnose Earlier and Refer Appropriately The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process. Conclusion At the end of the day it's about appropriate referrals always, not just a reduction. Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.  
Raza Toosy
over 6 years ago
Foo20151013 2023 159552n?1444774079
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105

Current Social Media Guidance

Hello & Welcome! You may have already read my blog on 'My Top 5 Tips to use Social Media to Improve your Medical Education' and if so you will have an idea of what 'Social Media' is and how it can be harnessed to improve medical education. There are also features that could improve health promotion and communication but today I would like to focus on where we have to be careful with these resources. In my last blog I circumnavigated the drawbacks of social media in medicine so that I could give them the full attention they deserve in their own blog today. But its not all doom and gloom! I also hope to give you a brief overview of the current social media guidance that is available to doctors and medical students and how we can minimise the risks associated with representing ourselves online. But firstly, what actually is social media and why do i keep blogging about it? If you are new here I recommend giving 'Social Media' a quick google, but the phrase basically includes any website where the user (i.e. you) can upload information and interact with other users. Thats a definition of the top of my head, so don't hold me to it, but most people would agree that this definition includes the classic examples of Facebook, Twitter, YouTube, Linkedin etc, but there are many many more. These sites are important to us as (future) health professionals because they can be both used and unfortunately abused. However, several medical bodies including the General Medical Council and the Royal College of General Practitioners agree that these resources are here to stay and they shouldn't (and probably couldn't) be excommunicated. With this in mind, there has been much guidance on the topic, but as you are about to find out a lot of it is common sense and your own personal discretion. Before you read on, I'd like to forewarn you that I try and keep things lighthearted with this topic. I'll hope you can excuse my levity of the situation, especially if any of the original authors of these guidelines end up reading this post. But as I am sure you are aware, this is a dry topic and hard to digest without the odd joke or two... British Medical Association - Using Social Media: practical and ethical guidance for doctors and medical 2011 The BMA guidance is the earliest guidance originating from a major medical body that i've come across. That said, I have not done a proper literature review of the subject. This is a blog, not a dissertation. But still, the BMA gives an early and brief summary of the problems facing health professionals using social media. Key points such as patient confidentiality, personal privacy, defamation, copyright and online professionalism are covered and therefore it is a nice starting point. It is also quite a short document, which may appeal to those who are less feverent on the subject. On the other hand, I personally feel that the BMA guidance does social media an injustice by not going into the great benefits these resources can yield. There are also no really practical tips or solutions for the drawbacks they've highlighted to students. Read it for yourself here or just google 'BMA Guidance Social Media' Royal College of General Practitioners - Social Media Highway Code Feb 2013 The RCGP guidelines are my favourite. After a cheesy introduction likening the social media surge with the dawn of the automobile they then take a turn for the worse by trying to continue the metaphor further by sharing a 'Social Media Highway Code'. Their Top 10 Tips that form the majority of the code don't look to be much more than common sense. However, each chapter there after dissects each of their recommendations in great detail and provides practical tips on how to make the most from social media whilst protecting yourself from the issues raised above. As I mentioned earlier, the RCGP recognise the inevitability of social media and they acknowledge this in the better part of their introduction. They make a great point that older doctors have a responsibility to become technologically savvy, whereas younger doctors who have grown up engrossed in social networking probably have to develop their professionalism skills more than their older colleagues (I'm aware this is a generalising statement). Either way, the RCGP highlight that everyone has something to take away from this set of guidelines. Read it for yourself here or google; 'RCGP Social Media Guidance,' but be warned, this is one of the more lengthy documents available on the topic. General Medical Council - Doctor's Use of Social Media April 2013 The GMC guidance kicks off with a little summary of the relevant bits of 'Good Medical Practice.' Again, nothing much that isn't common sense. That being said, they then go on to write that 'Serious or persistent failure to follow this guidance will put your registration at risk,' which sounds ominous and probably warrants a quick flick through (do it now! - the PDF is at the bottom of their page). Reassuringly, the GMC does not try and place a blanket ban on social media. They give a 'tip of the hat' to the benefits of social media and then go on to outline all the drawbacks as many of the guidance already has. Asides from the issue of anonymity there is really nothing new covered and the GMC actually gives a lot of autonomy to doctors and medical students. However, the GMC are, in many ways, who we ultimately answer to and so you would be a fool not to revisit the issues they cover in their version of the guidance. As I mentioned, the GMC brought online anonymity to the forefront of our minds. Should we, shouldn't we? A lot of health professionals believe that the human right to a private life extends to the right to have anonymity online. However, before we go into this any further lets take a closer look at what the GMC actually says... If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the view of the profession more widely. As you can see, the use of the phrase 'Should also identify yourself by name' gives some room for manoeuvre and is a world apart from what could have been written (i.e. you must). To those who believe their human rights are being infringed, perhaps a solution is to stop identifying yourself as a doctor online, although I appreciate this can be difficult if you are tagged in certain things. There are a number of good points why doctors shouldn't be anonymous online and it is certainly a must if you are in the trade of offering health promotion via the world wide web. However, I can see the point of those who want to remain anonymous for comical or satirical purposes. A quick google of the topic will reveal that the GMC has said that they do not envisage fitness to practice issues arising from doctors remaining anonymous online, but from the temptations that arise from running an anonymous profile such as cyber-bullying and misinformation. Read the GMC guidance yourself here. National Health Service (Health Education) - Social Media in Education May 2013 The NHS-HE guidelines are high quality and cover the entire scope of what social media means to medicine. There are several key issues that I haven't encountered elsewhere. This set of guidance is written from a managerial, technical perspective. It doesn't really feel aimed at doctors or medical students but it gives such an overview of the subject that I thought it was worth including. If you feel brave enough, read it for yourself here. Conclusion To my knowledge, these are the current key guidelines for the use of social media in medicine. I hope you have found this blog useful in providing a quick summary of a topic that is becoming increasingly swamped with lengthy guidelines. In the future we need to see material produced or delivered that educates health professionals in how to use social media, rather than regurgitating the pros and cons every couple of months. I think webicina is a good example of a social media 'training course,' . There should be more material like this. Perhaps this is where I'm headed with my next project... As always, if you have anything to add to this blog, please feel free to add to the comments below. I will be able to take difficult queries forwards with me to the Doctors 2.0 conference next week! If you are a student and interested in coming to the conference in Paris next week you should get in contact with me directly (@LFarmery on twitter). Also, it would be a great help if you could fill out my very quick pilot survey to help me understand how doctors and medical students currently use social media. Also see my website Occipital Designs LARF Disclaimer The thoughts and feelings expressed here are those produced by my own being and are not representative in part or whole of any organisation or company. Occipital Designs is a rather clunky, thinly veiled, pseudonym. If you would like to contact me please do so on Twitter...  
Dr. Luke Farmery
over 6 years ago
Foo20151013 2023 qo3u6t?1444774095
3
916

