Group Learning Sessions Research Articles

Sugar reduction during alcohol recovery: a qualitative study with service users and staff members of a service provider

BackgroundThe association between alcohol dependence and sugar intake is poorly understood with evidence suggesting that some adults undergoing alcohol recovery, primarily in the early stages, have sugar cravings. This may result in swapping of alcohol dependence for sugar cravings, and therefore have an adverse impact on the recovery process and overall health. This study aimed to explore experiences and views of alcohol recovery service users and staff members of a service provider on sugar cravings during recovery and possible ways to reduce cravings during this crucial time. MethodsParticipants for this qualitative study were recruited from an alcohol recovery services hub in West Sussex, UK. Adult service users (age >25 years) attending the 10 week Growth Workshop Programme, and service provider staff within the hub, were eligible to participate. The researcher attended the programme in week four and outlined the study and circulated the participant information sheet and consent form. The focus group took place in week five; written informed consent was obtained from all participants. Two focus group sessions were conducted with service users, and one session with staff. The focus group audiotapes were transcribed and data analysed using a framework approach for thematic analysis. Ethics approval was obtained from Brighton and Sussex Medical School (ERA/BSMS3653/3/2). FindingsSeven service users (two female) and ten staff (seven female) took part in the study. Key themes emerging from the study were lack of awareness of the impact of sugar on health, addiction swap (substitution of sugar for alcohol addiction), impact of the built environment (accessibility to sugary food and drink), barriers to healthy eating (eg, cost), drinking-related action and behaviour (eg, holding a can), and interventions. Suggested interventions included social marketing materials (posters, leaflets), fresh fruit in service hubs, and group learning sessions and staff training on nutrition. InterpretationOur findings are consistent with existing evidence about sugar cravings during alcohol recovery and could be helpful to inform future interventions focusing on a holistic approach to alcohol recovery. Our study's strengths include capturing the views of both a vulnerable population group and service providers, but the small number of sessions and participants is a limitation. FundingWest Sussex County Council, Public Health Directorate (for AT).

Development and Implementation of a Novel HIV Primary Care Track for Internal Medicine Residents.

Declining mortality has led to a rising number of persons living with HIV (PLWH) and concerns about a future shortage of HIV practitioners. To develop an HIV Primary Care Track for internal medicine residents. Academic hospital and community health center with a history of caring for PLWH and lesbian, gay, bisexual, and transgender (LGBT) patients. Internal medicine residents. We enrolled four residents annually in a 3-year track with the goal of having each provide continuity care to at least 20 PLWH. The curriculum included small group learning sessions, outpatient electives, a global health opportunity, and the development of a scholarly project. All residents successfully accrued 20 or more PLWH as continuity patients. Senior residents passed the American Academy of HIV Medicine certification exam, and 75% of graduates took positions in primary care involving PLWH. Clinical performance of residents in HIV care quality measures was comparable to those reported in published cohorts. We developed and implemented a novel track to train medical residents in the care of PLWH and LGBT patients. Our results suggest that a designated residency track can serve as a model for training the next generation of HIV practitioners.

Peer learning leaders: developing employability through facilitating the learning of other students

Employability is a key theme in higher education and attitudes towards its development have shifted from a focus on technical skills development to a broader focus on values, intellect, social engagement and performance contributing to graduate identity (Hager and Hodkinson, 2009). Peer Assisted Learning (PAL) and Language Conversation Clubs are both examples of student-led peer learning schemes at Bournemouth University (BU), and are reviewed to explore the development of students employed to lead and facilitate group learning sessions. Data from four annual evaluation surveys (n=239) is reviewed in addition to qualitative comments and reflective writing. Peer leaders were found to have developed employability attributes including: leadership, time management and organisation, communication, and cultural awareness. Above all, peer leaders identified with developing confidence in their roles. Comments provided examples of student leaders who had actively selected peer learning as an opportunity to develop their confidence and were able to transfer this to other academic and employment contexts.

Feasibility and acceptability of patient partnership to improve access to primary care for the physical health of patients with severe mental illnesses: an interactive guide.