Prostate and Bladder Cancer Staging and Grading - A review for students

Amended from Wikipedia and other sources T.I Lemon Stage means spread Grade means histology Prostate cancer staging – spread of the cancer There are two schemes commonly used to stage prostate cancer. TMN and Whitmore Jewett Stage I disease is cancer that is found incidentally in a small part of the sample when prostate tissue was removed for other reasons, such as benign prostatic hypertrophy, and the cells closely resemble normal cells and the gland feels normal to the examining finger Stage II more of the prostate is involved and a lump can be felt within the gland. Stage III, the tumour has spread through the prostatic capsule and the lump can be felt on the surface of the gland. In Stage IV disease, the tumour has invaded nearby structures, or has spread to lymph nodes or other organs. Grading - Gleason Grading System is based on cellular content and tissue architecture from biopsies, which provides an estimate of the destructive potential and ultimate prognosis of the disease. TX: cannot evaluate the primary tumor T0: no evidence of tumor T1: tumor present, but not detectable clinically or with imaging • T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons) • T1b: tumor was incidentally found in greater than 5% of prostate tissue resected • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate • T2a: the tumor is in half or less than half of one of the prostate gland's two lobes • T2b: the tumor is in more than half of one lobe, but not both • T2c: the tumor is in both lobes but within the prostatic capsule • T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2) • T3a: the tumor has spread through the capsule on one or both sides • T3b: the tumor has invaded one or both seminal vesicles • T4: the tumor has invaded other nearby structures It should be stressed that the designation "T2c" implies a tumor which is palpable in both lobes of the prostate. Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c. Evaluation of the regional lymph nodes ('N') NX: cannot evaluate the regional lymph nodes • N0: there has been no spread to the regional lymph nodes • N1: there has been spread to the regional lymph nodes Evaluation of distant metastasis ('M') • MX: cannot evaluate distant metastasis • M0: there is no distant metastasis • M1: there is distant metastasis • M1a: the cancer has spread to lymph nodes beyond the regional ones • M1b: the cancer has spread to bone • M1c: the cancer has spread to other sites (regardless of bone involvement) Evaluation of the histologic grade ('G') Usually, the grade of the cancer (how different the tissue is from normal tissue) is evaluated separately from the stage; however, for prostate cancer, grade information is used in conjunction with TNM status to group cases into four overall stages. • GX: cannot assess grade • G1: the tumor closely resembles normal tissue (Gleason 2–4) • G2: the tumor somewhat resembles normal tissue (Gleason 5–6) • G3–4: the tumor resembles normal tissue barely or not at all (Gleason 7–10) Of note, this system of describing tumors as "well-", "moderately-", and "poorly-" differentiated based on Gleason score of 2-4, 5-6, and 7-10, respectively, persists in SEER and other databases but is generally outdated. In recent years pathologists rarely assign a tumor a grade less than 3, particularly in biopsy tissue. A more contemporary consideration of Gleason grade is: • Gleason 3+3: tumor is low grade (favorable prognosis) • Gleason 3+4 / 3+5: tumor is mostly low grade with some high grade • Gleason 4+3 / 5+3: tumor is mostly high grade with some low grade • Gleason 4+4 / 4+5 / 5+4 / 5+5: tumor is all high grade Note that under current guidelines, if any Pattern 5 is present it is included in final score, regardless of the percentage of the tissue having this pattern, as the presence of any pattern 5 is considered to be a poor prognostic marker. Overall staging The tumor, lymph node, metastasis, and grade status can be combined into four stages of worsening severity. Stage Tumor Nodes Metastasis Grade Stage I T1a N0 M0 G1 Stage II T1a N0 M0 G2–4 T1b N0 M0 Any G T1c N0 M0 Any G T1 N0 M0 Any G T2 N0 M0 Any G Stage III T3 N0 M0 Any G Stage IV T4 N0 M0 Any G Any T N1 M0 Any G Any T Any N M1 Any G Bladder T (Primary tumour) • TX Primary tumour cannot be assessed • T0 No evidence of primary tumour • Ta Non-invasive papillary carcinoma • Tis Carcinoma in situ (‘flat tumour’) • T1 Tumour invades subepithelial connective tissue • T2a Tumour invades superficial muscle (inner half) • T2b Tumour invades deep muscle (outer half) • T3 Tumour invades perivesical tissue: • T3a Microscopically • T3b Macroscopically (extravesical mass) • T4a Tumour invades prostate, uterus or vagina • T4b Tumour invades pelvic wall or abdominal wall N (Lymph nodes) • NX Regional lymph nodes cannot be assessed • N0 No regional lymph node metastasis • N1 Metastasis in a single lymph node 2 cm or less in greatest dimension • N2 Metastasis in a single lymph node more than 2 cm but not more than 5 cm in greatest dimension,or multiple lymph nodes, none more than 5 cm in greatest dimension • N3 Metastasis in a lymph node more than 5 cm in greatest dimension M (Distant metastasis) • MX Distant metastasis cannot be assessed • M0 No distant metastasis • M1 Distant metastasis. Grade Urothelial papilloma – non cancerous (benign) tumour •Papillary urothelial neoplasm of low malignant potential (PUNLMP) – very slow growing and unlikely to spread •Low grade papillary urothelial carcinoma – slow growing and unlikely to spread •High grade papillary urothelial carcinoma – more quickly growing and more likely to spread  
Thomas Lemon
about 6 years ago
Foo20151013 2023 1hvig6h?1444774122
3
152

Mr Tim Smart “Learning to Lead” - Birmingham Medical Leadership Society Lecture 2

Last Wednesday (27/11/13) was Birmingham Medical Leadership Society’s second lecture in its autumn series on why healthcare professionals should become involved in management and leadership. Firstly, a really big thank you to Mr Smart for travelling all the way to Birmingham for free (!) to speak to us. It was a brilliant event and certainly sparked some debate. A second big thank you to Michelle and Angie – the University of Birmingham Alumni and marketing team who helped organise this event and recorded it – a video will hopefully be available online soon. Mr Tim Smart is the CEO of King’s NHS Foundation Trust and has been for the last few years – a period in which King’s has had some of the most successive hospital statistics in the UK. Is there a secret to managing such a successful hospital? “It’s a people business. Patients are what we are here for and we must never forget that” Mr Smart doesn’t enjoy giving lectures, so instead he had an “intimate chat” covering his personal philosophy of why we as medical students and junior doctors should consider a career in management at some point. Good managers should be people persons. Doctors are selected for being good at talking to and listening to people – these are directly translatable skills. Good managers should be team leaders. Medicine is becoming more and more a team occupation, we are all trained to work, think and act as a team and especially doctors are expected to know how to lead this team. Again, a directly transferable skill. Good managers need to know how to make decisions based on incomplete knowledge and basic statistics. Doctors make life-altering clinical decisions every day based statistics and incomplete knowledge. A very important directly transferable skill. Good managers get out of their offices, meet the staff and walk around their empires. Doctors, whether surgeons, GP’s or radiologists have to walk around the hospitals on their routine business and have to deal with a huge variety of staff from every level. To be a great doctor you need to know how to get the best out of the staff around you, to get the tasks done that your patients’ need. Directly transferable skills. Good managers are quick on the up-take and are always looking for new ways to improve their departments. Doctors have to stay on top of the literature and are committed to a life-time of learning new and complex topics. Directly transferable. Good managers are honest and put in place systems that try to prevent bad situations occurring again. Good doctors are honest and own up when they make a mistake, they then try to ensure that that mistake isn’t made again. Directly Transferable. Even good managers sometimes have difficulties getting doctors to do what they want – because the managers are not doctors. Doctors that become managers still have the professional reputation of a doctor. A very transferable asset that can be used to encourage their colleagues to do what should be done. A good manager values their staff – especially the nurses. A good doctor knows just how important the nurses, ODP, physio’s and other healthcare professionals and hospital staff are. This is one of the best reasons why doctors should get involved with management. We understand the front line. We know the troops. We know the problems. We are more than capable of thinking of some of the solutions! “Project management isn’t magic” “Everything done within a hospital should be to benefit patients – therefore everything in the hospital should be answerable to patients, including the hospital shop!” “Reward excellence, otherwise you get mediocrity” At the present The University of Birmingham Students Medical Leadership Society is in contact with the FMLM and other similar groups at the Universities of Bristol, Barts and Oxford. We are looking to get in contact with every other society in the country. If you are a new or old MLS then please do get in touch, we would love to hear from you and are happy to help your societies in any way we can – we would also love to attend your events so please do send us an invite. Email us at med.leadership.soc.uob@gmail.com Follow us on Twitter @UoBMedLeaders Find us on Facebook @ https://www.facebook.com/groups/676838225676202/ Come along to our up coming events… Thursday 5th December LT3 Medical School, 6pm ‘Why should doctors get involved in management’ By Dr Mark Newbold, CEO of BHH NHS Trust Wednesday 22nd January 2014 LT3 Medical School, 6pm ‘Has the NHS lost the ability to care?’ – responding to the Mid Staffs inquiry’ By Prof Jon Glasby, Director of the Health Services Management Centre , UoB Thursday 20th February LT3 Medical School, 6pm ‘Creating a Major Trauma Unit at the UHB Trust’ By Sir Prof Keith Porter, Professor of Traumatology, UHB Saturday 8th March LT3 Medical School, 1pm ‘Applying the Theory of Constraints to Healthcare By Mr A Dinham and J Nieboer ,QFI Consulting  
jacob matthews
almost 6 years ago
Foo20151013 2023 1njk26?1444774138
3
133

Doctor or a scientist?