IntroductionEven in countries with universal healthcare systems, excess mortality rates due to physical chronic diseases in patients also suffering from serious mental illness like schizophrenia is such that their life expectancy could be lessened by up to 20 years. The possible explanations for this disparity include: unhealthy habits (i.e. smoking; lack of exercise); side-effects of psychotropic medication; delays in the detection or initial presentation leading to a more advanced disease at diagnosis; and inequity of access to services. The main objective of this paper is to explore the feasibility and acceptability of patient partnership for developing an interactive guide to improve access to primary care providers for chronic diseases management and health promotion among patients with severe mental illnesses.MethodsA participatory action research design was used to engage patients with mental illness as full research partners for a strategy for patient-oriented research in primary care for persons with schizophrenia who also have chronic physical illnesses. This strategy was also developed in partnership with a health and social services centre responsible for the health of the population of a territory with about 100,000 inhabitants in East-end Montreal, Canada. A new interactive guide was developed by patient research partners and used by 146 participating patients with serious mental illness who live on this territory, for them to be better prepared for their medical appointment with a General Practitioner by becoming more aware of their own physical condition.ResultsPatient research partners produced a series of 33 short videos depicting signs and symptoms of common chronic diseases and risk factors for the leading causes of mortality and study participants were able to complete the corresponding 33-item questionnaire on an electronic touch screen tablet. What proved to be most relevant in terms of interactivity was the dynamic that has developed among the study participants during the small group learning sessions, a training technique designed for healthcare professionals that was adapted for this project for, and with patient partners.ConclusionThis research has shown the feasibility and acceptability of patient partnership and patient-oriented research approaches to the R&D process of a new medical tool and intervention for patients with serious mental illness, and its acceptability for addressing inequity of this disadvantaged population in terms of access to primary care providers.

Initiating small group learning in a Caribbean medical school.

Initiating small group learning in a Caribbean medical school.

Feasibility and Acceptability of Group Cell Phones to Promote Optimal Breastfeeding in a Women's Microcredit Program in Nigeria

We previously reported on a breastfeeding promotion intervention that successfully increased optimal breastfeeding practices using cell phone messaging and group learning sessions integrated into a women's microcredit program in Nigeria. Using a novel approach, one cell phone was given to each group of 5‐7 microcredit clients. The cell phone holder was instructed to share the weekly breastfeeding voice and text messages with group members. The feasibility and acceptability of group cell phones was measured through structured exit interviews with microcredit clients (n=195) whose babies were born during the intervention (target group), in‐depth interviews with phone holders (n=8) and non‐phone holders (n=8), and focus group discussions (FGDs) (n=16) with other microcredit clients. Exit interviews revealed that only 6% of women in the target group were phone holders, but 64% said the group phone worked well. 58% lived within 10 min walking distance of the phone holder and 52% said messages were shared once a week. The target group was motivated to try the recommended practices because they trusted the information (58%) and had support from others (36%). In‐depth interviews and FGDs indicated that most phone holders were elected, non‐phone holders had positive feelings toward phone holders, and the group phone met their needs. A few issues with message sharing and connectivity were noted. In summary, use of group cell phones to promote breastfeeding among microcredit clients is feasible and acceptable, and can be part of an effective behavior change package. Funding: Alive & Thrive small grants program

Teaching Note: Ethnic Sharing: Laying the Foundation for Culturally Informed Practice With BSW Students

This article describes the use of ethnic sharing, a structured, narrative exercise designed to increase cultural competence among students in social work programs. The premise of this facilitated exercise is that self-awareness and cultural awareness create the foundation for culturally informed practice. Twenty-five BSW students from diverse backgrounds participated in this guided group learning session and experienced brief cultural immersion. A content analysis of participant feedback about the exercise indicated that students engaged in self-examination, gained cultural awareness, and demonstrated a beginning understanding of culturally informed practice. Analyzing the students' written responses according to a phenomenological perspective revealed the following themes: (a) Don't stereotype or make assumptions, (b) remain open minded and refrain from making judgments, and (c) be aware of cross-cultural similarities and differences. The utility of ethnic sharing as an experiential learning exercise for...