"One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong" Sir William Osler Well, it's almost Christmas. I know it's Christmas because the animal skeleton situated in the reception of my University's Anatomy School has finally been re-united with his (or her?) Christmas hat, has baubles for eyes and tinsel on its ribcage. This doesn't help with my trying to identify it (oh the irony if it is indeed a reindeer). This term has probably been one of the toughest academic terms I've had, but then when you intercalate that is sort of what you choose to let yourself in for. I used to think that regular readings were a chore in the pre-clinical years. I had ample amounts of ethics, sociology and epidemiology readings to do but this is nothing compared to the world of scientific papers. The first paper I had to read this term related to Glycosaminoglycan (GAG) integrity in articular cartilage and its possible role in the pathogenesis of Osteoarthritis. Well, I know that now. When I first started reading it felt very much like a game of boggle and highly reminiscent of high school spanish lessons where I just sat and nodded my head. This wasn't the end. Every seminar has come with its own prescribed reading list. The typical dose is around 4-5 papers. This got me thinking. We don't really spend all that much time understanding how to read scientific papers nor do we really explore our roles as 'scientists' as well as future clinicians. Training programmes inevitably seem to create false divides between the 'clinicans' and the 'academics' and sometimes this has negative consequences - one simply criticises the other: Doctors don't know enough about science, academics are out of touch with the real world etc... Doctors as scientists... The origins of medicine itself lie with some of the greatest scientists of all time - Herophilus, Galen, Da Vinci, William Harvey (the list is endless). As well as being physicians, all of these people were also respected scientists who regularly made contributions to our understanding of the body's mechanics. Albeit, the concept of ethics was somewhat thrown to the wind (Herophilus, though dead for thousands of years, is regularly accused of performing vivisections on prisoners in his discovery of the duodenum). Original sketches by William Harvey which proved a continuous circuit of blood being supplied and leaving the upper limb. He used his observations to explain the circulatory system as we know it today What was unique about these people? The ability to challenge what they saw. They made observations, tested them against their own knowledge and asked more questions - they wanted to know more. As well as being doctors, we have the unique opportunity to make observations and question what we see. What's causing x to turn into y? What trends do we see in patients presenting with x? The most simple question can lead to the biggest shift in understanding. It only took Semmelweiss to ask why women were dying in a maternity ward to give rise to our concept of modern infection control. Bad Science... Anyone who has read the ranting tweets, ranting books and ranting YouTube TED videos of academic/GP Ben Goldacre will be familiar with this somewhat over used term. Pseudoscience (coined by the late great Karl Popper) is a much more sensible and meaningful term. Science is about gathering evidence which supports your hypothesis. Pseudoscience is a field which makes claims that cannot be tested by a study. In truth, there's lots and lots of relatively useless information in print. It's fine knowing about biomarker/receptor/cytokine/antibody/gene/transcription factor (insert meaningless acronym here) but how is it relevant and how does it fit into the bigger picture? Science has become reductionist. We're at the gene level and new reducing levels of study (pharmacogenetics) break this down even further and sometimes, this is at an expense of providing anything useful to your clinicial toolbox. Increasing job competition and post-graduate 'scoring' systems has also meant there's lots of rushed research in order to get publications and citations. This runs the danger of further undermining the doctors role as a true contributor to science. Most of it is wrong... I read an article recently that told me at least 50% of what I learn in medical school will be proven wrong in my lifetime. That might seem disheartening since I may have pointlessly consumed ample coffee to revise erroneous material. However, it's also exciting. What if you prove it wrong? What if you contributed to changing our understanding? As a doctor, there's no reason why you can't. If we're going to practice evidence-based medicine then we need to understand that evidence and doing this requires us to wear our scientist hat. It would be nice to see a whole generation of doctors not just willing to accept our understanding but to challenge that which is tentative. That's what science is all about. Here's hoping you don't find any meta-analyses in your stockings. Merry Christmas.  
Lucas Brammar
almost 6 years ago
Foo20151013 2023 10ztc2b?1444774144
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223

Digitalising Textbook initiatives in Africa...But, do the costs add up?

A recent review by World Bank Group has highlighted the enthusiasm for digitalising text books in Africa. Education officials seeking to acquire digital teaching and learning material have come to realise that it is actually quite a challenging and complex process. The procurement processes in comparison to acquiring traditional textbooks is proving to be less cost effective. Currently in Africa a few countries have been ambitious in wanting to roll out digital textbooks, referred to as 'teaching and learning resources and materials presented in electronic and digital formats'. Michael Truanco (Sr. ICT & Education Specialist) for World Bank, makes a clear point about the increasing consideration of the use of free content. Where free content is being used, this means the acquisition of the content is free. But is it really free? The costs associated with piloting small projects in order to introduce digital teaching and learning materials as a way to learn what the related costs are. There are three categories to consider, the costs related to content, the device related costs and ecosystem related cost. Michael highlights the costs related to content which are directly related to the acquisition of content. Although post acquisition - there are other costs to consider, including vetting (for accuracy), contextualising, embedding, classifying and distribution. Device -related costs and other costs which are related includes the end user device which digital teaching materials are viewed on, accompanied with the technical infrastructure. Further costs to consider include the repair and maintenance, replacement, upgrade and security. In order for a device to function efficiently the baseline of electricity needs to be considered. These are the direct related costs to the device, as well as costs associated to the ecosystem. The article does not seek to dampen the initiative of digitalising content but rather highlight the need to consider the finer details in finances, which is a fundamental element within the process of this great initiative. Previous initiatives include the World Bank in Latin America and Africa which sought to provide 'teacher generated content'. The initiative is an excellent one but the reality of digitalising textbook initiatives in Africa may need, further refining in terms of economics and overall financial costings. The question to really ask is whether digitalising textbooks in Africa will have a greater accessibility and outcome than traditional printed format? However, as discussed to achieve this, it will come at a price? But, does the costs outweigh the outcomes? Irrespective of the costs the overall outcome and benefit of digitalising text book initiative in Africa will have a much greater overall impact. Children and adults will be able to access mass content and learning materials in a much more accessible way. Thus, leading to a more effective and positive learning environment. To read more on this topic please feel free to click on the article by Michael Truanco of World Bank (see link below). http://blogs.worldbank.org/edutech/calculating-costs-digital-textbook-initiatives-africa  
helena kazi
almost 6 years ago
Foo20151013 2023 eztttu?1444774181
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Dealing with Personal Illness in Med School