Teaching Note: Ethnic Sharing: Laying the Foundation for Culturally Informed Practice With BSW Students

This article describes the use of ethnic sharing, a structured, narrative exercise designed to increase cultural competence among students in social work programs. The premise of this facilitated exercise is that self-awareness and cultural awareness create the foundation for culturally informed practice. Twenty-five BSW students from diverse backgrounds participated in this guided group learning session and experienced brief cultural immersion. A content analysis of participant feedback about the exercise indicated that students engaged in self-examination, gained cultural awareness, and demonstrated a beginning understanding of culturally informed practice. Analyzing the students' written responses according to a phenomenological perspective revealed the following themes: (a) Don't stereotype or make assumptions, (b) remain open minded and refrain from making judgments, and (c) be aware of cross-cultural similarities and differences. The utility of ethnic sharing as an experiential learning exercise for baccalaureate social work students to develop proficiency in diversity awareness is demonstrated.

Basic steps in establishing effective small group teaching sessions in medical schools

Small-group teaching and learning has achieved an admirable position in medical education and has become more popular as a means of encouraging the students in their studies and enhance the process of deep learning. The main characteristics of small group teaching are active involvement of the learners in entire learning cycle and well defined task orientation with achievable specific aims and objectives in a given time period. The essential components in the development of an ideal small group teaching and learning sessions are preliminary considerations at departmental and institutional level including educational strategies, group composition, physical environment, existing resources, diagnosis of the needs, formulation of the objectives and suitable teaching outline. Small group teaching increases the student interest, teamwork ability, retention of knowledge and skills, enhance transfer of concepts to innovative issues, and improve the self-directed learning. It develops self-motivation, investigating the issues, allows the student to test their thinking and higher-order activities. It also facilitates an adult style of learning, acceptance of personal responsibility for own progress. Moreover, it enhances student-faculty and peer-peer interaction, improves communication skills and provides opportunity to share the responsibility and clarify the points of bafflement.

The future of medical and nursing education

It would be very easy for this essay to be yet another paper on the problems facing doctors due to the European Working Times Directive, problems with nurse recruitment or the financial difficulties facing all new students. However, I wish to reflect on possible future improvement and curricular changes within both medical and nursing education. The last twenty years have seen the development and rise in popularity of Problem Based Learning (PBL) in the UK, Canada and medical schools elsewhere across the globe. So too have nursing courses across the UK embraced Enquiry Based Learning (EBL), a similar self-directed learning technique. Both PBL and EBL are considerably cheaper to operate compared to traditional courses. Nurses and doctors have to learn many similar topics over a broad range of areas, albeit to a different depth. It is suggested here that future course curriculum development may see moves to hold some teaching jointly with both nursing and medical students. The differences between nurses and doctors are vast, and it is not suggested here that nurses should attend all medical lectures, or vice versa, simply that there may be a benefit to holding some teaching jointly. The most obvious argument to make against this suggestion is that of knowledge depth. Arguably doctors are required to learn Medicine in far greater depth than nurses. Equally, there are areas of nursing that doctors remain ignorant of. What need is there for doctors to sit in on manual handling lectures, or for nurses to study the pharmacokinetics of Warfarin? Even if common ground can be found, or lectures rewritten to give a joint introduction to both professions, is there any real benefit to doing so? By teaching both groups together for some areas, an element of camaraderie and shared learning may occur with both sides enriching the other to become something more than the sum of their parts. The simplest argument to make in favour of some joint teaching is that of cost. As modern universities come under increasing financial pressure, savings must be found wherever possible. Lectures or tutorials on general topic introductions or practical skills such as inhaler technique or blood glucose monitoring could be held jointly. Efficiency savings could encourage universities to consider joint teaching and even a relatively small number of joint sessions would result in substantial savings. Inter-professional Learning (IPL) is a globally occurring phenomenon aimed at encouraging healthcare students to work cooperatively together. It is an attempt to foster inter-professional working relationships by increasing the level of understanding around professionals’ roles within a team. Sadly, IPL is generally not well received by students, commenting that it feels “forced” or “artificial”. In the author’s experience, students from the professions involved do participate, but occasionally appear to have professional stereotypes reinforced rather than rebuffed. Do nurses and doctors even want to study together or could such an approach widen the gap between “us” and “them” to new levels of mistrust? By conducting general teaching together, students would have opportunities to socialise and learn together in a normal environment. Artificial cooperation tasks would be unnecessary as students discovered their professional identities over the course of their degree, while studying together would encourage teamwork and understanding between courses. An added benefit of collaborative working is that it may start to break down the “us” vs. “them” attitudes that are common within both professions. By learning together and gaining awareness of what both professions can do, tolerance and acceptance may start to replace mistrust and judgement. To develop this idea further, PBL and EBL groups could merge and group learning sessions would facilitate closer cooperation between groups, nurturing professional relationships and friendships. Logistically this may be harder as both groups of students would also need time to discuss the more course-specific learning. However, it is suggested that if this were possible, the inter-professional educational and professional benefits of such a technique would have a large impact on the medical community. Although it is possible to argue that this would hinder inter-professional working, the same can be said of the current IPL system. This suggestion would clearly have benefits in terms of cost savings to universities, natural development of inter-professional relationships and encourage teamwork and teaching within student groups. Although clearly both courses do have different teaching goals and require different levels of teaching in many areas, there is no obvious reason why some teaching should not occur jointly, given the existence of common strands that tie both courses together.