Hey guys! I’m Nicole and I’m a second year medical student at Glasgow University. I’ve decided to start this blog to write about my experiences as a med student and the difficulties I encounter along the way, hopefully giving you something you can relate to. Since June of last year I have been suffering with a personal illness, with symptoms of persistent nausea, gastric pain and lethargy. At first I thought it was just a bug that would pass on fairly quickly, but as the summer months went on it was clear that this illness wasn’t going to disappear overnight. I spent my summer going through a copious amount of medications in hope that I’d feel better for term starting. I visited my GP several times and had bloods taken regularly. After 2 months, I finally got given a diagnosis; I had a helicobacter pylori infection. I started eradication therapy for a week and although it made my symptoms worse, I was positive would make me better and I’d be well again within the week. The week passed with no improvements in my condition. Frustrated, I went back to my GP who referred me for an endoscopy. Term started back the next week and despite feeling miserable I managed to drag myself out to every lecture, tutorial and lab. Within a few weeks I began to fall behind in my work, doing the bare minimum required to get through. Getting up each morning was a struggle and forcing myself to sit in lectures despite the severe nausea I was experiencing was becoming a bigger challenge each day. In October I went for my endoscopy which, for those of you that don't know, is a horribly uncomfortable procedure. My family and friends assured me that this would be the final stage and I’d be better very very soon. The results came back and my GP gave me a different PPI in hope that it would fix everything. I waited a few weeks and struggled through uni constantly hoping that everything would magically get better. I gave up almost all my extra-circular activities which for me, the extrovert I am, was possibly the hardest part of it all. I wanted to stay in bed all the time and I become more miserable every day. I was stressing about falling behind in uni and tensions began to build up in my personal life. It got to the point where I couldn’t eat a meal without it coming back up causing me to lose a substantial amount of weight. I got so stressed that I had to leave an exam to throw up. I was truly miserable. I seen a consultant just before Christmas who scheduled me in for some scans, but it wasn’t until January. I was frustrated at how long this was going on for and I thought it was about time I told the medical school about my situation. They were very understanding and I was slightly surprised at just how supportive they were. I contacted my head of year who arranged a visit with me for January. During the Christmas break I had a chance to relax and forget about everything that was stressing me. I got put on a stronger anti-sickness medication which, surprisingly, seemed to work. The tensions in my life that had built up in the last few months seemed to resolve themselves and I began to feel a lot more positive! I met with my head of year just last week who was encouraged by my newly found positive behaviour. We’ve agreed to see how things progress over the next few months, but things are looking a lot brighter than before. I’ve taken on a new attitude and I’m determined to work my hardest to get through this year. I’m currently undertaking an SSC so I have lots of free time to catch up on work I missed during the last term. My head of year has assured me that situations like the one I’m in happen all the time and I’m definitely not alone. I feel better knowing that the medical school are behind me and are willing to help and support me through this time. The most important thing I have taken from this experience is the fact that you’ll never know the full extent of what a patient is going through. Illness effects different people in different ways and it may not just be a persons health thats affected, it can affect all aspects of their life. This experience has definitely opened my eyes up and hopefully I’ll be able to understand patients’ situations a little better.  
Nicole Mooney
over 5 years ago
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268

Top Resources for Medical Essay Writers

All stages of essay writing can be tricky, from the choice of a proper topic to the organization of the paper to the actual writing. Moreover, you also have to edit and proofread the paper in order to make sure it’s clean of all spelling errors and logical gaps. The content has to be free of plagiarism, and all sources you have used need to be properly referenced. When you have all those rules in mind, essay writing can become really confusing. However, there are online resources that can help you through every stage of the process, and we will list some of the most useful ones in the continuation. Help with your topic and thesis The first stage of the process can often be the most troublesome one. However, there are online tools that offer great topic ideas, which you can later turn into thesis statements with the help of thesis generators. Writinghouse is citation generator that will create the needed bibliography entries and in-text citations in your paper. How to write a college application essay – 10 practical ninja tips by Ninja Essays. This simple guide offers practical tips for writing impressive application essays. Paying attention to this advice will relieve you from the stress of college applications. Thesis Generator 1.0 is a great tool for drafting clear thesis statements for argumentative and persuasive essays. In order to get a suggestion for your thesis statement, you will need to enter the topic and main argument of your paper, along with two reasons that support the main argument. Thesis Statement Creator is also requires you to enter all components of the thesis statement, after which you will get a suggestion for a thesis statement that you can directly use into your essay. Understand the types of essays All types of essays have different requirements, so you need guides that will help you understand their principles. Roane State Online Writing Lab provides clear information about various types of essays, as well as samples that will help you get an impression of how great academic writing is done. Writing Detective provides a useful online lesson that will teach you how compare/contrast essays are written, after which you can take a quiz to test your abilities. The organization of your paper Proper essay organization isn’t difficult to achieve, but many students struggle with it. These are the tools that will improve the structure of your papers: Essay Map by ReadWriteThink will help you organize your paper through an interactive guide. From outline… to essay by iCivics is a lesson with side-by-side examples of appropriate organization. Essay Organizer is an app for smartphones, which you can use to go through the detailed steps of essay writing and take notes at any time. Great essays don’t come without proper grammar and syntax! These tools will help you make sure your paper is error-free: PaperRater will not only provide you with suggestions on how you can improve your paper in terms of style and vocabulary, but will also check it for plagiarism. Purdue OWL offers any information about essays you could possibly need. It will teach you about proper grammar and syntax, as well as the general requirements for different types of essays. UNLV Writing Center provides practical tips on essay writing that will teach you how to avoid the most common mistakes. Check the uniqueness of your paper! Professors don’t forgive plagiarism issues, so you better use these tools to make sure your paper is unique before you submit it: PlagTracker is a simple, but very effective tool that provides links to articles and webpages of duplicate content. Viper is another effective plagiarism checker, but this one requires a download. Conclusion Education is an aspect of life that has been particularly transformed due to the remarkable digital changes. Now that you have practical tools within reach, essay writing doesn’t have to be a struggle. Online tools will make this activity less stressful and less time-consuming!  
Robert Morris
over 5 years ago
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3
153