Practice-based small group learning (PBSGL) for CPD: a pilot with general practice trainees to support the transition to independent practice

The paper describes a small-scale enquiry with UK-based general practice specialty trainees (GPSTs) at the time of transition from training to independent practice. It aimed to identify whether they were supported in making this transition through attending practice-based small group learning (PBSGL) sessions. Participants in the study reported that the sessions helped them to consolidate their learning from their third year of training (GPST3), improved their ability to identify and use evidence in practice, and shifted the focus of their learning needs away from the two UK general practice postgraduate exams (applied Knowledge Test or aKT; and Clinical Skills assessment or CSa) and towards 'real world' practice. The two pilot groups have become established as means of peer support and continue to meet, with small changes in composition. The work has led to the wider roll out of PBSGL for newly qualified GPs across Wessex.

Genitourinary Exam Skills Training Curriculum for Medical Students: A Follow-up Study of Comfort and Skill Utilization

We developed a genitourinary skills training (GUST) curriculum for incoming third year medical students (MS3) and performed a follow-up study of comfort with and utilization of these skills. GUST consisted of a didactic lecture followed by skills sessions including standardized patient testicular examination (TE) and digital rectal examination (DRE), male and female Foley catheter (MFC and FFC) placement training, suture-knot tying, and a faculty-directed small group learning session. Precourse and postcourse, and 6 and 18 months after the course, MS3 rated comfort with each skill (Likert scale 0-5), and quantified skill usage. Results were compared with 4th year students (MS4) who had not undergone GUST. Participants were 281 MS3 GUST students and 44 MS4. Post-GUST, mean comfort on a Likert scale (0=uncomfortable) increased for all four skills (88.2%-96.9% vs 8.3%-18.5%, P<0.0001). This was maintained at the 6-month and 18-month follow up time points (P<0.0001). At 18 months, MS3 trended toward higher comfort with TE compared with MS4 (74 vs 54%, P=0.068), while with the other skills, both groups showed equal comfort. MS4 learned exam skills from faculty and MFC and FFC from nurses on the wards. Eleven percent of MS4 were never formally taught TE or DRE. MS3 and MS4 performed TE and/or DRE on <8% of newly admitted patients. MS3 described improved comfort with the GU skills at all time points during follow-up. This was particularly important because both MS3 and MS4 reported using their skills infrequently during their clinical training years.

Evolution-Centered Teaching of Biology

University teaching remains an area of concern, and perhaps the most difficult discipline for both teaching and learning is evolution. The concepts that underpin evolution, although complex, have been shown to be fairly straightforward, yet students arrive at and leave university with serious misconceptions, misunderstandings related to language, and often a reluctance to learn the subject because of cultural or societal pressures. Because of the unifying power of the theory, however, it is necessary not only for biology students to have a thorough understanding of evolution, but also for them to learn it in their first year so that this knowledge can then be taken into further years of study. Rather than teaching evolution at the end of a degree program, embedding it as a semester-long first-year course will ensure that a far larger number of students are made aware of misconceptions that they have brought with them from high school. Teaching through traditional passive lectures makes learning difficult conceptual material more difficult, and needs to be replaced with more interactive lectures coupled with inquiry-based practicals and small group-learning sessions to increase student engagement and interest in the subject. A new approach in pedagogy, curriculum design, and academic staff professional development is essential, especially at this time, when enrollments across science courses in many countries around the world are in decline.

Small group effectiveness during pharmacology learning sessions in a Nepalese medical school.