Doing more with less: own Pride and Joy.

“There is nothing new under the sun” - Ecclesiastes 1:4-11. If any of you have read one of my blogs before you will have realised that I am a huge fan of books. The blog I am writing today is also about a book, but more than that, it is about an idea. The idea is simple, practical and nothing especially new. It is an idea that many call common sense but few call common practice. It is an idea that has been used in every sort of organisation for over 20 years. It is an idea that needs to be applied on a greater scale to the health service. The idea is not new. How the book is written is not new. But how the book explains the idea and applies it to healthcare is new and it will change how you view the health service. It is a revolutionary book. The book is called “Pride and Joy” by Alex Knight view here. How I came to read this book is a classic story of a Brownian motion (a chance encounter), leading to an altered life trajectory. The summer before starting medical school I was working as a labourer cleaning out a chaps guttering. During a tea break in the hot summer sun he asked me what I was going to study at Uni. As soon as I said “Medicine”, he said “then you need to come see this”. He took me into his office and showed me a presentation he had given the year before about a hospital in Ireland. He was a management consultant and had been applying a management theory he had learned while working in industry. With his help the hospital had managed to reduce waiting times by a huge amount. The management theory he was applying is called "The Theory of Constraints" (TOC). I thought that his presentation was fascinating and I could not understand why it was not more widely applied. I went away and read the books he suggested and promised that I would stay in touch. Four years later and I had been exposed to enough of the clinical environment to realise that something needs to change in how the health service is run. To this end, a couple of colleagues and myself founded the Birmingham Medical Leadership society (BMLS) with help from the Faculty of Medical Leadership and Management (FMLM). The aim of which is to help healthcare students and professionals understand the systems they are working in. The first thing I did after founding the society was contact that friendly management consultant and ask him for his advice on what we should cover. He immediately put me in contact with QFI consulting, @QFIConsulting. This small firm has been working with hospitals all over the world to implement this simple theory called the Theory of Constraints. They were absolutely fantastic and within 2 emails had promised to come to Birmingham to run a completely free workshop for our society’s members. The workshop was on March 8th at Birmingham Medical School. Through our society’s contacts we managed to encourage 15 local students to take a revision break to attend the workshop on a sunny Saturday. We were also able to find 11 local registrars/ consultants who wanted to improve their management knowledge. It just so happens that the chap leading this workshop was Mr Alex Knight. The workshop sparked all of our interests and when he mentioned that he had just written a book, pretty much the whole crowd asked for a copy. When I got my copy, I thought I would leave it to read for after my end of year exams. However, I got very bored a few days before the first written paper and needed a revision break – so I decided that reading a few pages here and there wouldn't hurt. Trouble was that this book was a page turner and I soon couldn't put it down. I won’t spoil the book for all of you out there, who I hope will read it. I shall just say that if you are interested in healthcare, training to work in healthcare, already work in healthcare or just want a riveting book to read by the pool then you really should read it. The basic premise is that healthcare is getting more expensive and yet there appears to be an increase in the number of healthcare crises'. So if more money isn't making healthcare better, then maybe it is time to try a different approach. “Marketing is what you do when your product is no good” – Edward Land, inventor of the Polaroid Camera. Mr Land was a wise man and I can happily say that I have no conflict of interest in writing this blog. I have not been promised anything in return for this glowing review. The only reason that I have written this is because I believe it is important for people to have a greater understanding of how the health service works and what we can do to make it even better! As a very junior healthcare professional, there is not much that we can do on a practical level but that does not mean we are impotent. We can still share best practice and show our enthusiasm for new approaches. Healthcare students and professionals, if you care about how your service works and you want to help make it better. Please find a copy of this book and read it. It won’t take you long and I promise that it will have an impact on you. NB - Note all of the folded down corners. These pages have something insightful that I want to read again... there are a lot of folded pages!  
jacob matthews
over 5 years ago
Foo20151013 2023 e7fpn8?1444774293
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339

The Importance Of Clinical Skills

In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees. Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this. In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment. In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room. What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it? Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important. Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.  
DR William LeMaire
over 5 years ago
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3
31

Principles of Medical Physiology

This book has been specifically designed with the needs of the student in mind. Lengthy explanations are avoided and the material is presented in a concise form that not only makes it easy to understand but also easy to remember and reproduce, which is precisely what the student needs. Key features - Short chapters are organized in the sequence preferred by most physiology teachers - The contents of each chapter are tailored to provide just enough material for a single lecture (occasionally two lectures), making it very handy for teachers. (The book contains 120 chapters) - Basics of relevant physics and chemistry are made extremely simple. This is welcomed by both physiology teachers and students, for efficient teaching and learning - Schematic diagrams in 3D perspective are employed to elucidate difficult anatomical concepts, including the gross structure of the brain - Simple analogies of difficult concepts are given, often comically illustrated. Apparent paradoxes are highlighted and simple answers are provided - Difficult topics are presented with elegant simplicity and brevity without compromising on the core concepts. These include membrane electrophysiology, electromyography, hemostatic balance, electrocardiography, cardiac output, hemodynamics, respiratory mechanics, counter-current multiplier system, body fluid and electrolyte balance, gastric acid secretion, calcitropic hormones, fetoplacental unit, memory and learning, synaptic transmission and sensorimotor mechanisms  
books.google.co.uk
over 4 years ago
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3
161

Crash Course Obstetrics and Gynaecology

The new series of Crash Course continues to provide readers with complete coverage of the MBBS curriculum in an easy-to-read, user-friendly manner. Building on the success of previous editions, the new Crash Courses retain the popular and unique features that so characterised the earlier volumes and are fully updated throughout. More than 350 tables and illustrations present clinical, diagnostic and practical information in an easy-to-follow manner Friendly and accessible approach to the subject makes learning especially easy Written by junior doctors for students - authors who understand exam pressures Contains ‘Hints and Tips’ boxes, and other useful aide-mémoires Succinct coverage of the subject enables ‘sharp focus’ and efficient use of time during exam preparation Contains a fully updated self-assessment section - ideal for honing exam skills and self-testing Self-assessment section fully updated to reflect current exam requirements Contains ‘common exam pitfalls’ as advised by faculty Crash Courses also available electronically! Online self-assessment bank also available - content edited by Dan Horton-Szar! Feeling daunted? Worried about passing your exams? Need to brush up on a particular topic? Then Crash Course is for you!! Now celebrating over 10 years of success - Crash Course has been specially devised to help you get through your exams with ease. Completely revised and updated throughout, the new edition of Crash Course is perfectly tailored to meet your needs by providing everything you need to know in one place. Clearly presented in a tried and trusted, easy-to-use, format, each book in the series gives complete coverage of the subject in a no-nonsense, user-friendly fashion. Commencing with 'Learning Objectives', each chapter guides you succinctly through the topic, giving full coverage of the curriculum whilst avoiding unnecessary and often confusing detail. Each chapter is also supported by a full artwork programme, and features the ever popular 'Hints and Tips' boxes as well as other useful aide-mémoires. All volumes contain an up-to-date self-assessment section which allows you to test your knowledge and hone your exam skills! Authored by students or junior doctors - working under close faculty supervision - each volume has been prepared by someone who has been in the exam situation and so can relate closely to your needs. So whether you need to get out of a fix or aim for distinction Crash Course is for you!! Be safe - rely on Crash Course!  
books.google.co.uk
over 4 years ago
Preview
3
27

Stahl's Essential Psychopharmacology Resource

Cambridge University Press is part of the University of Cambridge. It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence.  
stahlonline.cambridge.org
over 4 years ago
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3
570

Inguinal region: dissection of a female body

This video and its channel are supported by "Human Anatomy Education" page on Facebook http://www.facebook.com/AnatomyEducation Check related video: Anatomy ...  
youtube.com
over 3 years ago
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2
64

Evaluation of curricular integration between physiology and semiology:faculty point of view

We discuss the integration between two disciplines during the secon year of the medical course and the future impact into the course.  
Iêda Aleluia
almost 10 years ago