Small group learning sessions are used in pharmacology at the KIST Medical College, Lalitpur, Nepal. Feedback about student behaviours that enhance and hinder small group effectiveness was obtained. This will help us improve the small group sessions and will also be useful to educators using small groups in other medical schools. The small groups were self-managing with a group leader, time-keeper, recorder and presenter. Small group effectiveness was measured using the Tutorial Group Effectiveness Instrument (TGEI) developed by Singaram and co-authors. The instrument was administered in June 2010 and key findings obtained were shared with students and facilitators. The instrument was administered again in August. The mean cognitive, motivational, demotivational and overall scores were compared among different categories of respondents in June and August. Scores were also compared between June and August 2010. A total of 89 students participated in the study in June and 88 in August 2010. In June, females rated overall group productivity higher compared to males. The cognitive and motivational scores were higher in August 2010 while the demotivational score was lower. The small group effectiveness was higher in August after the educational intervention which utilised feedback about problems observed, theoretical considerations of effective small groups and how this information can be applied in practice.

The resources and obstacles of creative collaboration in a long-term learning community

In the framework of a subject-centred socio-cultural approach, this study investigates creative collaboration and the resources for and obstacles to it in a long-term learning community of ten teacher students. The study focuses on five different learning situations over a 2-year period. The data were taken from teacher students’ evaluations and accounts (on given criteria) of their videotaped group-learning sessions, and their reports of the obstacles to creative collaboration. Using the students’ evaluations of the five videotaped group learning situations, the sessions they assessed as the least and most creative were compared, the aim being to discover the most important situation-specific contextual resources for collaborative creativity in the learning settings addressed. The findings showed that creative collaboration was manifested by the presentation of alternative views, and in most situations also by the production of new ideas. However, it was less evident that group discussion would in every session reveal contradictions or lead to the disclosure of opposing views concerning different meanings; nor would it necessarily create an elaborated understanding of the learning topic. The main obstacles to creative collaboration were related to the emotional atmosphere and power relations of the group. A comparison of the contextual conditions of the least and most creative evaluated situation illustrates that the least creative situation was characterised by participants’ disputational talk, aimed at invalidating opposing opinions. Here, the group atmosphere was emotionally charged in a negative sense, and mutual care taking was lacking. The unsafe atmosphere made group members afraid of being emotionally bruised by other members. The most creative situation was characterised by complementarity in participants’ talk and by inclusive utilisation of each other's views. The shared history of the group was an extremely important resource for group dialogue, allowing alternative future scenarios to be constructed reflectively. The emotional scaffolding between students was rich, and the tutor's resources were utilised. Results are discussed in terms of complementarity, emotions and power relations.

Journal clubs and case conferences: From academic tradition to communities of practice

As small group learning sessions, Journal Clubs (JCs) and Case Conferences (CCs), if structured interactively, have potential as educational formats that can change practice. However, the degree to which these formats, as currently typically structured, lead to practice change is unknown. We used concepts of communities of practice (COPs) to structure JCs and CCs. We conducted an observational descriptive study of the learnings, implemented learnings, and barriers to implementing learnings identified in JC and CC sessions conducted in 2005-2006. Two hundred learnings in 10 different categories emerged from 73 JC or CC sessions. By self-report, over half of identified learnings were implemented in practice; 60 barriers to implementing learnings (8 different categories) were also identified. Patterns of learnings, implemented learnings, and barriers varied among sessions. JCs and CCs can be structured with explicit intent to articulate learnings and facilitate implementation of learnings in practice. Further work is needed to validate the learning and barrier categories we identified, objectively verify short- and longer-term practice outcomes, explore the role of JCs and CCs in addressing barriers to learning, and facilitate sustainability of learning in practice.

Training with simulation improves residents’ endovascular procedure skills

Endovascular procedure simulators are now commercially available and in use for physician training. The purpose of this study was to evaluate the role of simulation-based training in vascular surgery residencies. Residents from vascular surgery programs in a five-state area were invited to participate in a series of 2-day endovascular training programs that used a high-fidelity endovascular procedure simulator (SimSuite; Medical Simulation Corporation, Denver, Colo), didactic instruction, computer-based training, and tabletop procedure demonstrations. The curriculum covered arteriography and intervention for treatment of aortoiliac, renal, and carotid artery disease. Nine residents participated, with one to three per training session. Each completed an average of 9.5 simulated endovascular cases. Performance on a standardized TransAtlantic Inter-Society Consensus B iliac angioplasty/stenting case was used to assess endovascular skills and knowledge at the beginning of the training program, and this was repeated at the completion of the training. Performance metrics were measured by the simulator, faculty observed trainees' performance of simulated cases, and trainees provided their evaluations of the usefulness of the simulation experiences. Endovascular procedural skills on the standardized iliac intervention case improved after completion of the training program. Compared with performance early on day 1, performance improved (P < or = .05; paired t test): total procedure time decreased 54%, volume of contrast decreased 44%, and fluoroscopy time decreased 48% (mean change from baseline). Selection of angioplasty balloon catheters and stents was improved, and the average number of catheters used and stents deployed decreased, although this did not reach statistical significance. Faculty observation allowed identification of shortcomings of knowledge and skills, including common problems with selection of catheter, balloon, and stent sizes; correct positioning of the sheath; and intraprocedural monitoring. Postcourse evaluations indicated support for the use of simulation in vascular surgery residents' endovascular training. Training with a simulator, incorporated into an individual or small group learning session, offers a means to learn and realistically practice endovascular procedures without direct risk to patients, with measurable improvements in key performance metrics. How simulation training affects subsequent clinical performance has yet to be established.

Design of a Prospective, Randomized Evaluation of an Integrated Nutrition Program in Rural Viet Nam

Few prospective studies of child growth and its determinants take place in programmatic contexts. We evaluated the effect of Save the Children's (SC) community empowerment and nutrition program (CENP) on child growth, care, morbidity, empowerment, and behavioral determinants. This paper describes the research methods of this community-based study. We used a longitudinal, prospective, randomized design. We selected 12 impoverished communes with documented child malnutrition, three comparison, and three intervention communes in each of two districts in Phu Tho Province, west of Hanoi. SC taught district trainers in November 1999 to train local health volunteers to implement the 10-month CENP, including situation analysis, positive deviance (PD) inquiry, growth monitoring and promotion, nutrition education and rehabilitation program (NERP), deworming, and monitoring. PD inquiries aim to discover successful care practices in poor households that likely promote well-nourished children. NERPs are neighborhood-based, facilitated group learning sessions where caregivers of malnourished children learn and practice PD and other healthy behaviors. We dewormed all intervention and comparison children. We randomly selected 240 children 5 to 25 months of age (120 intervention and 120 comparison). We gathered information on nutritional status, diet, illness, care, behavioral determinants, empowerment, and program quality, monthly for six months with a re-survey at 12 months. We collected most information through maternal interview but also observed hygiene and program quality, and videotaped feedings at home. Some implementation and research limitations will attenuate CENP impact and measurement of its effectiveness.

Design of a Prospective, Randomized Evaluation of an Integrated Nutrition Program in Rural Viet Nam

Few prospective studies of child growth and its determinants take place in programmatic contexts. We evaluated the effect of Save the Children's (SC) community empowerment and nutrition program (CENP) on child growth, care, morbidity, empowerment, and behavioral determinants. This paper describes the research methods of this community-based study. We used a longitudinal, prospective, randomized design. We selected 12 impoverished communes with documented child malnutrition, three comparison, and three intervention communes in each of two districts in Phu Tho Province, west of Hanoi. SC taught district trainers in November 1999 to train local health volunteers to implement the 10-month CENP, including situation analysis, positive deviance (PD) inquiry, growth monitoring and promotion, nutrition education and rehabilitation program (NERP), deworming, and monitoring. PD inquiries aim to discover successful care practices in poor households that likely promote well-nourished children. NERPs are neighborhood-based, facilitated group learning sessions where caregivers of malnourished children learn and practice PD and other healthy behaviors. We dewormed all intervention and comparison children. We weighed all children less than 24 months of age living in the intervention and comparison communes and randomly selected 240 children (120 intervention and 120 comparison). We gathered information on nutritional status, diet, illness, care, behavioral determinants, empowerment, and program quality, monthly for six months with a re-survey at 12 months. We collected most information through maternal interview but also observed hygiene and program quality, and videotaped feedings at home. Some implementation and research limitations will attenuate CENP impact and measurement of its effectiveness.

Evidence-Based Medicine: A New Paradigm for the Teaching and Practice of Medicine

Evidence-Based Medicine: A New Paradigm for the Teaching and Practice of Medicine